Read the full transcript of Pulse's exclusive interview with incoming RCGP chair Dr Clare Gerada.
What are your priorities as chair, and where will your energies be most focussed?
Three areas I was most concerned about which I said when I was pitching to be college chair are preservation of the generalist, I am absolutely convinced that the role of the generalist is the most important role within the NHS, and is one that is always under threat because patients think if they go to a specialist they might get a better service. In the next three years I will do everything in my power to make the role of the generalist stronger than when I came in. Second is about supporting leadership roles in the next generation. First Five [an RCGP scheme for young doctors], and the whole profession. I am also concerned about promoting training for GPs, and in particular five year training for GPs.
Obviously the white paper has been published since I became chair-elect and I will be working incredibly hard to make sure I shape the white paper so we can preserve the best of general practice and the best of the NHS. And actually make things better for patients.
You recently described GPs as being like ‘rabbits in the headlights' in relation to the white paper plans. What do you gauge the mood of the profession to be now, and where do you stand on the GP commissioning proposals?
It was a bit unfortunate saying rabbits in the headlights. What I meant was I think that GPs are rightly concerned about what the white paper means to them and their advocacy role for patients, and them as the profession of general practice. I have absolutely no doubts that GPs will rise to the challenge. What I am concerned about is that GPs will be blamed for the issues in front of them, for over-referring, over-prescribing, and in that blame they will be corralled, forced to limit their prescribing, forced to use referral management centres, they will not able to refer to named consultants, or consultants at all, under the guise of demand reduction. I am concerned about that because I think it pressurises GPs and it isn't a good way forward. So there are lots of risks around the white paper, and in my mind, one of the big unsaid risks is to us as GPs being corralled and de-professionalised.
We've heard a lot this week about the role GPs will be expected to play in rationing services. What are your views on the proposals, and what concerns, if any, do you have about GPs' being expected to take a lead on this?
I am very, very concerned about what I'm reading about NICE. I think if anything. NICE needs a much, much stronger role. I am concerned, as many GPs are, that we will be lobbied by patients, and quite rightly, we are the patients advocate, but we will be put now in the invidious position of having to always be the patients advocate but at the same time be mindful of the cost it's going to be for the consortia. I think NICE protects us, it's the only organisation that can put into context cost and quality alongside, and I am absolutely convinced that NICE needs to be strengthened not reduced. And I am very, very anxious that that seems to be the opposite direction. I'm long enough in the tooth as a GP to have worked pre-NICE, and I know what postcode lottery is about and I practised in Lambeth in a place that didn't have access to the same opportunities as other more leafier areas and I'm very concerned about that.
Pulse's campaign is calling for GP consortia to be given a clean slate financially when they take on commissioning. Is it feasible for GPs to inherit debts from PCTs, or are you concerned that it could create inequalities?
Clearly it will create inequalities and clearly it's very complicated because where does a GP commissioning group, and particularly where do individual GPs lie in the responsibility for that overspend. I would hope that all of this is going to be sorted out during the transition period because the last thing you want is for GPs to be inheriting debt. I think that's a non-starter. It's not up to us at the College to work out what should be done. That's up to elected Government, they have brought in the white paper and they need to sort it out. From my point of view, anything that detracts from GPs being able to deliver holistic care to patients across the domains of physical, social and psychological care from cradle to grave is a non-starter. If consortia inherit debt which means they start off not being able to deliver excellent care then clearly the college will have a role in speaking out. But it's up to the Government to sort out the mechanics of that.
Based on what you've heard from Andrew Lansley to date, are you satisfied that his vision is the right one? Which areas of the white paper are you most concerned about?
Let's be clear. I think we as GPs have been asking for years to be placed at the centre of making decisions about our patients. So I think we are actually getting what we asked for. There is a maxim which says ‘be careful what you wish for' and I am concerned as many people are about the extent of the white paper. The white paper is a revolution. Some revolutions end well, some end badly, but all are dramatic. I don't revolution is about putting GPs at the centre of commissioning. We can stand up to that, we've done it before. I think the revolution is abolishing PCTs, SHAs, putting public health into local Government all at the same time. I think against a time when we're seeing a 45% reduction in management costs, and £20bn saving, that is the revolution and that is what concerns people. I sometimes worry we are spending an awful lot of money to be at a place in a few years time where we are now, but just with bigger PCTs and less management. There might possibly be simpler ways of doing this.
