After a year as Chair of the Royal College of GPs, Dr Clare Gerada's vocal criticism of the Health Bill has shaken up the establishment. She tells Stuart Gidden that standing up for GPs is her most crucial concern…
After a year as Chair of the Royal College of GPs, Dr Clare Gerada's vocal criticism of the Health Bill has shaken up the establishment. She tells Stuart Gidden that standing up for GPs is her most crucial concern…
After a year as Chair of the Royal College of GPs, Dr Clare Gerada's vocal criticism of the Health Bill has shaken up the establishment. She tells Stuart Gidden that standing up for GPs is her most crucial concern…
It is an ironic, yet perhaps incisive, endorsement of the first female to preside over the Royal College of GPs (RCGP) for more than 50 years. "At last," reads a GP's online post beneath a report that Dr Clare Gerada clashed with predecessor Professor Steve Field over her critical stance on NHS reform, "a chair with balls!"
Dr Gerada has certainly been a strident and outspoken ambassador for her profession in the short time – just over a year – she has held the post of RCGP Chair. Inevitably this was never going to be a low-profile tenure, coinciding with radical NHS reforms in England putting GPs in the financial driving seat of the health service.
Even so, the London GP of nearly 30 years' standing has made a particularly noticeable impression, with suggestions that GPs' "rationing" responsibility could lead to patients lobbying outside surgeries in protest and, more recently, that Andrew Lansley's plans for the NHS could lead to a health service more akin to a two-tier "budget airline" having hit the newspaper headlines. Her approach has won her plaudits, and she was recently named Women in the City's Woman of Achievement 2011 for her value-driven leadership.
We meet in late October at the RCGP annual conference in Liverpool, where Dr Gerada has made a typically forthright keynote address, calling for a "revolution in values" and for GPs to reject "the language of the market" and get "the actuaries, the risk adjusters and the shareholders out of the health service". It's precisely the kind of no-prisoners language that might ruffle feathers in Whitehall but has made her a popular figure among her peers.
In person, she is, as expected, upfront and to the point. On the subject of the Health and Social Care Bill, for instance, on which she has been a notable critic (a claim by the prime minister in September that the RCGP supported the thrust of the Health Bill was swiftly rebutted with an RCGP statement expressing "a number of concerns" including the risk of "an increase in damaging competition, an increase in health inequalities and massively increased costs"), she angrily rejects the notion that the bill's long passage through parliament could be potentially damaging to GPs wanting clarity and result in confusion over the current state-of-play.
"I can't bear people saying that," she says. "I don't know GPs who say they're confused. If we're heading down a motorway the wrong way we should get off at the next junction. Nobody has explained to me why we need to move on. The system is safe now."
The comments fly in the face of the views of such figures as GP Dr James Kingsland, the government's special adviser on commissioning, who recently told GP Business that "we've largely dismantled the old system" and "there's nothing to go back to" if the reform plans were not carried through.
Dr Gerada insists this isn't so. "We can stop now," she says. "We have primary care trust (PCT) clusters – very, very competent NHS management staff – engaging with the clinical commissioning groups (CCGs) in various degrees of readiness, doing superb stuff. Some are pushing forward, some are still in their infancy. Why don't we stay where we are? I don't understand people who say, 'we are where we are'. If I hear that one more time… We are where we are because they've moved so rapidly ahead of it going through the House of Lords."
She has far greater regard for the peers who debated the Health Bill in its second parliamentary reading in October 2011, praising the "spectacular discussions" that "restored my faith in the upper chamber". Around the time of these debates, the RCGP published a survey of its members that revealed 70% of nearly 2,000 respondents agreed with proposals by organisations including the British Medical Association (BMA) that the Health Bill should be withdrawn.
Despite such a majority view, Dr Gerada is quick to say the college "has never had a position" itself on this issue. However, she adds: "We've always said we've never been in doubt about commissioning being a good thing, that GPs should be involved. But I and many people have serious concerns about why we've gone down this route, spending £3-4bn just in redundancies and reorganisation in order to – what we know is going to happen – end up with more or less the same situation we started with but with more confusion because they'll be more statutory bodies and we'll have opened up the NHS to the market."
