Intended for healthcare professionals

Feature Interview

Clare Gerada: “It’s like the wild west in healthcare”

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5911 (Published 02 October 2013) Cite this as: BMJ 2013;347:f5911
  1. Gareth Iacobucci, news reporter
  1. 1BMJ, London WC1H 9JR, UK
  1. giacobucci{at}bmj.com

As the national figurehead for UK general practitioners during a huge period of upheaval, Clare Gerada has barely been out of the news in recent years. Here, as she prepares to move on to new challenges, she gives a typically honest exit interview to Gareth Iacobucci

“It’s been like an episode of the West Wing, every single day,” Clare Gerada tells me when we meet on the eve of her final Royal College of General Practitioners annual conference as chair. Her comparison with the American TV drama may be tongue in cheek, but it does offer a revealing insight into how the previously placid role as head of the largest medical royal college in the UK has been recast by Gerada’s firebrand politicising. Much of this, she argues, was driven by circumstance, as she led the protracted and bitter fight against the government’s unpopular healthcare reforms in England.

Listen to more of Gareth Iacobucci's interview with Clare Gerada

But she has also faced other battles since taking over the reins in November 2010, including accusations of racial bias in the college’s examination processes and building a case to put to ministers to extend the length of GP training. 1 As she prepares to take on a new role with the London branch of NHS England, Gerada has a new battle in her sights, to convince GPs that the independent contractor status is outdated and needs remoulding.

Quick start

Gerada admits that the fact her tenure coincided with a period of huge upheaval in the NHS made the job tougher than she ever imagined.

“I’d had a lifetime of holding quite senior roles at a national and international level that were political with a small p,” she explains.

“[But] nothing prepared me for the first five days of my chairmanship. I was catapulted onto the front page of the paper [and] the first item on the Today programme. That first weekend, I called 40 people for advice about what was going on, and at the end of it all, I realised that nobody could tell you what to do, you had to do the thing yourself. That was a real awakening of what leadership meant.”

This leadership was repeatedly tested as Gerada became the figurehead for doctors, academics, and campaigners who opposed the coalition government’s controversial Health and Social Care Act. Her tenacious stance won her the support of many of her peers but few friends in the corridors of power, and criticism from some who believed she was acting beyond the remit of a royal college.

As chair, Gerada instigated a very different culture in the college to her predecessor, Steve Field, who favoured a more constructive relationship with government. Field’s approach helped him gain the trust of ministers and eventually led to him being appointed to head up the government’s “listening exercise,” held during an unprecedented pause in the legislative process to allow for greater consultation over the health act.

NHS frustrations

But although she may not have won many friends in Whitehall, Gerada is unapologetic, arguing that doctors had a duty to speak out for patients.

“What are royal colleges for if not to speak out?” she says. “It’s part of every single charity’s objective to speak out around healthcare . . . For example I am now urging medical speakers to speak out around the issues of poverty and austerity. Where is the medical leadership talking about food banks? We have to speak out. We have Sir Michael Marmot who did, but we need to be speaking out. If it’s not us, who is it?”

Charismatic and effusive, Gerada seized on this remit with gusto, quickly gaining a reputation as an outspoken, passionate defender of the NHS.

As she prepares to step down next month, when she will be succeeded by Maureen Baker, she talks candidly, yet at times wearily, about the “mess” she believes the NHS has been left in by the government’s reforms.

Gerada concedes she “lost her humour” at times during a turbulent three years in post. She reserves withering scorn for politicians, particularly the former health secretary Andrew Lansley, who devised, and ultimately pushed through, the unpopular reforms.

“I think the BMJ front cover said ‘Lansley’s monster.’ We’ve certainly have got a monster,” says Gerada. “It’s like the wild west in healthcare; no one really knows who is in charge.

“The government set the exam question, had the exam answers, but still failed the exam. It’s a complete mess.”

Like many of her peers, Gerada believes the new compulsion for commissioners to tender services to the open market is particularly damaging and laments that new clinical commissioning groups lack the power or ability to integrate care.

She is exasperated that the government ignored repeated warnings and ploughed ahead with expanding the NHS market and describes the economic regulator Monitor, charged with regulating competition, as “superfluous.”

