What do you think are the strengths and weaknesses of general practice in the UK?
‘I think that one of the biggest strengths of the NHS is our strong tradition of primary care and general practice is at the heart of that. I am a big fan of what GPs can do to help make the NHS sustainable. I think we have to be much, much better in helping people to stay healthy at home and for me as a member of the public, I think it is my GP who is the central person in making that happen.'
One of the first things that GPs experienced with you as health secretary was the imposed contract. In hindsight is that something you regret?
'No, the GP contract is not perfect but all parts of the NHS are having to make efficiencies, do more for less to deal with the simple fact that demand for NHS services are going up by 4% a year but our budget is flat and I am afraid that applies to primary, secondary care, district nursing, ambulance services, all parts of the NHS.
'I wouldn’t want those changes to the GP contract to be the last word because I think that actually we do need a more fundamental rethink about whether that GP contract is achieving things that it was set out to achieve in 2004 and whether it allows GPs to have that personal relationship with people on their list that I think is at the heart of what general practice is about.'
Do you want changes to the contract to help reduce the bureaucracy that GPs face?
'Yes, I think the unintended consequence of the changes to the GP contract in 2004 was to weaken the personal relationship between GPs and the people on their lists because it meant that GP income was related to a lot of targets that in their own right are very important but collectively mean that, as one GP said to me, when someone comes into my surgery sometimes it feels like we have got our agenda and the patient has got theirs. I think having a personal relationship between GPs and the people on their lists is at the heart of what family doctoring is about.'
Do you think that changes need to be made to the QOF - for example to reduce numbers of targets, because they went up this year?
'Quite possibly, yes. I think it is something we need to look at. We need to look at whether the way we have structured the GP contract actually allows GPs to take personal responsibility for people on their list or whether we have created a targets culture that actually gets in the way of that personal relationship between doctor and patient.'
GPs saw your comments about ‘taking on the GP contract’ as a criticism of the profession. What would you like to say to them about that?
'Read the speech. The last thing it was, was a criticism of the profession. I took great trouble to say that I think GPs work very hard, they have very long days and I think they have a very pressured job. This is not about asking GPs to work harder because I don’t think they have the capacity to do that. It is about whether we have created the structures that allow GPs to have the personal relationship with the people on their lists that they would want to have and that we need them to have if we are going to give people the support and care they need outside of hospital that keeps them healthy and well.
'I think we have created a structure which makes it very difficult for GPs to look after people proactively. In some ways GP surgeries beat to the same rhythm as an A&E department in that your job as a GP is to get through all the 10-minute appointments on your EMIS list, to see anyone who has come in for an emergency same-day appointment, to deal with your paperwork. But we have crowded out the possibility of actually checking up on somebody who may have been discharged from hospital that day or somebody who you know has a complex long-term condition and may be vulnerable and that is why I think we need to ask whether in fact we can do something to rediscover the traditional role of a family doctor in a modern context.'
How would you like to see the GP contract change in respect to out-of-hours care?
'I think the problems with the 2004 contract changes was that by saying that GPs were no longer responsible for out-of-hours care, it basically said that GPs were responsible for people on their list when the surgery is open. But when the surgery is not open that responsibility passes to someone else. So we broke that sense of personal responsibility of a GP for the people on their list.
'I don’t think we can go back to GPs being on call at weekends, they have families, they work very hard and I recognise that those days are gone. But I would like to see GPs taking more responsibility, particularly for the frail elderly, the most vulnerable people on their lists and for making sure that they are actually able to access care in an urgent or emergency situation in out-of-hours. How we do that is something that we need to discuss and may involve changes to the GP contract. But I do think we need to look at regaining a sense of GPs being the accountable clinician, where the buck stops for vulnerable older people who are the people who most need the NHS.'
The RCGP is calling for 16,000 more GPs and says that general practice does not have the capacity to make GPs the named, accountable clinician for vulnerable elderly patients. What do you say to that?
'I think they are probably right. I am sure we do need to increase the capacity of general practice. It is a huge misconception to characterise this government as anything other than strongly supporting the role of GPs. I made the comments I made because I want GPs to do more and I want them to be more central to the way we tackle the challenge of an ageing society. This government has put GPs in charge of commissioning healthcare so we have given them an absolutely central role in terms of the way we spend our health budget.
'And now I think we need to look at how we can do something that has eluded governments for many, many years which is make this shift from secondary to primary care so that we actually spend our resources on helping people stay healthy and well at home and not wait until it gets too late and they get tipped into A&E.'
Do you think that the resources will move out of hospital settings if the patients are moving out of hospitals?
'People that I talk to in hospitals actually say that they don’t think it is appropriate that some of the frail elderly who come into A&E departments should come there. They say it would be much better for them if they were looked after in a community context and what we need to do is to make sure that the structures and incentives make that possible.'
So you would like to see resources move out if patients are moving out of hospital?
'We definitely need to increase the amount of resource going into primary care, we definitely need to increase the capacity of primary care and we definitely need to increase the number of GPs, without a doubt.'
And how is the government doing that?
'We have protected the NHS budget which has meant that other government departments have had much bigger cuts in their budget. We are looking at whether taking a more proactive approach to primary care could actually make efficiencies and savings across the whole of the NHS because it would mean that we have less emergency hospital treatment so if we get this right it can actually save money for the NHS.
'We also need to look at the way we integrate primary care provided by GPs with the social care system and whether we can break down barriers so that there is more joint working so that for vulnerable, older people the service they receive is completely seamless and it is irrelevant then whether it is provided by the local council or by their GP or by the NHS.'
What you would like your legacy to be in terms of the NHS?
'I would like my legacy to be a transformation in the role of GPs so that they return to being the people who really are in the driving seat for our health and particularly the people who take responsibility for all the care provided by the NHS to vulnerable older people. Because I think that is what GPs want. I think it is that personal relationship, that personal responsibility, that wanting to be connected to a local community, that is why people want to become a GP. And it is what makes me most proud of our NHS that we have our network of GPs who do this and they work extremely hard.
'I think the structures that we have created, the QOF, the DES, the LES. They make it really difficult for GPs to have that personal relationship and make it really difficult for them to have the time to actually spend proactively thinking about the most vulnerable people on their lists and what they need. I would be incredibly proud if my legacy was to create structures that allowed GPs to return to that.'
Do you think it is possible that some of that could be changed?
'Absolutely. I think it is essential that it is changed because otherwise we won’t make the NHS sustainable. Unless we invest in primary care, unless we invest in what GPs can deliver in terms of being the linchpin of joined-up integrated services for vulnerable older people then we are never going to make the NHS sustainable.
'I am the biggest fan of GPs. I really am. If you look at what we have done, of course it means GPs doing more but it is because I believe in what GPs can do and I don’t think they can work harder, it is not that.
'I think most GPs in their hearts find it difficult to deliver the personalised care they would like to. We have done a lot for GPs and we will do more.'