“The future of health”: Dr Arvind Madan

9 December 2014

General practice for the 21st century

Is the system unsustainable?

A combination of factors conspires to make the current challenges facing the NHS perhaps the greatest ever. Reducing budgets, increasing complexity and rising patient expectations mean that general practice and urgent care are creaking under the pressure. Add to this the drive towards greater regulation, poor infrastructure and the recruitment crises and we have a system approaching breaking point. Meanwhile politicians bid for the public’s trust with their beloved institution. What is also becoming evident is that the hope being placed in initiatives such as federating, crossorganisational integration, or even the merging of health and social care budgets, is unlikely to bridge the emerging funding gap alone.

So what needs to change? 

So we turn our focus to wellness, prevention and earlier intervention, all of which are the natural territory of primary care. But how does a system struggling to even be reactive become proactive? This involves a paradigm shift from commissioners’ current drive to measure and monitor slithers of activity, towards a focus on population based outcomes created through frontline innovation. This requires a permissive and supportive commissioning environment, tangible support for federated working and real terms investment in primary care. When many secondary care providers face bankruptcy, it takes a brave commissioner to see beyond the current crises. Following the earthquake in Christchurch, the healthcare system was required to respond quickly. The co-payment system prevalent in New Zealand was suspended within an hour and GPs were allowed to design the solutions. Whilst the journey had started before the disaster, the pace of change towards a more efficient and, ultimately more cost effective service was accelerated. Some of these answers are now being adopted internationally.

How do we respond?

The recruitment crisis in general practice has now reached the point of no return. The pain is starting to hit as practices around the country fail to recruit. This will inevitably get worse before it gets better, whichever initiatives are now adopted. So we have no choice but to explore the role of skill mix, centralised demand management and revisit what we tell our patients they can reasonably expect. The system evolves at times of stress but general practice is more fragile than ever and we are in danger of losing the magic that happens between doctors and patients in the consulting room. We press ever closer to the edge of most GPs’ discretionary effort and goodwill. We bear some responsibility for this, as we have failed to adequately explain the value of our place in the system, and face losing the space to make the real connections with our patients that change many of their outcomes. Meanwhile commissioners continue to invent more innovative ways to measure our processes.

The answers should come from within. How does general practice cope with delivering personalised care a million times a day? Our response has been to develop technology that allows us to safely manage and segment demand, giving us more time with patients who need our generalist skills and abilities to manage risk and the needs of our most complex patients. This is the real art of general practice and can never be automated. We trialled a new system using GP practice websites to allow patients to use symptom checkers, self-help content, sign posting to alternate resources and the ability to email their own GP using webforms on 100 common minor conditions. Our study of over 133,000 patients top-slices face-to-face demand and demonstrates better access, health outcomes, practice efficiency and commissioner savings, as fewer patients overflow into urgent care settings. Alongside empowering patients with access to their medical records, these are examples of how we bring scalable technological solutions to the frontline of primary care.

Dr Arvind Madan, Chief Executive, Hurley Group

This blog was taken from an article written for the brochure that accompanied Reform’s major health conference on the 2 December 2014.



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