Jeremy Hunt at Pulse Live: ‘If I was a doctor, I’d want to be a GP’

Jaimie Kaffash, editor of Pulse: The first question is I think it’s probably fair to say you weren’t the most popular among GPs or junior doctors when you were health secretary – so how can you now say that you’re the saviour of primary care?

Former health secretary Jeremy Hunt: I don’t think I’m the leader of the campaign to rebuild general practice, but thank you for attributing me to that. I’m very proud to support them. I agree with what they’re doing. I can understand why I wasn’t popular with junior doctors, because we had a very bitter strike, which I was very sad that we had when I was health secretary.

With GPs, I did try very hard to address some of the big issues in general practice, and I wasn’t anything like as successful as I wanted to be. And I think the thing that probably is most notorious in the minds of the audience is my promise in 2015 – the first speech I gave after the General Election – to recruit 5,000 GPs by 2020. And when I left office three years later, we’d only got an extra 300. And in fact, since then, we’ve gone backwards, you know, 1,500 fewer GPs.

And I hold myself completely responsible for the failure to deliver that. But also I hope that people understand that my commitment to doing it was because I really do believe in general practice. I think it’s the best thing about the NHS, as far as the public are concerned. And also it’s the secret to the success of the NHS in the long run, because general practices are now preventative. Without general practice, the NHS won’t be as sustainable and hospitals will fall over.

So I’m sure we’re going to talk about it. But, you know, I’ve done lots of reflection about why I wasn’t successful in that pledge. And I’ve talked about it often because I really do want the Government to be more successful than I was in expanding the capacity of general practice.

JK: So what conclusions did you come to in those reflections and what would you have have done differently? And, perhaps even more importantly, what can be done to reverse the current situation?

JH: Well, so, a very specific observation, and then a more general one. You don’t make promises as Secretary of State to have 5,000 more doctors or 50,000 more nurses or whatever the promise is, unless your officials have advised you if it’s possible, and if you’re planning to deliver it.

So it wasn’t a number that was plucked out of the air. And we all believed that we were going to get an extra 5,000 doctors into general practice. What happened was we succeeded in increasing the number of doctors leaving medical school going into general practice to 3,250, which ended up being about half of all medical school graduates.

So that we did exactly as planned. But what happened at the same time, which was not planned, was a very big increase in the number of GPs taking early retirement, or new GPs deciding to go part-time, or older GPs deciding to go part-time. And we didn’t expect that to happen. And I think that’s what we have to think hardest about.

I think we have a crisis at the moment in general practice. I think if you look at the statistics, that people like Martin Marshall would say, burnout is a massive issue – 61% of GPs say their mental health has declined over the last few years, a further 60% say they’re not expecting to be in general practice in five years’ time.

And, you know, a third of them, I’m sure Martin Marshall has probably said today, feel they can’t cope with their workload once or twice a week. And I actually had the conversation with a GP that has just got a CCT. And I asked him a question – I asked him how many of the people he qualified with are working a full five day week. And he said he didn’t think any were. Maybe one in his entire group. Or maybe none.

And I said: “why is that? Is that a kind of millennial thing where people just want to work part time?”. And it’s absolutely not. He said if you’re seeing 40 patients in ten minutes slots in one day, you have to make a decision at the end of each ten minutes. You really worry.

You’re going to get tired, you’re going to make a mistake, and a patient is going to get harmed, and he said there is moral injury in continuing to work too hard for too long hours because you’re worried that you’re going to do damage to a patient. And he said it’s just not possible to work at that level of intensity for five days a week. And I think we have to recognise that the traditional model of general practice is broken.

And if we want general practice to be at the heart of the future of the NHS, as I personally very strongly do, then we have to think about how we can reduce that pressure, so that people don’t do the job and say: ‘I can’t manage to do more than three days a week’. And so that we bring back this, I think, Chaand Nagpaul once described to me, we bring back the joy into the profession that lots of older GPs remember. And I think that’s the heart of it. It’s the retention issue, rather than the recruitment of new GPs that’s the heart of our issue.

