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What NHS England's top GP really thinks

Dr Arvind Madan, head of primary care for NHS England, reveals all in an explosive interview with Jaimie Kaffash

pulse cover aug 18

pulse cover aug 18

Grassroots GPs have long been derided for believing NHS England is comfortable with small practices closing.

But Pulse’s explosive interview with NHS England director of primary care Dr Arvind Madan reveals they might have a point.

Pulse interviewed Dr Madan at the NHS England headquarters in London, accompanied by the national director of commissioning, Dom Hardy, following comments attributed to Dr Madan that said: ‘Most businesses are pleased to see a rationalisation of providers, as it makes the remainder more viable. In the general practice market, there are too many small practices struggling to do everything patients now want for their families in a modern era of general practice.’

Dr Madan stands by these comments, as well as his assertion that practices must take part of the blame for failure to recruit.

There are too many small practices struggling to do everything patients now want for their families in a modern era of general practice

Dr Arvind Madan

There is a streak of thinking running through this. It’s the belief that general practice has to move towards modern, efficient businesses – specifically in larger groupings – where the practices that thrive reap the rewards. Those unwilling or unable to transform are left – as one former NHS England medical director put it – to fail and wither’.

This means working at scale, embracing technology, entrepreneurialism and innovative staffing.

But GP leaders have pointed out this ignores the reality that some practices are simply unable to transform or upscale. Their location may prevent this or they may have tried to do so and failed. In many cases, though, they are so consumed by simply keeping their heads above water that they don’t have the time or headspace to think about it.

Furthermore, these GPs point out that small practices are popular with patients, who value their continuity of care.

He stood by these comments and explained: ‘General practice here is built on a foundation of 7,400 small and medium-sized businesses. In all markets, there is some degree of difficulty for a proportion. The environment is a big factor within that. But actually, I think we would all like modern, thriving general practice available to us and our families.’

These comments bring to mind those made by Paul Twomey, medical director of the Yorkshire and Humber NHS England area team in 2016, who sent an email to practices saying vulnerable practices must ‘transform…or be allowed to fail and wither’. The comments – unveiled by Pulse – made the BBC 10 O’clock News and NHS England immediately denied this was national policy at the time.

But Dr Madan’s comments seem to suggest that, in NHS England’s thinking, there are ‘too many’ small practices.

He is clear on his vision, pointing to the rollout of between ‘1,000 and 1,500 primary care networks, covering 30,000-50,000 patients’, saying grassroots GPs should embrace this (see box).

But what about those that don’t transform? He says: ‘I think it is our job to help every practice on this journey. There is a degree to which the central national team can create the environment in which all practices can thrive. But there is also a degree of responsibility within practices, which I am sure they will accept, to take up the opportunity because I am not clear that passively waiting for the system to change around them is sufficient.’

NHS England has pointed to the support it has given smaller practices to transform and stay afloat. It is spending £50m on the ‘vulnerable practices’ and ‘practice resilience’ funds, and that its Estates and Technology Transformation Fund (ETTF) has helped 1,670 schemes as of March 2018.

Partners actively decide between profits and access

Dr Arvind Madan

Yet managers admit they have struggled to tackle the biggest crisis engulfing general practice – recruitment. ‘We are clearly challenged on GP numbers,’ says Dr Madan.

The figures bear this out. England has lost more than 1,000 full-time-equivalent GPs since September 2015, when former health secretary Jeremy Hunt set his target of 5,000 extra GPs by 2020.

Comments attributed to Dr Madan suggest he believes GP partners make a trade-off between access and income, and better organised practices get the staff.

Again, he stands by this and explains: ‘In the era of undersupply, it is the case that the environment in which practices are looking to recruit is not easy. Clearly there are elements that are within our control. People are looking for different ways of working, they are looking for more flexibility. They are looking for more family-friendly balance in their work/leisure ratio. We need to respond to this.’

He points to NHS England’s efforts to increase GP numbers through the international recruitment scheme, the induction and refreshers programme and incentives for older GPs to stay on. But he adds: ‘Equally there are lots of factors within the control of individual practices around how much pay, how much flexibility and how much individuals are made to feel part of a team with a purpose.’

