Standing up for general practice

Outgoing RCGP president Dr Iona Heath has just condemned health ministers for 'immensely irresponsible' failures on out-of-hours care. She turns to the press officer sitting in on our interview and asks if she's being too indiscreet, then jokes: 'Though you can only sack me, and I'm going anyway!'

Meeting me shortly before completing her presidency last month, Dr Heath has always seemed determined that her role as the college's figurehead would not modify her emotional, at times controversial, views on modern healthcare.

Dr Heath speaks with clear pride in general practice, occasionally gesticulating with a hand emblazoned with a swirling henna tattoo from a recent trip to India.

The NHS reforms

She is enthusiastic about the RCGP's move to new headquarters near Euston in London, where we now sit, and the 'terrific' resources it will offer members.

But her tone changes when we discuss the coalition's health reforms. Dr Heath's views are unambiguous: the reforms threaten the heart of medical generalism.

She describes the mass purchase of swathes of practices in England by private companies as 'a fundamental problem' for the NHS, and another step towards a US-style health system. 'It always seems extraordinary to me, our enthusiasm for following behind the most expensive and least effective health service in the world,' she says.

Dr Heath worries about conflicts of interest for GPs in privately run practices. 'People will say GPs have always been private and had conflicts of interest. But conflicts of interest are much less sinister and much easier to scrutinise at the level of a small practice.'

She believes many practices now think they need to get bigger just to remain profitable. But she asks: 'Whose interest is that in? Certainly not the interest of the patient. Patients like small practices.'

She also rejects the notion that general practice needs somehow to become industrialised to meet the pressures facing the modern NHS. 'I think perhaps we need to be more vigorous in defending the smaller local unit as the fundamental thing in the health service.'

In particular, Dr Heath sees out-of-hours care as a critical casualty of recent changes to the general practice model, and is again angered by the rise of private companies.

Continuity of care

She insists maintaining continuity of care is vital to a humane health service and that this is best provided by co-operatives of local GPs.

'The old woman who falls ill in the middle of the night: you need to know what her life has been like, what's left of her life, what she wants, who is there for her and who is not there for her. Even in the best records, it's very hard to communicate those most important things.'

But Dr Heath is not hopeful that GP out-of-hours co-operatives will survive, accusing governments of making them 'financially unviable'.

She is a critic, too, of performance-related pay, and voted against the 2004 contract, which introduced the QOF. 'It distorts priorities. It's very destructive of any notion of professionalism and individualised care.'

She says the GPC was 'naive' to have negotiated the deal, admires GPs who opt out of the QOF and is adamant that it fails to tackle health inequalities. She believes it should be replaced with a smaller scheme using a smaller proportion of GP income.

'You need to give GPs space to be creative and innovative within a basic financial framework. Then you should be able to use a small amount (of money) for incentives you want to change, to shift a bit.'

Former health secretary Andrew Lansley's vision will be realised from April when clinical commissioning groups take charge. Dr Heath implores her colleagues to maintain their focus on patients.

Among the disillusionment and anger over the direction in which the NHS is heading, Dr Heath believes GPs have reasons to be positive. 'It is the most fantastic job,' she says.

'That's the basis of my optimism. There are not all that many jobs that can make a real difference to people's lives, and we can.'