JK: The point about general practice being broken is a really interesting one and one I want to come back to. But in the more immediate term, you did talk about five-day working. Obviously in your time, you did push for full weekend work as well. I think everyone here will know that the new GP contract does stipulate that anyone who’s part of the PCN will have to offer nine to five on Saturday. Considering the current workforce pressures, do you think that this is actually feasible? Or do you think that we should be concentrating on the routine work Monday to Friday?

JH: I think we have to make a distinction between the availability of the NHS, which has to be 24/7.

And we have to make sure that we avoid weekend effects. We know that things go wrong at any time – you can’t guarantee that’s going to be on a weekday. We have to differentiate that from the workload of individual doctors, which has to be on a sustainable basis.

And I know that among some people I’m notorious for talking about seven day working weeks. But it was never, from my perspective, about asking people to work longer hours, and it was focused – that particular debate was focused on hospital issues.

For me, if you asked me what my priority would be, I fully understand that with changes in working patterns, there are going to be some people who can only see the GP on the weekends. And there will be some people who need to see their GP in the evenings, and we need to make sure that totality of our offer, that we have an opportunity for those people to get a consultation.

But for me, there is a much bigger priority, which is continuity of care. I think that the Norway stuff from last year provides the clearest evidence, but there are many, many more studies before that, that people who see the same GP over many years are 30% less likely to go to hospital, 30% less likely to use out of hours services, and 25% less likely to die. And so of course, having a family doctor is something that’s appealing to patients.

And by the way, I’m not saying that you should always see the same doctor. I’m not saying this is a right to always see. But I think it is important that we go back to everyone having one doctor who’s responsible for their care, even if that care will be provided by different people. It might be provided by a practice nurse, it might be provided by weekend cover, it might be provided by different people at different moments, but going back to that principle of everyone having one doctor responsible for their care, I think there’s now very, very strong clinical evidence that that’s the way to go.

But I also think, if we’re talking about bringing the magic back into general practice, I think the thing that’s amazing about this job, and it might seem really a sick joke to talk to exhausted GPs about the magic of their work, but, if I was a doctor, heaven forbid, I imagine you’re all thinking, but if I was a doctor, I think I’d want to be a GP.

Because you have that longstanding relationship with people over many years, with people in their families, which is something that hospital doctors don’t have. And I think that’s a special thing. And I think that’s the heart of general practice, putting them in the community. And so that’s what I hope we can find a way of rediscovering.

JK: I think many GPs would agree that continuity of care is the essence of general practice, and I think many would say that it was actually through your time there that we did see a lessening of continuity of care. And it was, as I said, a push for extended hours, for greater access. And again, we’re sort of seeing that again now, with greater access. Do you think that continuity is possible, while at the same time trying to extend access?

JH: So first of all, during my time, I did try very hard to move towards continuity of care. We brought back everyone having a named GP. I don’t think it’s worked, I don’t think it’s happened in the way that I was hoping it would. And the reason is capacity.

And so if you’re asking me what would I prioritise, weekend access or evening access or continuity of care, I would prioritise continuity of care. How do we get there? We need to increase the capacity of the system.

And I think this is the second point that I would make about workforce planning. I think we have to recognise if it takes ten years to train a GP, that the number of GPs we train, we need to find a way of taking us out of the Parliamentary five-year cycle, and making sure that there’s a discipline on governments always to have for the future.

Now, when I was health secretary, we selected five new medical schools that have big increases in the number of doctors and training bases. But I think the truth is that this is something that has been neglected by different governments over very many years.

And that’s why I was very disappointed that yesterday the Government voted down the amendment I, [former NHS England chief executive] Simon Stevens and many other people wanted, supported by the BMA, the RCGP and many other people, that there should be independent analysis done every two years, as to how many doctors and nurses are in every specialty, how many midwives as well, how many people in social care, in the NHS, that we should be training for five, 10, 15, 20 years a head.

