WHEN Tory Prime Minister Harold MacMillan was asked by a journalist what is most likely to blow governments off course, he famously said, "Events dear boy, events."
I am reminded of his pithy reply when I speak to Dr Clare Gerada exactly three months to the day since she assumed the position of Chair of Council of the Royal College of General Practitioners. For while she has been in post just 90 days, she was voted in before the last general election on a medical manifesto that nowhere mentioned health secretary Andrew Lansley and the handing of control of £80bn worth of health spending to the group of doctors she was elected to represent.
So have political events – what many are calling the biggest shake-up in the NHS’s history – blown her off course? "Yes they have, to a certain extent," she concedes. "I, like everyone else, believed there was going to be no new top-down reorganisation of the NHS. I still have the aspirations which I was voted in on, but clearly a reorganisation of the NHS where my profession has been put at centre stage has brought tremendous responsibilities. Ninety per cent of my time at the moment is spent doing commissioning."
"Doing commissioning" has involved getting to grips with the detail of the new government’s plans for the NHS in England, understanding their potential impact and responding to them on behalf of the RCGP. The reforms include abolishing all Primary Care Trusts (PCTs) and Strategic Health Authorities by 2013 and replacing them with 'consortia' of general practices. Primary care doctors in these consortia will then take charge of the NHS budget for mental health, hospital and community services.
While she has no doubt GPs will be able to handle any new responsibilities that come their way – and in fact has already set up the RCGP Centre for Commissioning to help them develop the skills they will need – Dr Gerada has questioned the need for such root-and-branch reform.
"I am absolutely delighted that my profession has been put at centre stage of influencing and planning the health service," she says. "Putting clinicians in that role is something we’ve asked for years and at the College we welcome that. It’s just that you could have achieved exactly the same thing by merging PCTs, capping management costs and putting GPs in the majority on the board. These things could have been achieved much more easily and more cheaply."
Dr Gerada has also expressed concerns at the speed at which the reforms are being pushed through, the potentially increased fragmentation of care, a reduced ability to provide co-ordinated comprehensive services and the fact that they will produce "a perverse postcode lottery that is based not on need but on resources".
What’s more, she believes that GPs, with their hands on the purse strings, may well be put into the public firing line when it comes to sticky financial issues such as health cuts or winter crises.
Voicing these concerns has pitched her into the middle of the political fray and garnered controversial headlines, describing her as an "outspoken opponent of reform". In one article she was quoted as suggesting the moves will signal the "end of the NHS as we know it".
Does she stand by that? "It will be the end, in a sense. We’ll see what the legislation says, but if you line the ducks up, so you have the commissioning consortia as the insurer, Any Willing Provider, patients able to register with any consortium, and with a personalised health budget, you’ve lined up an insurance-based model of a health service."
Ultimately, though, and despite the headlines, she remains hopeful. "I think the money is on that the outcome is not going to be altogether different from where we started, with GPs helping the commissioning agenda but not doing it," she says. "And I think, with GPs having the authority, things will be done without significant consultation, whereas in the past managers may have felt unable to deliver change because they were worried about GPs’ reaction. So it’s not a bad thing in that respect."
Daughter of a local GP
The government’s health agenda is a fact of life that must be faced, but Dr Gerada is also determined to make progress on her own agenda, the one she was elected on – which talked of preserving the role of the generalist, encouraging leadership in general practice, extending the length of GP training from three to five years, looking after troubled doctors and addressing social and health inequalities.
The latter, in particular, is a subject very close to her heart. It has run through her whole career as a GP – as a partner of a group of practices that specialise in providing care to deprived, inner-city populations – and stretches back to her upbringing in Peterborough, where on home visits with her GP father she witnessed first-hand the delivery of healthcare amid serious poverty and slum conditions.
Originally from Malta, her father brought the family to the UK from Nigeria in 1963 and set up as a single-handed doctor. At first his practice was in the front room of the family home – "Our front door was the entrance to the surgery, so I have always been immersed in patients" – and she started accompanying him on home visits at the age of nine. He would talk her through the cases and this helped lay the foundations for her future career.
At the same time he instilled in her an understanding that the GP was very much a part of the community. "People would come round who were struggling and you would help them. I would sometimes go and sit with them and babysit their kids. That’s what being the local GP’s daughter was."
She loved what her father did and there was never any question but that she would study medicine. After finishing at University College London, she did house jobs at the Whittington before training in psychiatry. At the Maudsley and Royal Bethlem psychiatric hospitals, she developed a strong interest in treating patients with addiction problems.
But even as she progressed in psychiatry she kept finding herself setting up and working in community-based services. Finally the penny dropped. "Every job I did just drew me more and more towards general practice. I missed looking after kids and pregnant women. I used to run a service for pregnant drug users, and I thought, why am I doing this? And then I ran a barefoot service for drug users, providing GP services in a street agency. And you know, that’s general practice – so I decided I might as well do that."
She joined the Hurley Clinic in Lambeth and as part of her work there immediately set about developing the Consultancy Liaison Addiction Service, a shared-care substance misuse service providing support to GPs in delivering effective care to drug users. It is a service that has since been replicated across the country.
Perhaps because she has always taken the widest view of what general practice is about, Dr Gerada has throughout her career made 'extracurricular' medical contributions, whether it was sitting on her LMC, acting as a senior policy advisor to the Department of Health or being on the board of the South London Faculty of the RCGP.
"I’ve always done national stuff, middle stuff and GP stuff, all at the same time," she says. “I don’t know why. I think it’s just because it’s there."
Whatever her reasons, it was a drive that resulted in her proudest achievements to date. In 2000, she established the RCGP’s groundbreaking Substance Misuse Unit as well as the Certificate in Substance Misuse, which has now trained over 4,000 GPs. And then in 2008 she helped to establish the Practitioner Health Programme, a confidential service for doctors and dentists in London with mental or physical health concerns and/or addiction problems.
And even now, she continues to combine 'national stuff' with 'GP stuff' and runs four to six clinical sessions a week with two groups of patients – sick doctors and drug users. It is something that, in some ways, distinguishes her from her predecessors in the RCGP role, many of whom have been educationalists.
"What I need to make sure during my chairmanship is that I don’t lose the clinical side of it," she says. "Understanding what it's like to be a lonely GP going out on a home visit."
Adam Campbell is a freelance journalist and regular contributor to MDDUS publications