Exclusive: Health minister denies setting GPs up to take rationing rap

Health minister Lord Howe explains the GMC already requires GPs to make best use of resources. Neil Durham reports.

Lord Howe: 'What I faced was a task of battling an internet-based campaign based almost entirely on misunderstanding and falsehood.' Picture: Jason Lancy

‘I’d be fibbing if I said to you that I didn’t have a certain sense of achievement when it was all over.’

Lord Howe, 61-year-old father-of-four and health minister responsible for primary care, is telling GP about his role in bringing the controversial Health Bill into law during an exclusive 30-minute interview.

The seventh Earl Howe and son of Royal Navy commander and film actor George Curzon is perhaps best known as being the only member of former health secretary Andrew Lansley’s health team to survive this summer’s post-Health Bill reshuffle.

When GP last interviewed him almost two years ago we were in Number 10 and he was introduced as the man responsible for bringing the Health Act into being. But how does he feel about that period now, looking back on it from the comfort of his office sofa in the DH’s Richmond House base in Whitehall, central London?

‘What I faced was a task of battling an internet-based campaign against the Bill which frankly was based almost entirely on misunderstanding and falsehood that gave rise to tremendous anxiety and scepticism,’ says Lord Howe, apparently reading occasionally from prepared answers.

‘We dealt with that by amending the Bill, not changing the main provisions, but by building in explicit safeguards to reassure everybody about possible unwanted consequences.

‘Although the Lords could’ve defeated that Bill it was passed with its key provisions completely undamaged and that I think was a remarkable result for a measure which was greeted on its arrival in the Lords with such vocal concern.’

He agrees with the suggestion that he views the period now with a mixture of fondness, accomplishment and ‘glad it’s all over’.

‘It was, however, immensely hard work,’ he adds. ‘You don’t want to do a Bill like that every year I can tell you.’

GP rationing role in CCGs

The late autumn sun shines through the window as Lord Howe explains his vision for the 211 clinical commissioning groups (CCGs) which will take over the responsibilities of PCTs from April and are, coincidentally, having a first NHS Commissioning Assembly meeting 170 miles away in Doncaster, South Yorkshire as we speak.

So what is the health minister’s vision for CCGs?

‘The government’s modernisation programme is all about creating a service which is more responsive to the needs of patients and results in improved health outcomes. The logical consequence of that is that decisions about local services are going to be made by those with most contact with patients,’ he says.

‘I’m the first to acknowledge the importance of good management but the reforms will help the health service to develop from a system of management control to a system where power and decision-making is devolved to the most appropriate professional level.

‘GPs are the group of professionals who have the closest understanding of their patients and are able to take a measured and professional assessment of health needs in a particular geographic area and to inform the needs assessment which in every local area will need to be made,’ he adds.

But isn’t the government setting up GPs to take the rap for rationing of treatment as pressure to make savings increases?

‘The rationing of services on the basis of cost alone is wrong. It compromises clinical values and patient care. Imposing blanket bans over treatment on the basis of cost is unethical and it’s unacceptable for PCTs to put caps on the number of people who have certain operations. By transferring commissioning powers to GPs we are empowering them to make these decisions and work with their local patients to ensure that they get the care that they need,’ he says.

Previously GPs were able to blame the ‘PCT down the road’ for rationing but will now be part of the organisation making those decisions. Should they feel their patient advocacy role has been compromised?

Lord Howe says: ‘I put this very question to a group of GPs a few months ago and they said it was a red herring. GPs shouldn’t feel compromised because they have always had in front of them the GMC code of practice which obliges them to take decisions on the best use of resources in the interests of all their patients, not just an individual patient.’

The health minister is encouraged by CCG progress. ‘Obviously there are some CCGs which got off the mark very quickly and others which have perhaps got further to go. We want to ensure those who still have some uncertainties and hesitations about what they should be doing are supported properly without anybody feeling they are being directed from above.’

Any qualified provider

Lord Howe also signalled that commissioners will have greater freedoms to use the any qualified provider policy (AQP), meaning commissioners are better able to look outside the NHS for the best service provider, for a wider range of services.

The health minister says: ‘The main thing to say about AQP is that the implementation has been led locally by NHS organisations. It has emphatically not been a process imposed from above.’

Would he like to see a lengthening of the list of services under which AQP can be implemented if commissioners wanted this?

‘If commissioners want to do it, it’s up to them,’ he says. ‘If they see no need, there is no need. They must do what is in the interests of their patients. Children’s wheelchair services have been cited as a good example where the existing service letting patients down. It was commissioners who cited that as a particularly pressing need.’

GP contract changes

Negotiations over changes to the GMS contract have broken down with the GPC unhappy about government proposals including a 1.5% uplift in exchange for the biggest overhaul of QOF since its inception, which GP leaders fear could slash £15,000 on average from practices, and the scrapping of MPIG over a seven-year period starting in 2014.

Lord Howe’s message to GPs contemplating calling for an industrial action ballot is: ‘Firstly, think about the patients. Secondly, recognise that the process of discussion and negotiation has not reached the end of the road.’ He emphasises NICE’s work in evaluating the proposals and the benefits they promise for patients.

Quality premium

Another thorny issue is the quality premium, which could be worth up to £30,000 to the average practice, depending on success in the Commissioning Outcomes Framework by which CCGs will be judged.

Lord Howe is initially unenthusiastic about explaining his hopes for the controversial funding mechanism but eventually explains: ‘We believe that there is a place for rewarding good quality commissioning, to incentivise that. Quite how that is done is for discussion and I fully recognise the sensitivities that GPs have around certain forms of reward which could in theory put them in a compromising position.

‘It ought to be possible to work through those worries and again I hope that this is something that the profession will feel able to engage with us on.’

He adds: ‘In view of reservations of the profession, we have had cause to look again at the model. There is no point in rolling something out that is going to be unpopular and isn’t going to work and I’m the first to realise that.’

He hopes CCGs will find out how it will work by early next year.

As GP arrived at Richmond House there was a patient sat on the floor slumped against the reception desk apparently complaining about his care while flanked by ambulancemen. A sign of trouble ahead?

Given his success with the Health Bill, Lord Howe could be just the man to nip it in the bud.

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