It’s then up to the Government to decide whether it wants to meet those numbers. But I think it’s really bad that we don’t have those numbers in the public arena so that we can see whether or not we’re training enough doctors for the future. And I think that’s a really important reform that needs to happen.

JK: Of course. Slightly moving away from workforce, the big thing over the past year has been the health secretary’s push for more face-to-face appointments, and I’d say that the majority of GPs would probably say that this has been sort of fuelled by a bit of media panic.

First of all, do you think he’s right to criticise GPs for a lack of face-to-face appointments? And secondly is he right to push for more face-to-face appointments?

JH: Well, you know, I think that patients, of course, should have a right to get in front of their GP. But I think we also have to recognise some of the trade-offs involved. And the first thing I would say is that if you are trying to encourage a GP in his or her 30s to work five days rather than three days, if you’ve got young kids, for example, being able to do appointments from home, being able to access your system and records from home for a couple of days a week might be a way that you can get an extra couple of days’ work out of someone. Otherwise, they’ll say actually I’ll go down to three days.

So I think we need to make it easier for people to stay engaged in the workforce longer. And I would say that, going back to the continuity of care point, one of the problems at the moment in structure is that the only real way you can get total flexibility over your powers is by becoming a locum, which, of course is terrible for continuity of care.

And we need to make it much easier for people to work part-time without having to become a locum. And, indeed, being able to do some of your appointments virtually is part of that.

I really don’t like this entire debate about face-to-face versus virtual. I think there are some people whose virtual appointments are more convenient, for example if they’re at work or travelling or something like that.

But most importantly, I think it goes back to the point that we were talking about earlier. When it comes to continuity of care, if patients were seeing or talking to their own GP, then many would be very happy with a phone call or a video conversation.

What worries us is if they’re talking to a doctor who doesn’t know them from Adam, and they’ll probably never see again. I’ve called this the ‘Uberisation’ of general practice, so, say, you’re seeing the GP with the same frequency as you would see the same Uber driver, and I think that’s a terrible step back and that’s partly what is driving patient worries.

So I would say that we need to take a look – I don’t think you can restore continuity of care overnight – as I say, there are big capacity issues that need to be overcome to get there. But once you start addressing that issue, then it becomes not just easier, but something that patients will be enthusiastic about having, is virtual ones, because they’re very often more convenient for them as well.

JK: Sajid Javid is currently in favour of GPs working under hospital trusts. Firstly, is this something that you think is a good idea? And secondly, would you be in favour of a salaried GP service?

JH: I think that there are parts of the country where GPs do work for trusts, and I believe very successfully. So, Salford is one where I think all but one, maybe all practices in Salford now are part of the Salford Royal Hospital group, and it’s extremely well run, a CQC Outstanding hospital.

And that works very well for those GPs, and it works very well for patients because you have highly integrated care.

So I have absolutely no problem with that happening in parts of the country where it’s being experimented with.

But I would not be in favour of mandating that, because I’m a supporter of the partnership model.

And the reason I like the partnership model is because it injects an element of entrepreneurialism and innovation into general practice. What I found when I was travelling around the country as health secretary was that there was a lot of despair in the profession. But there were probably – and I’m plucking this number out of the air – maybe 10% of the practices, had the most extraordinary innovation, and fascinating things that were happening, and that was often because of the freedom of the partnership model.

Now in other practices, people felt so ground down by the intensity and the weight of work, that they didn’t really have the bandwidth to innovate. And that was, you know, that is a very worrying thing when you get to that point, but I think that there is so much innovation that’s made possible by the partnership model – I wouldn’t want to lose that.

JK: So as somebody who’s spoken in favour of the partnership model, what can we do to resurrect it if fewer GPs are wanting to go into partnership?

