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: 'I'd be fibbing if I said to you that I didn't have a certain sense of achievement when it was all over.'
The seventh Earl Howe, son of Royal Navy commander and film actor George Curzon, is the only member of former health secretary Andrew Lansley's team to survive this summer's post-Health Bill reshuffle.
When GP last interviewed him almost two years ago, he was introduced as the man responsible for bringing the Health Act into being. How does he feel about that time now?
'What I faced was the task of battling an internet-based campaign against the Bill, which, frankly, was based almost entirely on misunderstanding and falsehood, and which 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 building in explicit safeguards to reassure everyone about possible unwanted consequences.
'Although the Lords could have defeated that Bill, it was passed with its key provisions completely undamaged. That was a remarkable result for a measure that was greeted on its arrival in the Lords with such vocal concern.'
GP rationing role in CCGs
He views the period now with a mixture of fondness and accomplishment, and is '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.'
Lord Howe explains his vision for the 211 clinical commissioning groups (CCGs) that will take over from PCTs in April. 'The government's modernisation programme is all about creating a service that is more responsive to the needs of patients and results in improved health outcomes,' he says.
'The reforms will help the health service to develop from a system of management control to a system in which power and decision-making are 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 geographical area.'
Rationing NHS care
But isn't the government setting up GPs to take the rap for the 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 on 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,' he says.
Previously, GPs were able to blame the 'PCT down the road' for rationing, but they will now be part of the organisation making those decisions. Should they think that 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 that got off the mark very quickly and others that have perhaps got further to go.'
CCGs in the latter group will be offered support, he says, 'without anybody feeling they are being directed from above'.
Lord Howe also signalled that the policy of using any qualified provider (AQP) would give commissioners greater freedom, allowing them to look outside the NHS for providers for a wider range of services.
'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,' he says.
Would he like to see a wider range of services opened up under AQP? 'If commissioners want to do it, it's up to them. If they see no need, there is no need. They must do what is in the interests of their patients.'
GP contract changes
After talks broke down on the GP contract, the DH threatened to impose changes that could see practices lose six-figure sums while workload soared. Lord Howe's message to GPs contemplating industrial action is this: 'First, think about the patients. Second, recognise 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 if their CCG hits targets in the Commissioning Outcomes Framework.
Lord Howe is initially unenthusiastic about discussing the controversial funding mechanism, but eventually explains: 'We believe there is a place for rewarding good quality commissioning, to incentivise that.
'Quite how that is done is up for discussion and I recognise the sensitivities GPs have around certain forms of reward that could, in theory, put them in a compromising position.'
He adds: 'In view of the 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.'
He hopes CCGs will find out how it will work by early next year.
As GP arrived at Richmond House, a man was sitting slumped on the floor against the reception desk, apparently complaining about his care while flanked by ambulance staff. 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.