“I respect enormously the people [in Monitor], but what we need in times of austerity is cooperation and collaboration. We need to be working across professional boundaries, not competitively.”

New models of care

Gerada is particularly concerned that reforms designed to make GPs take responsibility for the commissioning of healthcare have distracted from what she views as the more important business of reforming the way NHS care is delivered.

Her vision is a radical but clear one: the end of the internal market, replaced by integrated provider organisations, led by GPs, that bring together all elements of the health system, including community services, social care, mental health, and, crucially, acute care.

When she steps down next month, Gerada hopes to advance her plans in a new one day a week role with NHS England, as clinical chair for primary care transformation in London. It is here that she hopes to influence the redesign of healthcare in the capital and beyond.

“It’s trying to take off where [Ara] Darzi left off a few years ago, and coincidentally Darzi is leading a commission for the mayor so we’ll be working very closely together,” she explains.

“It’s trying to move my profession from where it is now to where I think we should be, which is much more integrated working and protecting what’s best about general practice but moving it on.”

The mention of Ara Darzi, the respected surgeon turned health minister who led a review of healthcare in London, and later nationally, immediately evokes memories of his vision for single units where GPs and specialists work under one roof. “Polyclinics”—as they were billed—became a dirty word in some circles, and Gerada knows her ideas, particularly the view that GPs’ independent contractor status is outdated, will not be easy to sell to her profession.

“I think it’s a tall order for GPs at the moment because they can’t put their heads above the parapet because of the workload. But when they start to think about it, I think the small business model of general practice has served its time,” she says.

But she adds: “I think we need to protect what’s best about generalism but move us closer to our hospital and community colleagues so that we become one organisation and one service.”

Not content with challenging GPs to embrace new ways of working, Gerada has also laid down the gauntlet to hospitals to relinquish control and allow more specialists to work in the community.

“The big people that need to change of course are the foundation [hospital] trusts,” she says.

“We’re not talking about vertical integration; we are talking about new organisations with joint funding, where we can start to say, ‘how can we work differently? Can we eliminate the internal market and actually reduce some of the transaction costs?’”

A fierce advocate for generalism, Gerada is adamant that the new integrated organisations must be run by GPs, no matter how unpopular this might prove with some hospital doctors.

“I think only GPs can run integrated services,” she says. “I know that from my experience of running multidisciplinary teams—it takes a long time for specialists to get out the habit of just wanting to refer to another specialist. Only generalists have the skills and the training to start looking at what true multidisciplinary working is.”

For this vision to become a reality, Gerada says a huge investment in primary care is required, with more GPs trained and more resources shifted into community settings.

She also believes that a more federated model of working would raise standards in primary care and tackle the historical lack of empirical evidence about GPs’ performance.

But she warns further regulatory measures will hinder rather than help matters. The Care Quality Commission recently appointed Gerada’s predecessor, Steve Field, as the first chief inspector of primary care in response to the findings of the Francis inquiry into standards of care at Mid Staffordshire trust. But although she respects Field “immensely,” she questions the need for the role.

“We pile more regulation on more regulation. What I worry about is that standards will all be operational standards.

“We have to deal with what I think is this very small tail [of poor performers]. But I think the way to deal with it is not to bang all of us on the head and make us all jump through more hoops.”

“I think we need to be looking at them, dealing with them, and then letting peer pressure move and deal with the others. I don’t think anybody understands the pressure general practice is under at the moment. It is heaving under the workload; we cannot cope.”

Despite her Duracell bunny-like energy levels, the outgoing chair gives the impression of someone whose batteries need recharging, as she recounts stories of GPs struggling to meet demand and seeing more than 60 patients a day.

But Gerada, who with her husband, the psychiatrist Simon Wessely, has partaken in gruelling cycling treks from London to Paris for charity, is not the type to put her feet up, and she talks of taking on new leadership roles.

“I’m tired. I’d quite like a couple of days off. [But] I’ve got one big job ahead of me for NHS London, and I think I’ve got a big job ahead of me after that,” she says breezily.

Politicians won’t be resting easily just yet.

Notes

Cite this as: BMJ 2013;347:f5911

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Footnotes

  • Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References