What needs to be in place to ensure the transition goes as smoothly as possible?
The transition is going to be the most difficult time. It's very easy to shut down a PCT, it's much harder to keep a PCT open long enough to be able to shut it properly. And I think PCTs at the moment, which have some very talented managers, are trying to make things as safe as possible during the transition and actually trying to get rid of some of their deficit and trying to put in place systems so that GP consortia can take over in a safe way. But I have concerns, there are only two years to turn the NHS upside down, and there will be an awful lot of things that come out of the woodwork which nobody has thought about that could put patients at risk and could put GPs and doctors at risk. In terms of mitigating, I think one of the most important areas is to get patients on side. If there's one thing I'd recommend for consortia and practices to, it is to set up patient participation groups, because we absolutely have to get patients and the public on side. Patients have got to understand what's going on. At the College, we are working very closely through our new centre of commissioning to produce the patient information. I think we need to make sure patients know as much as we can know what's going on and what they should be expecting.
Where do you stand on the Government's choice agenda, the abolition of boundaries and the any willing provider policy?
I think choice is a well meaning policy but I think it's misguided. I think patients of course have to have a choice and decision about what treatment they get. That choice and ability to deliver that choice is done in the consultation. But the idea that patients can have any provider, any practice, any treatment, any hospital, I think is a misnomer and I don't think its deliverable. And I'm not sure it's actually what patients want. I think it's a well-meaning but misguided policy. With respect to choice of GP, the College has always been in favour of the registered list. Having a patient who can go from one GP to another doesn't do continuity of care well, I think it creates all sorts of problems. That doesn't mean that patients can't access, we now have walk-in-centres where they can be unregistered. That's absolutely fine and young people like to access care that's 24 hours, but the idea of losing the registered list is something that I will work incredibly hard over my three year tenure to not allow to be put in place.
We've had some discussions clearly in our white paper response around the involvement of the private sector. I'd like to reassure. People often say, ‘GPs are private contractors', GPs use their small surplus in order to pay themselves. If they switch the light off they take home more, and if they use a colour photocopier they take home less. People often say, GPs are private providers. No they are not. They are public servants who deliver care through that quirk of the NHS. So we did have a discussion. And there are of course anxieties about bringing in any willing provider, and of course there are anxieties about involving external providers and removing money from the NHS.
Following its consultation on revalidation, the GMC claimed it had support for all the key aspects of the process. Are they right to, or do you feel there are some elements that remain too bureaucratic?
Let's be clear. Revalidation is important, revalidation will reassure the public and reassure doctors that they keep up-to-date and they maintain their skills. The college is not about producing a monster of bureaucracy for GPs to go through. I promise it will be sensible, it will be fit for purpose. However, I do have concerns that unless we get a system of remediation alongside revalidation that what we're doing is in a sense what's always been done which is load up the dice around monitoring, regulation, control versus doing what I think needs to be done, alongside that rather urgently, which is around support and remediation, especially now that we're asking GPs to take on phenomenal responsibilities. So whilst I think revalidation needs to come in and it's a bit of an embarrassment because its been discussed at every council for about the past ten years, we need to also put in place a system for supporting doctors and I think that has to be in place at the same time as revalidation.
How long do you see that taking?
The timescale for revalidation is now April 2012. I would hope we'd be able to put in place a robust system of support and remediation for doctors along the same timescale. Many of your listeners and readers will know that I run a practitioner health programme which is the sick doctors' service, which has seen over 450 doctors and dentists in the last two years. Unfortunately its funding is not secure and it is the only support system that provides confidential advice. I would hope that the NHS, at the very least would put a system in place that gives doctors a confidential place to get support.
The BMA said this morning that revalidation pilots are running into the sand, with some people dropping out, due to frustrations with the revalidation toolkit. What do you know of these issues? Could they derail the plans?
I must say I don't know of those issues. I'm very happy to take the question and get back to you. The last I knew the pilots were running along ok, but if the BMA know something I don't then I'd like to research that a bit more.
We recently learnt that the RCGP has commissioned academics from King's College to investigate possible racial and sex biases in its MRCGP exam. Based on the feedback so far, is the College thinking about modifying the exam?
