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At the heart of general practice since 1960

I'm cautiously optimistic about what NHS England has achieved this year

Dr Arvind Madan, director of primary care at NHS England and a GP in London

December marked one year in my role as director of primary care for NHS England. As you might expect, I haven’t instantly managed to reverse the impact of a decade of underinvestment and the pressures rising demand is placing on GPs. However, what I have done is contribute to the NHS England’s understanding of the issues general practice faces, argue for greater investment, help develop a range of practical initiatives and lay them out in a five-year strategy for how we start to turn things around.

I do believe we are making progress in some of the key issues

I appreciate that the broad scope of the GP Forward View can sometimes feel like an array of initiatives. The new NHS England website should also make it easier to get a picture of everything that is happening now, as well as details of what is coming next but this feels like a good point to reflect on where we have got to and how it ties together.

Our focus remains on stabilising practices and although we have accelerated 'getting the money out of the door', we also need to work with CCGs, LMCs and others to ensure this translates into practical frontline help. In addition to £33m in the 2016/17 contract, we have committed to re-running the Winter Indemnity Scheme this year and covering the increased practice costs related to GP indemnity in 2017/18 and 2018/19.

We have launched the £30m three-year General Practice Development Programme with approximately a third of all practices already in line to receive support and secured the funding for a nationwide increase in general practice capacity by 2019 which builds on the 57 Access Fund sites currently covering 17 million people. This is to support both in-hours pressures, and locally determined need out of hours at evenings and weekends.

To ease the burden or bureaucracy we have made six fundamental changes to the Standard Contract designed to stop unnecessary hand-offs to general practice from hospital episodes and are working closely with the GMC and CQC to reduce the frequency of inspections for good and outstanding practices and streamline all reporting, monitoring and regulatory processes.

We have started to tackle the workforce deficit, with more GPs in training than ever before, improvements to the induction and refresher scheme and the retainer schemes, £20k bursaries in under-doctored areas and the launch of phase two of the Clinical Pharmacy Scheme to name a few.

So I do believe we are making progress in some of the key issues that have undermined general practice for too long but of course challenges remain. For example, we need to make sure we embed the doctor-patient relationship in to the core of our plans, whilst making the most of the opportunities offered by improved use of self-care, technology and collaboration across practices and wider stakeholders. Another will be keeping people on board while the improvements take effect.

As a practising GP, I am well aware that all the improvements the GPFV is bringing might not have fully filtered down to consulting rooms yet. The daily pressures and negative headlines continue. However, this progress will continue to flow through the system and decision-makers are now strengthening general practice in the knowledge that without this, the acute sector will fall over.

I have noticed over the last year that the mood music from GPs I meet has begun to change. At the LMC conference a year ago the view was that 'general practice is being systematically destroyed'. This was followed in the summer by 'we don’t believe the General Practice Forward View is real'. Now it seems to be 'we believe it, but it’s not happening fast enough'. Progress of sorts and I do understand the sentiments expressed.

So we’ve reached a small milestone of what will be a long journey. I am under no illusion from my own experience, and the many conversations I have with struggling practices each week, that the key to turning morale around is to make general practice more attractive. At the heart of this sits feeling in control of a manageable workload again. This in turn helps with recruitment and stability issues. One of my personal missions continues to be reversing the tide of low value burdensome activities encumbering general practice now, hence the changes to the Standard Contract with hospitals.

During my first year I have learned two valuable lessons. The first is that robust execution on a positive strategy is insufficient. The GPFV will be judged on whether people know what is happening, and also if they think we are being honest about where we fall short, and why this is the case. The second is that there is probably nothing I can say that won’t attract critics. I used to be one. But after 20 years as a GP I reached the stage where I wanted to do more than describe the problems. I want to work with others to see past the noise, navigate the complexities and find the solutions. My own cautious optimism continues based on seeing growing numbers of people who feel like I do, and are getting on with doing all they can to improve things now.

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Readers' comments (7)

  • If it's happening at all, it is far far too slow to stop GPs retiring early, emigrating and refusing GP as a career. Present GP partners see nothing attractive in becoming an employee on a lower income paying PAYE in a massive practice of 200,000 patients run as a rigid corporate PLC. Where is the personal family GP practice of old in that? GPs will lose all autonomy and be answerable to their up line manager. Well you could say that this is like like being a consultant in hospital, but at least they have the option of private practice. Besides most present GPs chose general practice for the simple reason that it would send to have a degree of independence!

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  • Arvind - How is it preferable to have hundreds of pots of money (all with conditions attached) for a practice to bid for, instead of increasing the global sum?

    Why are you supporting the government in its quest to crush small and medium sized practices by eroding core funding?

    The comments made by Hunt recently made it abundantly clear that he thinks the GPFV money is in exchange for 7 day working. Are you so naïve you didn't realise this?

    As for the lip service paid to indemnity - that put a smile on my face. Indemnity is now over £1,000 per session worked and rising. This is an absolute scandal and you think putting a few extra quid into the partnership pocket will fix that?

    You are the Director of NHSE. Do something useful, for Christ's sake. Put a stop to the erosion of PMS funding. Put a stop to the astronomical service charges through PropCo. Offer a lifeline to practices that are failing and Partners end up being personally liable for the costs.

    Stop selling the lie of the GPFV and show some courage

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  • This comment has been moderated

  • 1. If you want more extended hours why not just increase the payments in the existing system to reverse the 2011 slashing of payments?
    2. Over the past decade the NHS has saved millions by dumping all clinic and inpatient follow up to GPs who do this due to a fear of being left liable. Why does NHSE trust GPs enough to dump the work on them but can't give an extra penny without surrounding it with KPIs and onerous requirements?

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  • Looked at Pulse's workforce figures this week-£33 million works out at approximately £900 per GP!
    Well that's that fixed then!

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  • We are tired of all the games.

    We are tired of the giving with one hand and taking away with the other (no lifeline at all when we are already drowning)

    We are tired of the soundbites of £xx millions promised here and there (amounts to not a lot per patient or per practice)

    We are tired of all the initiatives that we have to bid for (just give the money to us, no hoops attached)

    We are tired of all the dishonesty and collusion with every single regulatory body out there in the active destruction of General Practice (just come out and be honest with the public)

    We are tired of the disingenuous bailouts of failing practices, or the similar incentives to others to take on their work (why destabilise and let practices fail in the first place?)

    We are tired of the increasing workloads yet seeing a real term cut in pay every year for over a decade, now currently standing at 20% less than 2004-5 levels (who else would work like that?)

    We are tired of these grandiose delusions where glossy brochures of plans detailing different ways of working with fewer staff, fewer resources, fewer beds, less funding somehow translates into being able to do more and more and more

    Please do more before we are all so tired that you will have no-one, absolutely no-one, to engage with, whichever 'forward view' you happen to subscribe to next

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  • Put a chap on the pedestal, give him a good salary and get him to sing like a canary - just anything from Hunt's musical notebook. That's life and the whole truth. Nobody in his/her right mind would have an inkling of optimism about NHSE's shenanigans.

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  • So you are cautiously optimistic are you? And what would your employers at NHS England say if you announced on these pages that you were "frankly pessimistic" like the rest of us?

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