THE NHS Long Term Plan (LTPlan), and national GP contract reform in England: ‘Investment and Evolution – a five year framework for GP contract reform to implement the NHS Long Term Plan’ were published in quick succession in January 2019 with very little publicity.
Yet these secretly imposed changes heralded a colossal intrusion of the structures developed by the American health insurance industry, into what remains of our NHS.
These two reports announced the imposition of new ‘core Primary Care Networks’, developing into ‘wider Primary Care networks’ all over England by June 2019 and 42 overarching Integrated Care Systems (ICSs) of 1-2 million people by 2021.
Primary Care Networks (PCNs) were originally developed in the US and called ‘Patient-Centered Medical Homes’ as a form of accountable care organisation, by United Health (UH), the largest American health insurance company.
Simon Stevens, UH’s Global Director from 2004 to 2014 was appointed head of NHS England (NHSE) in April 2014. His ‘Five Year Forward View’ (FYFV) of October 2014, pioneered the transplantation of this American model of accountable care, into the NHS.
Thus PCNs, the key ‘building blocks of ICSs’ according to the LTPlan, are simply US imports of American Accountable Care Organisations (ACOs), with a new name.
The new GP contract was brought in by stealth with the collaboration of the British Medical Associations’s (BMA) General Practitioners Committee in England, (GPC England or GPC), who agreed the GP contract reform with NHSEngland (NHSE), without a ballot of the whole BMA GP membership; an unprecedented move.
By June 30th 2019, the GP partners in charge of 7,000 GP practices had signed up to a new Network Contract Directed Enhanced Service (DES), which conjoined these practices into 1,259 ‘Primary Care Networks’, covering neighbourhoods of 30 to 50,000 patients or more.
These GPs were hassled into rapidly signing this second contract, on top of their core NHS contract for providing primary medical services to their own NHS patients… by the Clinical Commissioning Groups (CCGs) the Local Medical Committees (LMCs) and the BMA.
This was an enormous and historic step, with colossal implications.
In signing this Network Contract DES, the practice partners handed over their lists of NHS registered patients to the PCNs, under the direction of the ICSs.
The joining GP practices also agreed, in return for a network participation payment, to build the new PCN, organise its governance, decide where the new network funds should be received, and vote a Clinical Director onto the ICS board.
In addition, GP practice partners had to agree to perform network DES specifications for 2019/20. These included agreeing to:
- share patient data with all network practices, staff and other medical providers which may join in the future,
- perform extra access clinics,
- work in new network ‘Multidisciplinary teams’ (MDTs) of non-doctors (starting with social prescribing link workers, clinical pharmacists, first contract physiotherapists, Physicians associates and clinical paramedics),
- provide digital virtual clinics
- work according to managed care pathways, as instructed by the STP (Sustainability and Transformation Partnership)/ICS board
- and promote ‘service redesign’ to cut costs and make ‘shared savings’ from reducing referrals of patients to hospital.
Other specifications included ‘Anticipatory care’ of the chronic sick, enhanced health in care homes, special medication reviews for complex patients, ‘personal comprehensive care’ and early cancer diagnosis.
These Network Contract DES tasks would have to be performed on top of the duties of their core NHS primary care contract.
In addition, the GP partners joining the Network Contract DES had to sign a legal Network agreement.
This binds them to admit other providers of medical care, public and private; such as community providers, acute hospitals or mental health trusts, plus local authority social care, to create a ‘wider PCN’ as opposed to the ‘core PCN’ consisting of the original GP practices.
The legal agreement means that the different providers have to agree to cooperate in sharing network funding and new network staff and profits, and to run as a business entity.
This so called ‘triple Integration’ from ‘core PCN’ to ‘wider PCN’ sounds attractive until you realise that the word integration actually applies to the type of commercial contract being used and not to the care given.
The legal network alliance agreement is a form of ‘virtually integrated’ contract.