Yet there aren’t enough GPs out there, and in some areas, such as Plymouth, it is impossible to recruit, regardless of how well organised practices are.

Dr Madan concedes: ‘It is a real challenge, and Plymouth is one of those situations we are watching very carefully.’

However, he returns to primary care networks, saying they can ‘give GPs opportunities to work with a more diversified team, developing specialist areas of interest, working across groups of practices, which may focus on areas they have an interest in and trying to build up that broader proposition of a wider team of clinicians’.

But GP leaders approached by Pulse after the interview were not convinced by these visions of the future. Indeed, they expressed outrage at the comments, but say they have long suspected this is the view of NHS England officials behind the scenes.

Dr Zoe Norris, chair of the BMA’s GP sessionals subcommittee, says: ‘I’m surprised and disappointed. I would have more respect for NHS England if they were upfront about their agenda.

‘Many GPs have felt for a long time that there is only one direction of travel being pushed by NHS England: away from small practices and into groupings of a defined size as primary care networks.’

There are real concerns around the assumptions behind Dr Madan’s comments. Dr Rachel McMahon, England Conference of LMCs chair, says many practices are simply unable to transform. Pulse’s recent ‘Postcards from the Edge’ feature (pulsetoday.co.uk/postcards) highlighted that in areas such as Plymouth and Brighton, practices across a whole town are struggling to survive.

She adds: ‘To suggest practices in these areas have the headspace available to drive forward major transformation when all their efforts are going into just keeping the doors open seems naive to the issues these GPs are facing.’

And transformation in such areas is not cheap. As Pulse has reported, Bridlington – whose practices have all applied to close their lists – was promised a £10.8m ‘health and wellbeing centre’ through the ETTF in 2016. But when costs escalated, the CCG pulled the plug on the funding.

Patient satisfaction

But, perhaps more importantly, there seems to be a lack of governmental faith in what small practices bring to general practice.

As Dr McMahon puts it: ‘I am in the privileged position of being able to speak directly to patients at a variety of practices. My personal opinion is that the highest levels of patient satisfaction seem to be from patients who are registered with smaller practices, as they are able to experience a more personalised service.’

There is also an underlying principle here – do we want to see a ‘marketisation’ of general practice? As Londonwide LMCs chief executive Dr Michelle Drage says: ‘For general practice to do “everything you would want for your family” it shouldn’t be placed in a market. Market success or failure should not be the measure by which we judge it.’

This may not be a view shared in the corridors of power.

 

What are ‘primary care networks’?

There is no real definition of a primary care network that NHS England is promoting. They emphasise the networks are built from the bottom up, so they will differ.

However, they do have certain characteristics in common:

• They cover a patient population of at least 30,000-50,000.

• The GPs head up ‘multidisciplinary teams’, formed of nurses, mental health workers, and clinical pharmacy teams.

• There are expanded diagnostic facilities.

• They pool responsibility for urgent care and extended access.

Dr Arvind Madan suggests the networks comprise around ‘100-150 clinicians’.

NHS England says this model ‘does not require practice mergers or closures, or necessarily depend on physical co-location of services’.

It includes federations, ‘super-surgeries’, primary care homes, and ‘multispecialty community providers’.

NHS England is incentivising practices to join primary care networks through funds for extra staff and premises.

Pulse reported that in Essex, CCGs have stumped up £35m for practices to work ‘at scale’ by ‘significantly increasing investment in workforce, estate and digital solutions’.

 

Readers' comments (24)

  • This is very disappointing, but hardly surprising as it has been obvious for some years. My own practice had absolutely no support from NHSE since 2009 and the PMS review was designed to make it fail. I jumped before I could be ruined. Now that this is clearly official policy there is something to fight against rather than continuous denial. It is time to fight for what patients want and value, and also what is proven to be more efficient - Continuity of Care and knowing a doctor well and the doctor knowing a patient well. This cannot be provided in large 50,000 practices who have to open 7 days a week. General Practice is not about providing instant care to the worried well. It is about good chronic disease management and getting to know families and their issues. Cradle to grave medicine. If we don't reverse the current trend soon we will have lost everything that is best in UK General Practice. I am soon to retire, but I am moving towards the next phase of life as a patient. I want to know my GP well in the future, and I don't want to keep going over my history time and time again

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  • The poisonous face of NHSE agend raises it head again in a flawed Yankee based healthcare HMO based model that will bring down the fair and cost effective nature of the NHS.

