As the Health and Social Care Bill in England continues its record-breaking period of scrutiny (it has spent longer going through parliament than any public bill since 1997), Professor Steve Field has already played a vital role in its development. But with so many GPs, peers, ministers, critics and commentators still arguing over the ramifications of the legislation, is he caught in the middle?
As the Health and Social Care Bill in England continues its record-breaking period of scrutiny (it has spent longer going through parliament than any public bill since 1997), Professor Steve Field has already played a vital role in its development. But with so many GPs, peers, ministers, critics and commentators still arguing over the ramifications of the legislation, is he caught in the middle?
A practising GP partner in inner city Birmingham and the immediate past chair of the Royal College of GPs (RCGP), Field's commitment to general practice ensured wide popularity with peers. Yet most recently, as Chair of the NHS Future Forum that conducted the government's 'listening exercise' during the Health Bill's 'pause' through parliament, he has been seen as an establishment figure and has even faced criticism of being a government stooge.
Widely credited with combining authority with a straight talking 'common touch' (he raised his national profile when he said parents who smoke in cars are "committing a form of child abuse"), he seems to acknowledge the dangers of his Forum role when he jokes about advice he was given against the job offer. "A lot of people told me 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."
This isn't true of course. In addition to his fulltime role as a GP, Field also chairs the National Inclusion Health Board, a Department of Health body that advises on improving health outcomes for the most vulnerable, such as the homeless.
And now the government has asked him to continue his role on the NHS Future Forum, a 50-strong (and counting) panel of clinicians and NHS representatives that will carry on listening to patients, service users and professionals on four new topics: information, education and training, integrated care and public health.
Chairing the Future Forum has made Field a powerful figure across the entire health service. He describes his appointment "an honour" and is proud of the Forum's "hugely helpful" achievement over the summer in "clarifying issues" around the Health Bill.
He calls the listening exercise, which was an unprecedented decision that arguably weakened the health secretary's authority and stoked up opposition to the bill, "an important and historical moment".
He says: "I am actually on record as supporting the principles of the bill, but I do believe that, having heard a lot of people's views, this [listening exercise] needed to happen so that we could make the health service move forward in the right way."
Critics suggested 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 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 [Forum] teams heard."
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.
Was the experience what he expected? "Well, I didn't know what to expect when I was asked," he says. He first heard about the exercise on a train journey when a minister rang him to discuss "the four areas the prime minister wants you to lead on" – education and training, choice and competition ("obviously a thorny issue"), patient and public involvement and clinical leadership.
"It seemed to be an important thing to do," he says. "When I met the following day with the prime minister and Andrew Lansley, it became clearer what was needed."
Play continued
Published earlier this year in June, the Future Forum's recommendations have been largely adopted by the government. As a result, there will be a more phased transition to clinical commissioning groups (CCGs) instead of the former insistence that all such groups replace primary care trusts (PCTs) by April 2013.
But Field is explicit that GPs must take up the mantle and get on with it. "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," he says. "I do believe the commissioning group idea is the way forward and I think people should aim for April 2013."
He acknowledges that the risk of delaying the transition to CCGs might leave the new NHS Commissioning Board, headed by Sir David Nicholson (see interview this issue), with an unwelcome dominance. "The danger would be that, you know, why should the Commissioning Board want to give up [control]?" he says.
"You don't want a too centralised system so there's a balance between the two. I believe professional 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."
He appears to see a direct correlation between the role of CCGs and a doctor's duty of care. "If we don't get the local engagement and leadership from GPs and clinicians, I think patients won't be getting the best service they should be getting," he says. "So I think professionally we should be taking a leadership role and pushing forward there."
Competitive edge
A headline recommendation of the Future Forum report was that the bill should be amended with regards to the role of Monitor, the independent sector regulator. Monitor's core duty will now be to "protect and promote the interests of patients", not to promote competition as if it were an end in itself. In addition, new safeguards against price competition, cherry picking and privatisation will be introduced.
This failed to satisfy all critics. In early September Dr Hamish Meldrum, BMA Chair, wrote a letter to MPs warning that despite the changes, there "continues to be an inappropriate and misguided reliance on 'market forces' to shape services", with the bill embedding "a more central role for choice without a full consideration of the consequences".
Field, however, is mollified. "I think the government's response is appropriate," he says. "I think the recognition, when we were listening, was that competition had a place but needed to be managed."
While the BMA has criticised the "threatening and unnecessary powers" given to Monitor, and believes its primary role should be around integration, Field believes it does have an important function to play where competition is concerned. "We know we need a sector regulator, we know that protects us from the OFT – and to some degree European competition law – and that if we've got a good sector regulator managing the system properly it should allow us to do what we need to do," he says.
What does he think to the relationship between general practice and market forces? "I believe competition has a place but it's not the be all and end all. We know that some competition helps. And after all, we've had competition between the 8,000-plus GP surgeries for years. But what we should be doing is trying to provide much more seamless services for patients."
Bureaucracy charges
The reformed NHS appears to some, however, to be far from seamless. This was recently suggested by none other than Field's successor as RCGP Chair, Dr Clare Gerada, who told a Public Bill Committee that post-'pause' the number of NHS statutory organisations has increased from 163 to 521 and said this had the effect of "massively increasing the bureaucracy… within the new NHS". For CCGs, Gerada said such an environment is "neither liberating nor controlling. It neither allows for GPs to be innovative, nor does it give them tight restraints."
Field vehemently denies that an increasing number of NHS organisations could limit GPs' commissioning powers. "Nobody knows how many statutory bodies there are going to be, because we don't know how many consortia there are going to be," he said. "But the number will be less than the number of PCTs and SHAs, I'm sure."
Field also denies that clinical senates – collections of clinical specialists recommended by the Future Forum to advise CCGs – would add to any structural complexity. In any case, he says, there are only 15 senates in England, which "will help because they'll link in to the networks to provide a forum for people to talk, to help plan services and assist. But they're not a statutory body and they're not a bureaucratic block on change."
Next phase
Whatever happens to the bill now, the Future Forum exercise has been seen largely as a success. Field seems to have maintained his 'go-between' status, with both government and NHS figures lauding the report and even the fiercest critics of the Health Bill at least acknowledging it has, to a great degree, altered the course of the debate.
Field admits 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 have achieved such status 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 mainly 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."
Now begins listening phase two. "It's more about how you can improve the delivery and implementation of policy, rather than, in the first phase, what the bill and the policy is," he says. What might more listening uncover? Field suggests public health will be key. "What are the roles of professionals in improving the public's health, in hospitals and in primary care?" He asks. "That's an area I think there's scope to listen to different views coming forward."
The Forum is due to report to ministers again later in the year. No doubt they will be all ears.
A different version of this interview appeared in Management in Practice magazine.