Stevens’s LTPlan aimed for legislation to create ACOs on ‘fully integrated’ contracts to run ALL NHS services and social care on ONE contract for a lead provider.
On 13.2.20 a statutory instrument was slipped through parliament to make it possible for the NHS to contract a bidder to provide ALL medical services and social care in one single ICP (Integrated Care Partnership) NHS contract.
ICPs are what NHSE wants. ICPs could be given long term NHS contracts for all services, with GPs as salaried employees ending their independent NHS contractor status.
The ‘profit opportunity’ for the ICP contract holder comes from holding one fused budget and freedom to commission and provide or deny services, and to redesign services, so as to drop the the less profitable bits such as acute care and maximise the profitable bits, using a whole population capitated budget. This is the aim of the five to ten years of ‘investment and evolution’ of GP contract reform.
This aspect of the GP contract reform has received little attention, but it remains the elephant in the room as the major threat.
On 23rd December 2019, the second ratchet of the GP Network Contract DES specifications for the year 2020/21 were presented by NHSE, for a three week consultation.
There then followed an avalanche of dissatisfaction from GP partners, LMC leaders and PCN CDs, some of whom resigned en masse in parts of England, saying that the extra workload was impossible, given the crisis in general practice, especially the requirement to perform regular ward rounds in care homes, and that to even try and do it would render practices bankrupt.
Some LMCs, such as Berkshire, Buckinghamshire and Oxfordshire recommended that their constituent practices refuse to sign up to the Network Contract DES for the second year.
When GPC re-met on 16.1.20, it voted to oppose the new Network specifications for the coming year.
They also passed a resolution calling for a special LMC conference to discuss the outcome of the 2020/21 contract negotiations and what action the profession should take.
GPC then renegotiated the 2020/21 specifications and agreed to a raft of changes including more money, some slowing of the pace of change and other modifications.
NHSE seized the opportunity to add a further long list of new role non-doctor staff to be employed in the PCNs, including care-coordinators, health coaches, dieticians, podiatrists, occupational therapists, and mental health staff.
These changes were accepted by GPC, with a 71% vote in favour on 6.2.20. Thus for the second time the BMA GP membership has been denied a vote on the new national GP contract reforms.
According to Pulse magazine 4.3.20, ‘GP leaders to vote on wholesale rejection of the network DES’, GPC has let it be known that there can be no overturn of its recent decision to accept this year’s modified contract reforms, but leaders can protest their views at the emergency LMC conference on 11th March.
Berkshire is expected to propose the following agenda committee motion, which does not, however, call for complete rejection of the Network Contract DES, merely rejection as currently written; ‘That conference believes the PCN DES is a Trojan horse to transfer work from secondary care to primary care and that:
(i) this strategy poses an existential threat to the independent contractor model
(ii) there should be immediate cessation of LES and DES transfers from practice responsibility to that of the PCN,
(iii) GPC England is mandated to urgently survey the profession to get feedback on whether they intend to sign the new PCN DES.
(iv) GPC England must urgently negotiate investment directly into the core contract as the only way to resolve the crisis in general practice by trusting GP partners with realistic investment
(v) the profession should reject the PCN DES as currently written.’
Points (i) and (iv) are correct. It should be obvious by now that NHSE is determined to kill off the independent NHS contractor status of GP practices in England.
From the early ’90s, successive governments have proclaimed the private US Health Maintenance Organisation (HMO) Kaiser Permanente as the desirable model for the NHS.
Stevens’ FYFV called for US accountable care organisations ( ACOs), a variation of HMOs to be imposed in England.
These ‘new models of care’ were called MCPs (Multispecialty Community Providers) and PACS (Primary and Acute Care Systems). ‘Core PCNs’ and ‘wider PCNs’ are just the latest name for these same MCPs and PACs and have the same structures and principles as American ACOs.
The description of these, as ‘integrated care’ has confused many people into thinking they have something in common with the NHS as founded, which is not the case.