Purse strings
The latter point was a core theme of her conference address. "In this brave new cost-driven, competitive, managed-care world, I worry about the effect that the language of marketing is having on our clinical relationships," she said. She warned GPs of being "doubly jeopardised": having to choose between "the best interests of our patients and those of the CCG's purse".
This choice, she argues, could prove a distraction to what she sees as the vital wider role for GPs`in engagement with their communities, reducing health inequalities and becoming "social entrepreneurs".
Arguing that "provider reform" is more important than the government's commissioning reforms (which she says "will come and go") she explains this means GPs "looking at getting more resources into general practice, into the community, working with our hospital and nursing colleagues, freeing up resources in order to manage patients best".
Budgetary concerns, she believes, will serve to obstruct this objective. "What worries me is that our conversations and our clinical meetings are now going to be dominated by, 'How much money did we save the PCT or the CCG?'"
She shares concerns over the "perverse" and "unethical" quality premium – the government's proposed financial 'mechanism' for rewarding CCGs for "good performance", as the Department of Health puts it – to those expressed in the last issue of GP Business by Dr Laurence Buckman, Chairman of the British Medical Association's GPs' Committee.
"Clearly we are rewarded in the QOF (Quality and Outcomes Framework), but that is for delivering evidence-based medicine against a series of targets and standards that have been agreed are in the patients' best interests," she says. "But this [the quality premium] is about getting a reward for a behaviour that may not be in the patient's best interests. It will perversely affect the way we interact with our patients, it just will. And the patients rightly will be worried."
The Liverpool speech warned of the dangers of moving towards a US-style healthcare system (Dr Gerada said the US market had achieved the "remarkable double whammy" of having the most expensive system in the world and the greatest health inequalities) and she echoes this concern when she says: "If you look at America, they use quality premiums, they use all sorts of incentives to try and stop their doctors using resources."
But is really realistic to compare Lansley's envisioned UK healthcare system with that of the US? "Well, not in all ways, I don't want to scaremonger," she says, before adding: "But CCGs are like HMOs [US health maintenance organisations]. If you think about it, the NHS Commissioning Board is essentially the insurer; it is actually handing out resources to membership groups, which are CCGs. And they will be the ones that will determine what services will be provided for that sum of money."
The market-driven health system in the Netherlands, she says, has likewise seen "massively increased cost, reduced access and increased inequalities" since its introduction six years ago. Dr Gerada believes that "unfettered competition" in the UK would lead to similar outcomes. She staunchly defends the NHS, which she says has "worked with limited amount of transaction costs, and has delivered some of the highest quality outcomes at the lowest cost. And I think the government has to answer the questions, why are we doing this [reforming the system]? Not the rhetoric, but why?"
Standing up
Such comments may inevitably draw criticism that she is taking the RCGP in a more political direction, a markedly different path from that of predecessors such as Professor Field. But she defends the suggestion she is driving the college towards a critical space already inhabited by the BMA.
"When I was elected chair I never imagined for one moment that the Health Bill would define my first year in office so fully," she says. "It has made understand why leaders don't always want to speak out. However, I really believe it is so important for leaders to stand up and be counted, and to point out the risks and benefits of government policy as they are presented to us.
"It's not about party politics, or opposing the government – it's about representing the views of our membership and doing everything we can to ensure that GPs remain able to provide the best possible care to our patients, when and where they need it the most."
She appears driven by a passion for patient care, describing the consultation process as "the magic that goes on between us and the patient" and insists this is the only bottom line that matters. After a tumultuous year, Dr Gerada feels "proud" to represent GPs, and says she hopes she does their views justice in her role.
"But above all else, I am keenly aware of my responsibility to the profession, and in ensuring the continuance of high-quality generalist care in the NHS of the future. I know this depends on getting more GPs, with more training, spending time with their patients and their communities."
"If I achieve that," Dr Gerada adds, "I'll know I've done a good job."
