Dr Arvind Madan: ‘Practices waiting passively for change will not suffice’
Read the full explosive interview with NHS England’s top GP
Pulse editor Jaimie Kaffash: In comments attributed to you, you 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.’ Can you explain these?
Dr Arvind Madan, NHS England director for primary care: General practice is built on a foundation of 7,000 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 what we all would like to see is modern thriving general practice available to us and our families.
There is a degree to which scale plays a role within being able to provide that, which is why we are particularly keen to accelerate the rollout of something that is going with the grain, with the grassroots direction of travel around the development of somewhere between 1,000 and 1,500 primary care networks covering 30,000-50,000 patients, that I think will genuinely add a new layer to the system.
I think it is our job to help every practice on this journey. There is a degree to which in the central national team, we 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.
JK: In further comments attributed to you, you suggested there is some trade off partners make between accessibility and income and that better organised practices get the staff. But there are too few GPs – so how can practices ‘get’ the staff?
AM: In the era of undersupply, it is the case that the environment is not easy in which practices are looking to recruit. Clearly there are elements of that 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 their work/leisure ratio and we need to respond to that changing expectation. There are a number of things in relation to the international recruitment, the I&R scheme, the retention scheme, the GP career plus scheme to try and improve that environment to try and support that more flexible way of working.
But equally there lots of factors that are 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.
JK: How about areas such as Plymouth that are continuing to struggle?
AM: It is a real challenge, and Plymouth is one of those situations we are watching very carefully.
Primary care networks 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, 100-150 across a primary care network that can lead to those different roles that are maybe more attractive to bring people into an area.
Dominic Hardy, director of primary care delivery: They are also one of the sites that are going to benefit from the international GP recruitment programme. I know that we’re having some initial success in securing candidates who may well want to go down to the southwest. I do think that can supplement the kind of solutions that Arvind has suggested.
JK: So how is the international GP recruitment scheme going? The last reported figures that we saw were 85 at desk by April, are we expecting to see these numbers go up by September?
DH: We’re certainly heavily engaged with recruitment companies now out actively seeking candidates in EEA countries because they have direct recognition of their qualifications. We’d certainly expect a significant number of candidates to be over having initial interviews over the next few months.
JK: We had a partnership roundtable with Nigel Watson and a few others, and one thing that came up was the desire to bring in seven-day 8-8 access is actually affecting other elements of the system. That there are only so many GPs to go around. I know we’ve got a new secretary of state in play, but is this something that is going to be pursued?
DH: We’ve never said actually seven days 8-8. We’ve said evenings and weekends and that is still the commitment that we’re sticking to. That is still a commitment we are willing to make available to all parts of the country, we’ve said we’ll have 100% of the country covered by October. That is something we are determined to make happen because we know this is a service that patients find popular.
AM: But actually, I’d also add that in areas where access hubs are now up and running, which is the majority of the country, and as Dom says 100% by 1st October is the ambition, they serve as a significant support to hard-pressed practices for both in-hours as well as out-of-hours. It’s a sort of quiet transformation that’s happening across the system, in that regard, it’s actually a really tangible support to a bunch of practices in an area that is struggling to service the demands they are facing when an access hub opens up.
Clearly you are aware that we’ve got the highest numbers in training than ever before, but actually there is a degree of participation loss that we’re seeing as a result of the intensity of the work. And actually also in relation to the cost pressures of things like indemnity. So actually as we start to hopefully correct those things, we may see some of that capacity coming back off the bench.
JK: Do you think that GP partners have a duty to reduce their pay in order to improve access?
AM: No, I think the funding streams for what’s intended for partners in a practice and the funding streams directed at providing the wider range of services are different, and therefore I don’t see circumstances where partners should be necessarily reducing their income to service the requirements of other elements of the service.
In fact, I would say GP partners have gone above and beyond to protect the patients and their staff from the impact of a decade of under-investment prior to NHS England and we owe them our thanks for that. Which is why we are now starting to correct that through the step-change and investment trajectory that we’re now seeing up to the £2.4bn extra recurrently by 2021.
JK: How much of that £2.4bn can practices expect to come into global sum?
AM: I think that’s more a matter for the negotiators and I’m not involved in that, so I won’t go there.
JK: On your recent report on the GP contract change potential, you’re working on reform to the contract that will be the biggest since 2004. Obviously I understand again that’s a matter for negotiations, but can you give us any kind of indication about what kind of transformation that will mean. Are we going to change to the level of 2004?
AM: Well I think there’s a number of factors in play at the current time, which are in the public domain. There’s the partnership review, there’s the premises review, there’s the consultation we’re doing on QOF, there’s the out-of-area policy consultation. And clearly we’re in the middle of rolling out primary care networks, which I think are one of the most sizeable changes that we’re going to see in the coming years. There’s work going on in relation to the long-term plan and what that means for primary care. Indemnity is another one, that will mean significant changes.
JK: Have you looked at the Scottish contract, are there any elements of the Scottish contract that you’ve found particularly attractive?
DH: It’s a fundamentally different contract, and it’s a very different country with a very different starting place. I mean, of course we’ve looked at it, we’ve looked at all sorts of things, but I wouldn’t want to get drawn on whether we’re particularly attracted to any part of it or not, they’re a fundamentally different country and about a tenth the size of England, so they’re starting from a very different place.
JK: Is the GP Forward View something that you think will benefit all practices or is it only those that are willing to transform that you think it will be benefiting?
