National clinical director for primary care Appointed: May 2001

My achievements

Any achievements are never solely due to the national clinical director but to working with so many others. One of the requisites of the job, however, is to provide a clinical leadership within the very broad remit of primary care. The progress of primary care trusts, which are very new organisations, is of fundamental importance as we attempt the most radical of NHS improvements. In supporting primary care trusts, I work with the National Primary and Care Trusts Development Programme (NatPaCT) of the Modernisation Agency, most specifically on the role of the professional executive committees, whose members are predominantly clinicians. These committees have the task of improving and developing clinical services in primary and secondary care.

We have extensive programmes to improve primary care provision. These include a clear community nursing strategy and a new contract for general medical services (GMS). This contract is the most comprehensive quality based contract developed in any health system, and is being funded by a large financial investment.

I work closely with the primary care collaborative, whose outstanding work has supported huge improvements in general practice services. We are negotiating a more radical community pharmacy contract to enhance the role of this largely unsung group of professionals, and we are considering a new dental contract in the future.

My departmental work includes being a member of the "top team"—the senior management team of the Department of Health—and chairing the primary care policy board, whose remit is to coordinate and develop relevant policy.

I also have a new Department of Health role in developing primary care medical leadership and in encouraging the expansion of the number of practitioners with special clinical interests. There are currently 1250 such accredited GPs. I am also championing a higher profile for chronic disease management with a particular emphasis on comorbidity and self management.

Finally, I average at least two service visits a week in which I act as an interpreter of policy, generate ideas, and provide a conduit between the department and the NHS. This, and my two days a week as a general practitioner, keeps me well grounded.

What others say

Mike Pringle, head of the school of community health sciences and professor of general practice at University of Nottingham and former chair of the Royal College of General Practitioners: The prime minister announced David Colin-Thome’s appointment at a time when there was widespread disappointment in primary care at the NHS Plan, which seemed very "hospital-centric." Although his presentational and personal skills were not in doubt, as an old advocate of fundholding, he initially seemed an odd choice politically. However, his support for one Conservative reform was not a sign of right wing political allegiance—far from it.

It would be invidious to formally review his impact—to undertake a performance management review. Partly this is because his targets, the objectives to be achieved through his appointment, are not clear to us outside the Department of Health. The general role of advocating for, and offering leadership to, primary care doesn’t lend itself to objective assessment; if there were any harder targets agreed with him, then I haven’t a clue what they were. Further, any performance review should include a dialogue.

So I will only comment on what I have seen at first hand. David has been very energetic. Kinetic movement is not of itself positive, but it is a necessary precursor for success. David has been at numerous meetings, conferences, working groups, informal discussions, etc. He has not become an invisible bureaucrat.

And what has this energy achieved? He has been very influential in the GMS contract negotiations, the development of the initiative on GPs with a special interest, progress in clinical governance and clinical audit, and health informatics in general practice. There will be many other areas of activity that I don’t know about.

However, I think his greatest achievement is in listening to primary care health professionals and then articulating sensible views that are respected in the Department of Health. There are very few clinicians—and only three GPs—at senior levels of the department. Among them, David offers a down to earth opinion that carries considerable clout.

Overall assessment? Doing a near impossible job exceptionally well—a case of the right man in the right place at the right time.

Dr Steve Gillam, senior adviser in primary care at the King’s Fund; attachment director, public health, at the University of Cambridge; and a Luton GP: I’ve never seen the job description for a "tsar" and my understanding was that these have been personal appointments. As such, it is not easy to generalise about the role. They are all leaders in their field with a brief to implement government policy. They are supposed to symbolise the government’s commitment to seeking clinicians’ (for which, read doctors’—where are the nurse "tsarinas"?) input to policy making at all levels. The image of the tsar is a paradoxical one. What could better epitomise the centralising tendencies of "new" Labour?

One obvious way to characterise the tsars’ role is in the area of national strategic frameworks. The role for the tsars for cardiology, cancer, or older people has been very obviously linked to development of strategy and national service framework implementation. By contrast, David Colin-Thome has played a rather different role.

GPs were always central to new Labour’s plans for the NHS. Primary care trusts as the vehicle for its modernisation programme require GP ownership and support if they are to deliver. Negotiation of the new GP contract was always going to be a tough call.

In many respects, David Colin-Thome was a natural choice. He is charming and charismatic—a natural "rallier of the troops." A leftward leaning one-time Labour councillor, he had been at the forefront of the Conservatives’ market oriented reforms as a first wave fundholder. He exemplified the admirable GP virtue of opportunism with an ability to make the most of each twist and turn of health policy. He came from working at the London Regional Office with considerable experience and understanding of change management, street level bureaucracy, and the mindset of his colleagues. He is an excellent communicator and, given the potential for brickbats, has managed the public relations side of the role well. He tries to provide GPs on the ground with a practical vision of how today’s proposals can improve patient care.

I suspect that many of his most important achievements will have passed unseen—in "finessing" strategic and operational output that can often seem remote to his target constituency.

However, in the absence of an overarching strategy for primary care, his brief is fuzzy. This is well illustrated in relation to the biggest primary care policy item on the horizon: the new GP contract. The minister sensibly delegated negotiation to the NHS Confederation, giving the Department of Health officials a less direct role. Though intimately involved in these negotiations, David Colin-Thome wisely adopted a low profile at the most delicate stages. He therefore escaped the credibility-sapping vituperation heaped on the General Practitioners Committee’s negotiating team, for example. A central question nevertheless remains. With a strategy development team (wherein primary care is represented) within the Department of Health, what is the primary care tsar principally for?

Michael Dixon, chairman of the NHS Alliance: David Colin-Thome has been an effective and much needed champion for primary care in the Department of Health. His wide experience at the clinical frontline and London region combines with extreme intelligence—and a wicked sense of humour—to make him a natural tsar .He is a convincing advocate for primary care both on the public stage, where he is omnipresent, and behind closed doors, where he is well respected. His presence at the Department of Health’s "top table," which otherwise has no voice for primary care (or its trusts and practitioners), is crucial even if tokenistic.

As a modernist it has been easy for him to champion the department’s policy and play a major role in its implementation—for example, in developing primary care practitioners with a special interest and a primary care focus for the national service frameworks.

He sometimes overplays his fundholder origins, but his forte has been to vigorously challenge assumed opinions, vested interests, and negativism with conviction and integrity—especially among the primary care workforce. This has made him an effective opinion former and voice on government policy.

An inevitable consequence is that professional executive committee chairs and ordinary primary care professionals do not yet see him as their voice and popular leader in the department.

It is probably impossible to champion department policy, primary care, and primary care practitioners at one and the same time. Nevertheless he does have an important potential role in supporting the positive realists at the frontline of policy implementation, who are too often labelled "whingers," when they expose the impracticalities or contradictions in what they are being asked to do.

David has a touch of greatness about him. Tsars have not traditionally courted popularity. He could now afford to do so as means of bridging the abyss between Richmond House [headquarters of the Department of Health] and the frontline. His paymasters at the department must now allow him to shake their own cage a little. Especially if this enables him to deliver to them the hearts and minds of primary care.