Firstly, what can we do to encourage GPs to go into that? And secondly, just to sort of cover again another bit of old plans, how do we get GPs in the system in the first place? What would you do if you were health secretary again, what’s the first thing you would do to try and increase the number of GPs?

JH: So I think the first thing is, it’s one those curious ones where you’ve got to start with a long-term solution, and then work back.

So in the long run, all modern healthcare systems need to be trained in the numbers of doctors, midwives and nurses that they need for the future. And it is completely ridiculous that the NHS is not, and we are importing doctors, and we have more than 300 NHS health workers from Somalia across the NHS, and I’m sure they do really make a brilliant contribution – our foreign-born doctors and nurses, we’d fall over without them.

But I think it is ethically dubious to depend on importing doctors and nurses from much poorer countries to sustain our health system when they’re often quite badly needed at home. So we need to be training enough doctors and nurses for the future – that’s step one. But then, of course, if it takes seven years to train a doctor, ten years to train a GP, you’ve then got to look for short-term measures.

And I think there are some things you can do on immigration – make it easier for countries like Canada and Germany where we know they have good health systems. I don’t know why we make them take their exams all over again. I think that we could make it easier from countries where we’re happy for people to come here from. But I will also say that we need to look at the retention issues that we’ve just been talking about, we need to ensure we work full time, all those kinds of issues. So I think there’s a whole range of things we can do short term and long term.

People who become partners – what they like is the autonomy to innovate and have great ideas that can make a difference for their patients. And we make that very hard because we try and micromanage GPC with the GP contract. And I think we should look at scrapping QOF.

And I think we should still measure all the things that we measure in QOF – we should be transparent about what proportion of your patients are getting their diabetes tests, and so on. But we should look at replacing it with year of care contracts, which basically say that for, you know, based on people’s age and levels of social deprivation, you might get, you know, £500 a year for everyone between 80 and 90, and you know £70 a year for everyone under 40, whatever it is, but just try to give people sums of money and then give them the freedom and flexibility. And then be completely transparent about the metrics that matter to the NHS.

For example, the reduction of emergency admissions. I think that if a GP practice or a group of GP practices, perhaps a PCN, manages to reduce emergency admissions from their patients, by 20%, I don’t see why they shouldn’t benefit from the large amount of money that they have saved the NHS by doing that. And that’s when a prevention model starts to really work. And that’s what we need. I mean, GPs are the people who are making the NHS sustainable, they don’t play football, because they will keep people healthy and happy. And we need to give them the balance.

So one other point – because it’s going to be very difficult to get more GPs into the system in the short term, we need to be looking at other people who can help GPs do their work, GPs can leverage, who don’t take quite so long to get into the system.

So I think in the United States, for example, many GPs have a PA as a personal assistant, who works with them full time, who deals with all their admin after every appointment. And they might be someone who actually doesn’t have a medical qualification, but is able to work with and wants to get into medicine, maybe somebody who wants to go into healthcare management in the future. And they do, they work as a GPs’ – they call them physicians – they work as a physician’s PA, so not as a physician’s assistant. And that way, the GP doesn’t find that at the end of a day of seeing 40 patients, they’re having to do two hours of admin. And that makes the job more rewarding. So I think we need to be a lot more innovative about ways to allow our GPs to focus on their core work without having to be burdened by the admin.

JK: Of course, but this is something we’ve already tried. And we have been pushing through that additional roles reimbursement scheme to increase the number of non-GP healthcare professionals. And I would think it would be fair to say that it hasn’t worked – it certainly hasn’t reduced GP workload. I think a lot of GPs are probably asked about quite radical solutions.

Now getting rid of QOF sounds like an idea of a radical solution. Is there anything else out there? I’m sure there would be many GPs who would be pushing for the end of CQC inspections, that kind of thing. What else can we do about the very acute problem of GP workload, that potentially won’t be solved down by the line by GP in their 70s, or even other healthcare professionals in the short term? What can we do immediately about GP workload?

