Professor Steve Field has played a major role in the development of the NHS in England by leading the government's listening exercise. Stuart Gidden finds the former RCGP chair forthright about the future
With many practice professionals questioning England's Health and Social Care Bill at a time ministers are trying to preserve it, Professor Steve Field seems like a man in the middle.
The immediate past chair of the Royal College of GPs (RCGP), his commitment to general practice has ensured wide popularity with peers. But latterly, as the chair of the NHS Future Forum that conducted the government's 'listening exercise' during the pause in the passage of the Health Bill through parliament, Professor Field has been seen as an establishment figure and he has even faced criticism of being a government stooge.
He seems to acknowledge the dangers of his new role when he jokes about advice he received when offered it. "A lot of people told me that it probably wasn't the best career decision I'd ever make, that it was career limiting. But given that I haven't got a career, that was ok."
Of course, this isn't true. A practising GP partner in innercity Birmingham, Professor Field also chairs the National Inclusion Health Board, a Department of Health body that advises on improving health outcomes for the most vulnerable.
But it's his role on the NHS Future Forum, a 45-strong panel of clinicians and NHS professionals, which has made him a powerful figure across the whole of the modern NHS. Professor Field describes his position as chair as "an honour", and says the exercise was "an important and historical moment… that needed to happen so that we could make the health service move forward in the right way."
Some commentators – including online posts from Management in Practice readers – suggested that the exercise was a way for the government to rubber-stamp the Health Bill by demonstrating approval from a coterie of onside healthcare professionals.
But Professor Field insists this was not the case – that this was an independent, wide-ranging exercise in which he had a free hand. "I had not one iota of political interference," he says. "The prime minister said I could speak to anybody I wanted to. And the report is a synthesis of what I and the four [Future Forum] teams heard."
He points to the figures to support his assertion. The Forum members attended around 200 events across England and met with "thousands of people on the ground" to discuss "genuine and deep-seated concerns". Another 25,000 people sent their views to the Forum via email, and a further 4,000 sent private comments, completed questionnaires or website responses.
The Future Forum's report, published in June, made several key recommendations, including moving to a more phased transition to clinical commissioning groups, instead of the former insistence that all such groups replace primary care trusts (PCTs) by April 2013.
However, Professor Field is adamant that CCGs should still aim to be ready by then. "I do believe that the commissioning group idea is the way forward and I think people should aim for April 2013," he says. "I believe that the only way we're going to manage the financial demands on the NHS is with GPs leading with high-quality management support, working with specialists and others.
"But in some areas there might be some groups that can't take the full amount of powers in April 2013, and I think it's right to be flexible. But I believe clinical leadership will mean that patients will get better care and a better deal, and that's why I fully support the direction of where we are now."
"Glue between practices"
So, how much of a role does he believe practice managers can and should play in CCGs? Professor Field believes they have a key role to play, but this doesn't necessarily mean taking up a position on the board of a CCG.
"Practice managers are really, really important for making sure the core business runs in the practice," he says. "Some of them will want to take leadership positions in consortia if they've got the knowledge, experience and skills, and all of them are key because they will act as glue between the practices.
"But it's not just about being on a board, it's very complex. But practice managers are critical for the delivery of commissioning, because for things to change they will have to change within individual practices as well as through networks, and in a local area the practice managers working together will act as glue and make things happen."
In June, practice managers at a panel discussion at the Management in Practice Event in Manchester expressed a feeling that they had been left out of the government's listening exercise, and that many were being excluded from involvement in CCGs, despite having the skills and local population knowledge that local commissioners should value. This was also a view supported by online feedback on the MiP website.
When told about this, Professor Field's response demonstrates why, as RCGP Chair, he earned a reputation for straight talking (in the past he has said that parents who smoke in cars are "committing a form of child abuse" and, on the topic of managing obesity, wrote "it would be better if people didn't become fat in the first place").
"What's your evidence of this? Just some of them telling you?" He says. "Whenever we met in the listening exercise with people, everyone we seemed to meet with wanted to be on the commissioning board, and everyone seemed to feel left out. Even those GPs who said they didn't want to be involved felt left out. So it was heartening that people wanted to get involved."
But shouldn't savvy GPs be actively including their managers? "Practice managers vary in their background, and experience and knowledge and skills, so undoubtedly there are some brilliant people out there and they need to be embraced and brought in," he says. "Then there will be others who, just like GPs, will want to get on with what they're doing in their practice. So what I would say is for CCGs to be successful they need to get the best talent from whichever background – manager, nurse, doctor – they can."
On the subject of engagement in the Forum's listening exercise, he says: "Certainly my practice manager met the prime minister, who came to our practice and we talked, and [the practice manager] was very involved in discussions."
Does he know how many practice managers attended at listening events? "At a number of meetings around the country we met lots of managers, but I didn't add it up," he says. The Department of Health similarly does not hold any such figures.
Government response and moving forward
Despite the early warnings, the Future Forum exercise has been seen as a success and Professor Field seems to have maintained his 'go-between' status, with both government and NHS figures lauding the report and critics of the Health Bill placated by its recommendations – particularly over the need for new safeguards against competition and 'cherry-picking' by the private sector.
The government has already announced it accepts the core recommendations and has announced a wide range of changes, including the phased transition to CCGs.
Professor Field admits that the report was "written in a language that would trigger change in the Bill" – and appears happy with the government's response. "I think on balance what we read so far is very, very good. And they are continuing to think through and do some of the work outside the bill," he says.
Ironically, for someone who seems to achieved such a positive outcome from it, Professor Field described the 'pause' period as "a destabilising period for the NHS and an unsettling time for staff and for patients."
He explains this was largely because of the confusion it wrought for willing CCGs. "It was difficult in that many of the pathfinders who wanted to move forward felt they were being held back," he says. "We heard that in some areas the PCTs and clusters immediately took grip and prevented any change locally. And it must have been very frustrating for the Department moving forward."
So, post-'pause', is he now optimistic the NHS will begin to stabilise? "I think having come out of it and looked at it, I think it was hugely helpful and clarified issues," he says.
He insists again that practice managers "have a key role and an ongoing role" in this. "But not just on the [CCG] board, it's about facilitating networks and the practices and the leadership role within each practice," he says. "Because the NHS is the sum of individuals and organisations."