Let's be clear. The College exam does not have a bias around racial or sexual issues. Where there is a difference, and where all the postgraduate exams across all the colleges have, is a difference between doctors who qualified in the UK versus doctors who qualified overseas. The college are very, very keen to learn why that may be, and if it is bias because of anything to do with ethnicity or racial factors we need to amend that. It's the same for all the postgraduate exams across the board. With respect to what the results are, I don't know.
We recently reported that millions of pounds of funding is being stripped from GP education budgets. How concerned are you about this, and what evidence have you seen of how the cuts are affecting GP training?
I haven't myself noticed any. What I do say though is I'm absolutely committed to promoting five year training for GPs. We have to be good managers and commissioners at the same time and expected to do that in a 3 year window to me seems absolutely ridiculous. Whether money is an issue, I think one has to look at the quality of care that's being delivered to patients. Patient safety, and also GPs retention and recruitment.
The College recently revealed plans to develop a new centre to train GPs to run commissioning consortia. How are these plans progressing, what is the interest level like?
We're setting up an RCGP centre for commissioning, and it's around delivering support right from GPs who have just qualified right up to those who are leading commissioning groups. We are working with partners, at the moment we're working with the NHS institute of innovation to develop a whole curriculum around that, but also we're working with patient groups, we're looking at other areas such as leadership training. It is progressing, it's a very rapid timescale because clearly the first pilot sites are going to be up and running in April. We'll be letting you know more as time goes on.
How are talks with other colleges about the plans progressing? Where are tensions most keenly felt?
Can I just say, it's absolutely imperative that we don't commission in isolation. We have to commission in collaboration with our specialist colleagues and our social health colleagues, and that is what the College is doing as well. And I have been working very hard with the royal college of physicians, we produced teams without walls abut two years and we're taking that work forward. Now, currently, we're looking at integrated care organisations and the barriers to setting those up. We're working with the royal college of psychiatrists to look at good commissioning around whole areas of mental health. It is absolutely imperative, because if we put a split between primary and secondary, or primary and specialist, then I think we are going to run into serious problems. So the Colleges are doing it, and I would expect GP consortia to be doing it and also GP practices to do it.
The main tensions are going to be external organisations offering to take over the commissioning role of the GPs, and having GPs as merely advisors. And also, external advisors possibly also asking to take over the contracting and procurement in areas and I think that is a tension, and if this is going to work it has to be clinical commissioning, it has to involve partners around the specialist domains. I think if GPs go and close a hospital without involving patients and without involving specialist colleagues then they are onto hiding to nothing. They have to do it in partnership, this is about out NHS, our patients and our community. It is not GP commissioning, it is our NHS. If you get hospitals and specialists on side then everyone wants to do this together and everyone wants to make things better. It has to be collaborative. If there are tensions, if you get patients and patient groups involved and actually explain to them what's going on, they'll be your best advocates. And if you have to close a hospital or wards, or services, and you can explain why that's happening together, then I think it will be far easier than if GP commissioning groups, which I don't think they will do because I think GPs are collaborative anyway, but if they do, it will run into trouble.
Federations. How will they fit into commissioning agenda?
I think the federations document is absolutely excellent. I urge people to go online and look at it. Federations I see as provider units, at the moment they're provider units of GPs providing primary care services, within a consortia, but there is nothing stopping federations inviting other providers and pulling in social care providers, community care providers, specialist providers and actually tendering, putting themselves in a position to bid for services that will be commissioned by the commissioning groups. Then they'll be in a very strong position. I also think as things pan out federations are going to be a powerful force where patient groups can sit. So, I think they are actually going to be far more important in the future than they may seem at the moment. Watch this space.
Will they go some way to alleviating conflicts of interest?
I think GPs have always married the commissioning and the provider role at the same time. Clearly every time we write a prescription for a patient we are commissioners and every time we see a patient in the surgery we are a provider, and we've always managed to do that really well. The problem now is that we're actually going to be commissioning large healthcare and I think that's where the conflict might come on, and there has to be a split to make sure that GP commissioners are not just commissioning themselves to do the provision. There could potentially be a tension with that. At the same time, I think you mustn't put too many bureaucratic handcuffs on because clearly GP federations can provide services, for example, community nursing services, and so, why not? They are well placed to understand the needs of their population.
Dr Clare Gerada
