THE SIGNIFICANCE OF THE NEW GP CONTRACT – it introduces American Accountable Care methods into the UK NHS

The front of a huge national demonstration in London demanding no NHS privatisation

THE TITLE of the new GP contract is ‘Investment and evolution: A five-year framework for GP contract reform to implement the NHS Long Term Plan 31.1.19 (Framework)’.

The main aim of NHSEngland’s ‘NHS Long Term Plan’ (LTPlan) is to establish Integrated Care Systems (ICSs) throughout England by 2021 and for these to evolve into Integrated Care Providers (ICPs).

ICSs and ICPs were previously called Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs).

It was against the latter that Judicial Reviews were fought by NHS campaigners from 2017.

In January 2018, Pollock & Roderick exposed the potential for single contract organisation ACOs to be run by private companies to make profit out of commissioning and providing health and social care for large populations of NHS registered patients, on huge long-term contracts.

The purpose of ICSs and ICPs is to totally transform 1) the payment systems and 2) the commissioning and delivery systems of health and social care in England, along the lines of US Accountable Care.

In the latter, providers of healthcare are incentivised to work together, to commission and provide the vast majority of healthcare for a whole population, on a capitated budget.

The commissioner and provider align objectives to make a surplus on the budget, whilst pledged to achieve quality standards. The basic principle is that of the American Health Maintenance Organisations (HMOs): ‘the less care you provide, the more money you make.’

Methods used to commission and provide care below budget are to develop keen leaders, risk segment the population, have sophisticated digital systems to promote virtual consultations, share patient data and collect data on health service use and cost, and have ‘integrated multidisciplinary teams’ of mainly non-doctors adherent to managed care pathways providing 24-hour continuity of care to keep patients out of hospital, substituting for doctors as often as possible.

Ruthless imperatives are to:

  • reduce ‘skill mix’,
  • continually redesign care to cheapen and cut it and
  • stop patients accessing hospital care.

The favoured payment systems are:

a) capitated budgets (whole population budgets )

b) performance-related rewards, e.g QOF and CQUINs in England

c) ‘Shared Savings Schemes’

All of the above make up ‘A new Service Model for the 21st Century’ promoted in the LTPlan (Chapters 1&7) and the Framework.

However, the confusing way they are written disguises the US-style Accountable Care being smuggled in.

The reference to ICS boards on Page 30 LTPlan actually refers to the STP boards (Sustainability and Transformation Partnership boards) already imposed in 44 areas of England in 2016.

Their remit, known from STP plans, is to make huge cuts, reconfigure care out of District General Hospitals, develop a ‘local system workforce’ with ‘new roles’, divert elective care into the private sector and get GPs into ‘scale’ integrated primary care systems.

The barrier to the latter, despite all the super-practices, federations and primary care networks that have been created in the last five years by NHSE, is the fear amongst GP principals that they would lose their independent NHS contractor status and their life-long General Medical Services (GMS) contracts.

This would be the case in ICPs.

GPs are right to be worried. The strategy is to ‘supersede’ so-called ‘cottage industry’ GP practices, with ‘post-industrial’ care, through ‘family care networks’.

The Framework is being hailed as the final solution. NHSE is happy that GPs are being herded into new Primary Care Networks (PCNs) enabling the establishment of ICSs, all over England by 2021.

The BMA applauds the Framework as a victory for saving GPs’ core primary medical services contracts for now.

But the title gives the game away. It is five-year GP contract reform ‘to implement the NHS Long Term plan’.

GPs are being told to sign up to a Network Contract DES (Directed Enhanced Services) as an ‘extension’ to their core practice contract AND a Network Agreement, which is a legal integration agreem ‘The PCN is a foundation of all integrated care systems …’ (p30 para 4.28 Framework)

The practices, in agreeing to the Network Contract DES, AND the Network Agreement are bound to work together, share patient and other data, carry out network specifications, share network funding for new non-doctor network staff (22,000 of them over five years) and deliver other urgent care and extended hours services.

The network agreement requires that providers of other medical and social care join the new PCN, e.g. community providers such as dentistry, optometry, Virgin-run nursing, charities, acute and mental health trusts and local authority social care, over time.

In this way, the new PCN becomes an integration machine.

In signing the Network Contract and Network Agreement (and agreeing an area covering 30 to 50,000 or more population, giving their patient list numbers, choosing a Clinical Director to sit on the Sustainability and Transformation (STP) board, and deciding which NHS-contracted body will receive central network funds), the member practices would form a new PCN.

Practices are being jumped into joining new PCNs by 30.6.19. Although this is supposed to be voluntary, pressure is being applied for 100% coverage.

The new PCNs would work under the direction of the STP via the Clinical Director and must deliver LTPlan and STP directives and protocols, i.e. commissioner diktats, or network funding stops.

In this way, the STP in the area (1-2m population) would become REAL – in the sense of running GPs and patient lists as their delivery arm.

ICSs=STP boards+PCNs. ICSs cannot function without NHS-registered patient lists.

Astonishingly, whether practices join the new PCN or not, their patients will belong to the Network anyway (p28 para 4.19) and network services would still be provided to those patients.

Two critical consequences flow from this Framework:

1. Patient lists will in future belong to the practice AND to the network.

The ownership of NHS patient lists will in this way be acquired by the ICSs.

2. GPs will be working to their original practice contracts AND to the Network contracts. The two contracts would be double-running.

GPs are being assured that as they still retain their core practice contracts – albeit overlayed by the Network Contract DES, and the network integration agreement – that they are safe and their original GP primary medical services duties would remain the same.

But for those with eyes to see – with the augmentation of network funds over five years (£1.8bn nationally compared to £1bn for the core practices) the flooding-in of new non-doctor network staff to do GP work, requirements to perform new ways of working, and redesign care, and diktats to reduce hospital referrals and cut hospital care to achieve ‘shared savings’ for the ICS – GPs would lose their autonomous leadership role of patient advocate, prioritising optimal care for their patients.

GPs would find themselves driven by perverse incentives to endorse the constant cheapening of care and denial of hospital treatment.

GP practices would become entangled in the Networks physically and financially and find it difficult to get out again.

They would be better not to sign up. Over half of GPs are now salaried sessional or locums and the BMA GP membership has not had a vote.

This Framework is a thousand times worse than the GP contract change in 2004. It aims to herd GP practices into new integrating networks which form the basis of giant ICSs throughout England.

Through multi-year GP Network contract changes, the Framework enables ICSs to evolve, and paves the way for fully integrated ICPs on single long-term NHS contracts, tailor-made for international corporate takeover.

The American model has been pursued in England by successive governments since Enthoven recommended HMO Kaiser Permanente to Margaret Thatcher in 1990. Simon Stevens, (Blair’s health advisor 1997-2004, vice president of UnitedHealth the biggest US health insurance company 2004-2014) was appointed CE of NHSE in 2014 by David Cameron, and then advocated ACO-style ‘new models of care’ in the Five Year Forward View.

American accountable care methods are now being imposed in England from within by NHSE, well before President Trump opened his mouth about more US trade deals.

These proposals should be exposed and opposed by all who treasure the NHS publicly provided according to clinical need, comprehensive and free at the point of use.