The private health insurance sector in the US now runs most of the medical care provided by state funded Medicare, at a profit in their HMO/ACO models, and rip it off.
Stevens is the representative of the American health insurance industry in England, with a mission to open up one of the largest state funded national health systems to private company exploitation.
UH’s commercial arm Optum is already heavily involved in large financial/technical contracts for CCGs and PCNs. Stevens has just been knighted in the New Year’s Honours list.
The NHSE document published on the last day of the BMA’s ARM 27.6.19, restated that ‘PCN development is mission critical for ICSs and STPs to implement the Long Term Plan.’
It also threatened that if GPs that did not cooperate in making the PCN model work, they would end up being salaried, working for corporate providers.
‘Through the Network Contract we have given the independent contractor model a major shot in the arm. It is now down to PCNs to decide their own long-term future: take responsibility for securing a generation of partners, or by default (rather than choice) become salaried to other NHS providers.’
Shamefully many GPC leaders peddle the same untruth. Oh!, they cry, NHSE is trying to save the GP independent contractor model, with their new PCNs.
Nothing could be further from the truth. Once in a PCN, the GP partners have to obey the iron heal of the diktats coming from the STP/ICS boards, to cut, ration and reduce necessary hospital referrals and lose all traditional professional autonomy, and become completely financially intertwined with the networks and ICSs. PCNs spell the death knell of GP independent contractor status.
Ironically, the BMA itself warned in 2016 of the dangers of the loss of GP autonomy, and Commissioner dictatorship and the risk of perverse financial incentives from virtually integrated contracts tempting GPs to prioritise making savings and rationing at the expense of essential care for their patients.
Those who persist in seeing the new PCNs as benign ‘NHS’ entities might like to study the United Health 2012 handbook for building ACOs, with a forward by Stevens.
All the features listed are found in the current creation of the new PCNs and ICSs:
- the setting up of commercial style management to build the models (i.e. the STP and ICS boards.)
- a built-in role for corporate management consultancies and insurance companies like UH and Optum to manage the technical infrastructure and back office functions, of for-profit healthcare.
- the necessity of getting private firms like Optum to perform the ‘back office’ functions.
- a huge emphasis on digital virtual consultations
- the introduction of ‘new roles’ to act as doctor substitutes and enable a cheaper skill mix, with less trained staff ‘working to the top of their license’.
- risk segmentation of the population in order to parry the costs for the most frail, called Anticipatory care and whole population management. Encouragement of dying at home.
- cultivation of 24 hours community care provided by non-doctor MDTs, run by network care -coordinators.
- top -down managed care pathways, to cut costs.
- financial incentives to GPs to reduce hospital utilisation both emergency and elective starting with shared savings schemes and ending with risk share/gainshare models on whole population capitated budgets.
- quality targets like QOF with financial rewards.
The manual guarantees a two to one rate of return of investment for UH’s Person Centred Care Homes.
- GPs must demand a vote on GP contract reform so that all GP BMA members can take part.
- GPs should reject the imposition of the Network Contract DES
- The money going to Network funds must be redirected into core general practices and prioritise the retention and training of an extra 7000 GPs.
- The heist of GPs practices’ patient lists by PCNs and ICSs must be reversed.
- There must be no non-doctor substitutes doing GP’s work, for which they are not medically trained, as this constitute a risk to patients.
- The BMA must stop pandering to the down-grading of general practice and uphold the right of patients to see their own GP, in proper physical consultations, with adequate consultation times and continuity.
- Restrictions on GP referrals by rationing and referral management schemes must be abolished, and GP autonomy restored in respect of referrals and prescriptions.
We need to build a new leadership in the BMA to forward the struggle to preserve our NHS structures and the public service principles still embedded in the current workforce, and restore our NHS as a national publicly owned and provided health service, prioritising patient need not corporate profit.
As the capitalist system crashes into the worst global financial crisis for decades, it is clear that only Socialist planned economies can achieve these aims and the fight is on to build these world wide.