JH: I wouldn’t support getting rid of CQC inspections. I know that, you know, I introduced them, actually. So, it was in the wake of big stats. And I was asking myself the question, I wanted to make sure that we didn’t have another big stat.

And so it may well be that there are things that we can improve in the way that inspections work within general practice, I think that they have generally worked pretty well for hospitals as a kind of early warning system. And I think the issue with CQC inspections for general practice is that the inspector will come for just a day, and it’s very hard in a day’s visit to get to the bottom of the quality of advice being given to patients in a ten-minute consultation.

And so you can in the end look at more superficial things like how clean and tidy a waiting room is – not that that doesn’t matter, but you know, you can end up looking at those things rather than medical advice.

So I think the way that we would get better CQC inspections is by having better access to the data that really gets to the heart of the quality of clinical advice being given. I’m not a physician so, it’s not something I would be able to explain how it happens. But if you’re saying to me: ‘should we actively reduce bureaucracy?’, then absolutely. And I think there’s a lot of work that can be done on integration of medical records with hospital records, so that information that comes back from hospitals doesn’t have to be readmitted into someone’s GP medical record. By the way, thanks to our GP fraternity, we have some of the best longitudinal medical records in the world in this country.

And the NHS is hoping to steal a march on other healthcare systems in terms of our availability of medical records across the whole healthcare system. And the reason that we curiously might actually do that better than the United States, even though they generally better at care and they have much better hospital records, hospital records are not longitudinal – they are episodical. And in this country, we have standardised medical records that, you, as GPs, decided to put in place ignoring the Connected Health Project. And so that is going to be the heart of the NHS’s electronic revolution, but anyway lots we can do to reduce bureaucracy here.

JK: I think GPs will be glad to hear about at the end of QOF and CCQ! Can we also try appraisal and revalidation there as well?

JH: I didn’t say the end of CQC!

JK: Okay – how about revalidation while we’re on a roll?

JH: Well, I have to be really careful here because I’m sorry but appraisal and revalidations were another Jeremy Hunt decision. I think the principle of people being up to date with their training is a really important one. And there is a patient safety issue there, if people are not up to date with their training. If you’re saying to me, and that may well be the case, that it’s a very bureaucratic process, then we should change the process.

And we should make it an easy process that does what it’s intended to do, rather than bog everyone down in bureaucracy. And so I think that’s the way I would approach it.

JK: Okay, we’ve got a question from the audience. Obviously you were health secretary during most of the austerity measures – but it seems to have led to a two tier healthcare system. We’re seeing a lot more people going into going into private healthcare. First of all, is this something that you think to we need to be worried about? And if patients do want continuity of care and think going private is the most efficient way of doing it, is this something we need to be worried about?

JH: Yes. When you have long, long, waiting times for NHS care, people do go private, and I don’t blame Sajid Javid – this pandemic is huge. There was a big waiting list before. During my time in office, I think for most of the time, the proportion of people going private, or the number of people going private, was going down. But I think it will now go up – it has not been going up – because of the ways that we’ve gone in the pandemic. And this is a red flag – we need to recognise that unless we are offering the safest, highest quality care which people can access easily, then this will happen and it’s not a good thing.

So I think continuity of care is a is a very big thing for patients to feel they’ve got a doctor who knows them and their family. And that’s why I would start by making sure, certainly looking at continuity of care patients – the people who are in regular need of health advice. I think when it comes to younger people who are broadly healthy, it’s less important, but even that someone like me, I’m 55 and I hope I’m healthy, but I’ve got three kids who are seven, 10 and 11. So I think that continuity of care is one of the best ways that we can keep people in the NHS as I would like us to do.

JK: I’m going to touch on the pandemic now. Obviously we have gone through 25 minutes and only just mentioned the pandemic. So this is another question from the audience – as the longest serving health secretary, do you feel regret over the lack of preparation for the pandemic?

