Dr Mike Bewick is a straight talker, his sentences littered with phrases like 'frankly' and 'to be honest'.
Despite his powerful position as deputy to NHS England medical director Sir Bruce Keogh, Dr Bewick is clear that part of his role is to bring grassroots medical professionals' voice into the boardroom.
He refers frequently to his time at the coalface as a practising GP, but doesn't shy away from comments that might make him unpopular with the profession.
After launching the 'call to action' consultation on general practice this summer, the former GP and PCT medical director has been a fixture on the NHS conference circuit this autumn.
The consultation asks health professionals and patients for views on a dizzying range of issues, all threaded together by the warning that primary care, beneath the unsustainable weight of unprecedented social and economic pressures, cannot continue in its present form.
As a former GP, Dr Bewick recognises the fears of those who see the consultation as a precursor to yet more change imposed from above. But this is not about centrally imposed reorganisation, he insists.
There are three responses from GPs, he says - those who are already innovating for change, those who recognise the need for change and support it, but feel they don't have the resources, and those who are 'fearful of any further major change because change feels constant'.
'Being blunt, it is constant, it is constant for us all,' he adds. But while they may fear it, GPs do want change because they are 'drowning', Dr Bewick believes. 'They want help. And the call to action is partly about how we take the pressure off the system.'
While CCGs were being developed, Dr Bewick says the NHS provided resources and freed up time for clinicians on the ground to reorganise. 'What we neglected was how we reorganise the provision side.'
Working as a hospital doctor early in his career, Dr Bewick was attracted to general practice by the independence and became a GP in Egremont, West Cumbria.
| CV: Dr Mike Bewick |
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As medical director at Cumbria PCT, he helped lead an integration programme modelled on US health provider Kaiser Permanente, with GPs in leadership positions. When the coalition government's reforms took shape, 'we were ahead of the game', he says.
The call to action consultation is about pragmatism, not prescription, says Dr Bewick - it won't mean a new health bill or contract changes. 'The BMA has been pretty supportive,' he claims.
Dr Bewick's team will publish its response to the consultation, which will feed into NHS England strategy, this month.
'Most of this is about trying to get ideas from the grassroots about what has worked for them, and more importantly, what doesn't work, and what blocks it,' he says.
Simplifying targets
Dr Bewick is well aware of concerns voiced by the GPC and highlights one important area of continuing work - QOF, where GP leaders have been pushing to reduce and simplify targets. Dr Bewick says the BMA is 'pretty optimistic' about the changes being discussed and promises announcements soon.
But echoing recent comments by the official in charge of health regulator Monitor's parallel consultation on general practice, Dr Bewick says primary care needs changing roles and skills, not just more GPs.
The RCGP has called for 10,000 more GPs in the next decade. But he says: 'I don't believe we can make an argument to say we need 10,000 more GPs tomorrow.'
The workforce must keep pace with rising population and Health Education England is working to attract 50% of medical trainees into general practice. 'That is absolutely right,' he says.
But what is also required is to develop doctors' skills and transform how they deliver care. 'I think future providers of primary care will have to involve GPs who have perhaps a skill level above where they are now in terms of managing risk,' he says.
These GPs will need extra training to intervene early and manage vulnerable elderly people, those with mental health problems and children with complex problems.
'The alternative is those hospital walls become as porous as they should be, and specialists becoming generalist-specialists, outside hospital.'
A major theme of both the call to action, recent government pronouncements and continuing GP contract negotiations, is access. While the BMA recently signalled cautious support for seven-day services, there remains deep scepticism from the GPC, which fears underfunded schemes could spread skills too thinly, damaging core hours care.
But Dr Bewick says: 'This is about making services safer over seven days. And giving services to people who, bluntly, will never go to a GP in the hours they are open.
'I'm not expecting people to work longer hours; that would be detrimental to their care of patients. I'm not expecting people to do more bureaucracy. I don't expect their staff to work longer hours.
'But I do expect there will be a solution in areas where there are pressures that are different. And it might mean rescheduling, rather than anything else.'
Some GPs, such as those looking for more hours to suit their lifestyle, will welcome seven-day opening, he says.
Single-handed GPs
At the recent launch of the London NHS call to action, it was suggested that the need to 'scale up' general practice spelled the end for single-handed practices. Dr Bewick admits it will be 'very, very difficult to continue' for single-handers, but says if they remain networked with the rest of the profession and patient feedback is good, they 'have my support'.
After a pause, Dr Bewick looks up. 'Independent contractor status, come on,' he says, pre-empting the next question, clearly keen to add his voice to the fierce debate ignited by RCGP chairwoman Professor Clare Gerada.
'Would I say that in 10 or 15 years' time most GPs will be in independent practice? No. But the profession's moving that way, I'm not moving it that way.
'There is nothing in there,' he says, indicating the call to action document on the table, 'that is trying to make independent contractor status a thing of the past. But people will look at other models and when 50% of the population of GPs are in employment, they may wish to have a bigger role in strategy.'
He adds: 'Before there are any competition laws applied to general practice, this is the time for you to look and reflect: what would you like it to look like in 10 years? If your children were coming into general practice, what would sustain them and give them a happy and fruitful career? I'd question whether the current system is exactly what you'd propose - I don't think it is.'