AM: So I think the ambition is that it benefits all practices over the term of the five years, and what we know is that some of the initiatives are designed to be available to all eventually. Such as support for the access hubs, the rollout of primary care networks, protection against indemnity cost inflation, CQC fees, online consultations, care navigation, social prescribing, help with clinical correspondence handling, direct access to allied health professionals such as the clinical pharmacist.
We’re rolling out direct access to musculoskeletal services coming soon. Embedding the standard contract changes, the practice resilience programme, the general practice development programme. But not everything has reached everywhere yet, but the ambition is those are universal offers that everybody should eventually benefit from.
Others are more targeted, for example career coaching, leadership training, practice manager networks, things like ‘Next-Gen’ and ‘Collaborate’ doctors. I think we recognise this is a complex package, because we have a complex set of problems to solve, and we are trying to make it as simple as possible, because we are conscious of the concerns around over-bureaucratising, if that’s a word, the system. So we’re sensitive to that in all the design of all of the initiatives that we create. But we’re not faced, which we were, we’re not faced with a simple set of problems to solve.
JK: I’m sure you saw our coverage of the GPFV, where we gave NHSE a C minus so far, what grade would you give them?
DH: That would beat my GCSEs then!
AM: I’m not sure I’d characterise it as a grade, I would say that actually there is a significant list of initiatives that are up and running and helping a significant proportion of the general practice world. But we need to try harder to reach others with all the initiatives that are yet to unfold for them. We are, two and a bit years into a five-year programme. And on some things we are clearly challenged, for example GP numbers, on others we’re doing probably better than we expected. For example we have a 5,000 target for allied health professionals, and we’re almost at 4,500 already, in two out of five years through.
JK: One of the complaints that we hear quite often about GPFV, and it came up in our partnership review roundtable as well, is there’s these little small pots of funding, when actually many practices are in real crisis at the moment and they just need core funding increased. Knowing that there’s a real problem in general practice at the moment, is there a way of using this £2.4bn to do that, instead of having to attach strings to these little pots of funding?
DH: We certainly keep under review how we make that funding available, but it’s true to say that when we developed the GPFV we knew there were particular things that practices wanted. So we absolutely definitively wanted to respond to those kind of requests for clinical pharmacists or around support for change and improvement. On the one hand, we want to give flexibility to CCGs and member practices to be able to work and deploy that funding, but on the other, we need to be able to demonstrate that we’ve made progress in the particular areas where we’ve made commitment. There’s a degree of contradiction in that that we’re trying to make sure that we ride out, and we want to demonstrate that we are meeting the commitments that we made in the GPFV. That’s the bottom line.
AM: One of the things I would add, is actually, I recognise that there’s a degree of concern that funding feels piecemeal and the initiatives feel disconnected. However, I think the primary care networks is the unifying vehicle which draws together all of the elements of the GPFV to make it feel real in individual neighbourhoods around the country. Whether it’s around how they do digital, how they do self-care, how they align drivers for change, how they work at scale and actually how they do skill mix. I think the PCNs will hopefully start to make the GPFV feel more real on a neighbourhood basis.
JK: We’ve spoken to Babylon at a recent London conference, [NHS England chair] Malcolm Grant was praising Babylon. Is this a model that you think is workable? Do you think it is something that could be used elsewhere in the country?
DH: It’s certainly been a service that has seen some uptake in the London sites, when they’ve offered that service and we have commissioned an evaluation. We said we’d do that through the CCG and we want to look at the findings of this really carefully. It’s certainly not the only way of providing a digital service to patients, the online consultation fund that we’ve got is enabling practices to provide a really engaging way of accessing their practice and get rapid response from professionals who work in those practices. There are a range of model type there of which of course, GP at Hand is one.
JK: Do you have any concerns about the GP at Hand model?
DH: So the service has been through a clinical review during the last summer and I know that the findings of that were published by the Hammersmith and Fulham CCG primary care committee. They’ve obviously looked very carefully at that service and we clearly will continue to work with that CCG in our role as the insurer of that CCG to make sure that that service, just like any other, is offering a safe set of services to patients.
JK: But there’s also the effect on practices elsewhere, as well. Even the RCGP has said they are cherry-picking the younger, healthier patients, which is of great concern to our readers at the moment. Is this a concern to NHS England?
DH: It’s certainly true that the GP at Hand service requires people to deregister from their existing practice, in order to register with their base practice. I think it’s not yet proven about the impact on individual other practices from whom patients deregister. And given that the catchment is London at the moment, I think that is something that we would want to make sure that the evaluation explores properly. I’m not sure that’s proven actually yet Jaimie.
JK: But, in principle, the GP at Hand model does not prohibit people from signing up, but does strongly recommend they don’t sign up - so it does necessarily bring the younger, fitter patients which leaves elderly, more vulnerable patients, with these practices. In principle, is that something that you’re concerned about?
DH: It’s consistent with the choice of GP policy, which is the original policy on which this particular service is based. They haven’t departed from that and that’s the policy framework I think dating from 2014/15.
JK: The GP choice model, from my understanding, wasn’t as aggressively promoting competition as the GP at Hand model is. From my understanding it was to help commuters, and to allow people to stay with their practices when they move. This seems to be an aggressive market - is that something that GP choice model was meant for, and something you would encourage this new era of competition?
DH: I think you’re right that choice of GP policy was about convenience for patients, and I don’t think we’d necessarily disagree that that’s still what the policy is all about.
JK: Is this kind of competition, is this something that you think is inevitable in England now, and it’s something that you’d encourage, this level of competition, to offer these better services to patients from all over the country?
DH: Patients can choose where they register at the moment, so we’re not really departing from that basic premise.