JH: I think, and I’ve reflected on this many times, we did lots of preparations for the pandemic. We did huge exercises involving hundreds of civil servants, and John Hopkins University said that the UK was the second-best prepared health system in the world for a pandemic, the best prepared being the United States. And so we thought we were well prepared. In reality, we weren’t.

And the reason is because there was groupthink about the type of pandemic that we would face. And all of us thought, in our heart of hearts, that the most likely pandemic we would face would be a flu pandemic. And so the big exercises that we did, the ones that involved ministers, all the recommendations were acted on, but, for example, we didn’t look at testing capacity, because that’s less relevant for flu pandemics. Flu spreads much more quickly in a shorter period of asymptomatic transmission.

So there are big lessons to be learned about being better prepared for the many different types of pandemic you can get. The countries that did handle Covid best were the ones that had direct experience with SARS and MERS, particularly in Asian countries. I think the other thing when you’ve got so many unknowns, as we had with Covid when it started, is that you have to be looking around the world for the places that were doing best, much more than we did. And when the pandemic broke out, we were looking at China because that was where it started.

And we thought there’s not too much we can learn from China, because it’s a communist country, it’s autocratic, the Government can do things there that it couldn’t do here. And so we didn’t really look hard enough at other countries in Asia that were democratic, like Taiwan, like South Korea, and see quickly that had we followed what they were doing, we might have been able to avoid some of those lockdowns and contain the pandemic much more effectively. So yes, there were lessons from my time in office, but I think there are also lessons from what happened when the pandemic actually broke out.

JK: We are coming towards the end. So just a couple more questions if that’s OK Jeremy. So we’ve seen you said in 2013 the public are more willing to trust changes if they’re proposed by clinicians. Now, obviously, in healthcare we’re seeing the phasing out of CCGs. Is this welcome? Is this in danger of devaluating primary care even further?

JH: I think that the Lansley reforms were well intentioned, but ultimately they were flawed for quite a few reasons. There were some good things about them. I think setting up NHS England as a separate body with a high degree of independence was a good thing. And I think we’re going to keep that – I think that’s worth doing. But the complexity of the commissioning was something that, in the end, doomed those structures, and I think what Andrew wanted to do was to put clinicians in charge of local commissioning through the CCGs.

But then, because a part of commissioning is GP services themselves, GPs can’t commission their own services, so we’ll give all that to NHS England. So you ended up with, right from the start, two different people commissioning care in their way.

And I think the model we’re going to now is ICSs, which I hope will be clinically led as well. But all the care in a particular area being commissioned by one group of people, so that we can join it up. So I think these structures are better.

What I would say is that the lesson from many years of NHS reforms, not just under this Government, but under previous Governments as well, is that what you need is complete clarity about what you want each area to do, and then you’ve got the autonomy to get on and do it.

You need to avoid the kind of micromanaging targets. And we’ve got more targets in the NHS than any other healthcare system in the world. And the problem with targets is it focuses people up on their bosses in the hierarchy, that’s why they like QOF as it’s another function targeted effectively, rather than focusing down on the patients in front of you.

JK: We have gone over time, so I’ll make this the last question. I’ll make this a nice soft one for you! You obviously went for the leadership of the Conservative Party before. If for some reason there happened to be a vacancy coming up soon, is it something you would be interested in again?

JH: I’m not quite sure whether GPs would welcome that or not, given the up and down relationship I’ve had over the years! But I haven’t ruled out going into back into frontline politics in the future. I have actually enjoyed being on the backbenches, much more than I thought. I found it incredibly rewarding doing the Health Select Committee; I’ve written a book on patient safety, which is going to be coming out in a few weeks’ time. So, you know, who knows what’s around the corner, but my focus is on all those key patient safety issues that we’ve been talking about in the last hour.

And by the way, I should mention that my Select Committee is doing an inquiry into the future of general practice now. So we are really focused on hopefully coming out with some good recommendations that can give Pulse readers hope for the future. That’s certainly our intention.