As NHS England’s head of primary care, Dr Arvind Madan is faced with the mammoth task of implementing the changes set out in the General Practice Forward View (GPFV).
After only two years in the role, the east London GP has made quite an impression. With experience in turning around a dozen struggling practices, he has been working hard on achieving everything set out in the GPFV.
His ambitions to build a new version of general practice partly came from the frustration he felt about the devaluation of patients.
In his 20 years as a GP, he has seen the demand for appointments and the workload dramatically increase, while the workforce and financial constraints have never been so tight. Alongside improving primary care, he was tasked with rebuilding the relationship between NHS England and GPs. To do so, he will use his expertise, as he knows that progress can only be made if people work together.
Q What progress has been made in the GPFV or practices?
A We’re about halfway through the General Practice Development Programme, which is a £30m investment over three years, and we’re seeing a significant impact of the Time for Care programme to release capacity in practices.
We’re also working at reducing regulatory and administrative burdens on practices. We’ve already worked with the Care Quality Commission to reduce the frequency at which practices rated as good or outstanding are inspected by asking for data only once so that each different regulatory organisation can use it multiple times.
There are improvements on how the standard contract works with the acute sector and community services so that less work leaks back into general practice and ‘did not attend’ patients don’t automatically need another referral after their first outpatient appointment.
The government mandate suggested that 40% of the country should benefit from extended GP appointments by March 2018 but we’re probably on target to reach 50%.
It’s not just about evenings and weekends but also more capacity in hours. There are many areas, such as Lambeth, where the hub is opened during core GP hours and serves as a really big support in resilience terms for practices when they feel they’re struggling to meet demand.
In terms of infrastructure, we had an 18% increase in the amount of money spent in general practice.
We have about 1,000 practices with wi-fi access but want more to have it. We’ve unified coding across primary and secondary care, through electronic discharge and clinical health terminology product, SNOMED.
Q What are the biggest challenges you face in the GPFV?
A The main problem is we’re doing this on a decade of underinvestment in general practice and a scenario on which much of the machinery of the NHS has an acute sector bias, largely driven by the data feeds we receive in the centre and shaped through the lens of the media.
I would pick three challenges. The first one is we need a sustainable arrangement around indemnity. I don’t think indemnities are due to a lack of training because if you look at the evidence; even though claims are goingup, successful claims aren’t. It feels really unfair to GPs and it serves as a bit of a lightning rod for dissatisfaction with the overall system.
GPs are suffering cost inflation in the way that hospitals aren’t considering, which is why we put in place a number of steps in the GPFV around covering the average cost of that inflationary pressure for two years in the £30m payments and the winter indemnity scheme.
The second challenge is finding 5,000 extra GPs. We know a third of GPs want to leave the profession in the next five years. The number of doctors retiring early has increased in recent years, due to workload pressures and pension allowances capping at age 52.
Brexit means we have to work harder to convince overseas GPs to work in England. We’ll have marketing campaigns in the targeted countries, describing the level of support, and put £100m into a tendering process to cover their training, induction and relocation packages.
The third challenge is increasing the general morale of doctors and practice staff. I remain a frontline GP, so I know the pressures we face. GPs feel neglected, as the workforce hasn’t grown at the same pace as the consultant workforce.
Ideally, we want a more manageable working day for them, where they’re possibly seeing fewer patients with longer appointments to deal with complex problems, while operating at the top of their licence. We want GPs to be able to work with colleagues in their neighbourhood and primary care networks to provide collective services across what might become between 30,000 and 50,000 populations.
Q How will overseas GPs integrate into practices?
A They’ll be paired up and we’ll run processes to ensure they land in identified practices that are keen to have them.
We’re trying to streamline processes, such as checks to get onto the national performers’ list and visa responsibilities around sponsorship.
A dedicated team will handle many of these processes so that they can have a more personal relationship with the individual, hold their hand and give them reassurance to swim against what might be the sentiment of a tide that breaks.
Q Do you think the GPFV is going to heal the NHS?
A The GPFV is a practical document describing real-life and everyday problems with some sensible solutions attached. It describes an organisation that understands the challenges general practice faces and has some tangible steps towards getting us out of that position and moving into a different version of what general practice can be in the future.
If you take a look at the products and achievements in the first 18 months, the list is quite long, substantial and meaningful. It’s the start of the turnaround but it will take a while to get to the version of general practice that is optimal. It requires the resources and support of everybody to keep it on that road.
Q How has the practice manager development programme been progressing?
A We held four regional networking workshops in 2016/17, which were attended by more than 300 practice managers.
The development programme has funded a wide range of activities, with more than 400 practice managers engaging so far. Support included leadership and business skills development, sharing of best practice requirements and specific training to meet local needs.
We funded the new online best practice and training resources, through the Practice Index forum, which has more than 8,000 members.
Over the next two years, we will commission regional workshops across the country, for practice managers to share their experiences, and fund mentoring and career development coaching, which will enable more practice managers to have appraisals with trained peers.
Q What role does technology play in practices?
A We have 57 million people in England who increasingly use technology in their daily lives. We need to bring and accelerate the digital revolution so that they can start to enjoy their interactions with health.
I would like a GP-patient relationship that involves click, calling or coming into the surgery and be able to flex between those modalities, according to the nature of the problem.
We want to get to a point where patients have a different experience of care and are more independent around their healthcare needs. We want to start scaling up a patient’s ability to communicate electronically with their doctor, when appropriate and clinically safe, particularly if it’s something more effective and convenient for practices.
We want follow-ups and fit notes done via webcam and to use patients’ Fitbit devices to send biometric data to health organisations that can monitor deterioration in long-term conditions.
Q What is the main thing that motivates you?
A I’ve always practised in really deprived communities and I feel a real reward in being able to intervene with patients whose lives are challenged with wider determinants of health, in terms of housing, education opportunities and life chances.
It’s an area of work that we feel we have learnt a lot from and have something to contribute to.