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  • So many assumptions and so little listening to the patients or evidence.
    NHSE will fit the evidence to their desired outcome

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  • They have made conditions so difficult that doctors are leaving in thier droves and recruiting is impossible in some places . This has been planned and implemented by NHSE and friends for many years completely ignoring what patients want which is the old system, a highly qualified doctor from cradle to grave. A big practice with short term doctors is not working- Replacing with nurses and pharmacisits etc is more expensive in the longterm. Make working in practices more attractive not more unattractive and say there no doctors and get private companies to provide a service that has very little continuation of care.

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  • I totally agree with Michael Crow. I mark significant events and it is remarkable how many are due to lack of continuity in large practices. I work many extra hours doing paperwork, running the practice etc. If I was salaried in a large practice I would be leaving on the dot. The health board will be surprised how much it will cost to run the NHS. If I'm employing a plumber or builder I would always choose a small business over a large company. I'm sure the personal service offered by small practices outweighs any supposed economies of scale.

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  • I really wonder about this chap, how many hours of General Practice does he do a week, how involved is he in the running of the practice and where has his GP experience been based.
    As a retired GP of 40 years standing, continuity of care, and knowledge of your patients is not just desirable, it's fundamental. To compare GP practices to a business model is entirely flawed, and denotes a fundamental lack of understanding of a good GP practice. There is no business model for unlimited demand on a highly limited budget with ever changing contractual demands from the employing authority. Tell me one, please! Thus to suggest closing dozens of small rural practices to form a mega practice is not only absurd but detrimental to patient access. Fund General Practice adequately, if you wish a premium service. You'll never get a working Rolls Royce service for the cost of a mini.

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  • Vinci Ho

    Call me a conspiracy theorist:
    (1) Small practices are to be starved to extinction if they do not comply with grouping together .
    (2) The GP networking is the preliminary step towards forming mega- and super-practices . The currently formed networks are to compete against each other in a region for a relatively small amount of funding thrown out by NHSE:Cash chucked onto the middle of a motorway.The stronger networks win .
    (3) Winner takes it all : eventually the stronger networks take over the smaller ones as the latter will cease to survive. The strongest networks then take over the stronger networks.
    (4) The dream of 20-30 super-practices in the whole country will be fulfilled, as long as this government continues to starve the overall funding for general practice.
    (5) Still remember the Trilemma Theory: integration , sovereignty and democracy; you can only have two out of three but never all three together .

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  • Vinci Ho


    ‘’What chance do we have? The question is "what choice." Run, hide, plead for mercy, scatter your forces. You give way to an enemy this evil with this much power and you condemn the galaxy to an eternity of submission. The time to fight is now!’’
    Jyn Erso
    Rogue One

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  • What is it that the NHS has had against small practices,against the evidence, when every study shows they offer good or better quality, preferred by patients and offer better continuity of care. Of course there have been bad inner city small practices. But that problem is due to GP payments system whch pay on list size as if static. Inner cities have huge turnover of up to 30%: looking after 10,000 patients and hitting tagets is easier in static village, than inner city with a turnover, so in there looking after 12,500 but paid to 10,000

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  • And, to be honest, who on earth wants to work in that kind of system? Turn up, see the complex patients and the ones the ANP can’t deal with (that inevitably lead to you having to refer), get asked to “triage” lots of visits i.e. take responsibility for denying visits to people or spend 3 hours cramming 6 visits in, have some performance team criticise you, do another multimorbidity surgery, deal with ridiculous amounts of paperwork then go home dreading the next day whilst the executive board plan strategy in the boardroom and cream off profits. No thanks

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