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The News Line: Feature Some big issues for the London-wide LMCs Annual Conference
GPs protest against the ‘GP at hand’ online GP practice accusing it of cherry-picking patients
A NEW CONTRACT for GPs was signed by Dr Vautrey, the chair of the BMA’s GP committee (GPC), on 31st January 2019. Its full title is ‘Investment and Evolution, A five-year framework for GP contract reform to implement the NHS Long Term Plan.’

This is one of the burning issues being discussed at the Local Medical Councils (LMC) conference in London today. The NHS Long Term plan (Jan 2019) speeds up the demands of Simon Stevens’ Five Year Forward View (Oct 2014), especially the commitment to more massive cuts and transformation and redesign of services.

It is predicated on a huge shift away from hospital care into ‘care in the community’.
It aims to set up Integrated Care Systems (ICSs) all over England by 2021, to make huge savings and reduce hospital care. The contract that GP primary care contract holders are being told to sign up to by May 15th 2019 is called a ‘Network contract DES’, but it is very different from any contract GPs have had before in the NHS.

In fact, it is a wider Primary care Network Contract, or Network contract. It involves signing a Network Agreement with other providers such as community care providers. In registering for the Network Contract, and signing the Network Agreement, the GP contract holder would be signing his NHS patients over to the control of the wider Network and ICS in his area.

This framework of rolling contract change over five years enables the heist of NHS patients with their capitated budgets eventually away from independent provider GP practices to corporate style ICSs.

The immediate financial offer sounds attractive as the core GP contract is to receive a guaranteed increase in funding by around £1bn in the next five years, while the Network Contract is to provide a funding stream of around an extra £1.8bn in the same period. However, the latter is tied up to stringent new commitments or strings.

The ‘Network Contract DES’, alias Network Contract, demands that GP partners sign up to a Network Agreement, which involves carrying out Network-specified services. These include participation in an ‘Out of Hospital Community Emergency Care Scheme’ (LT Plan) to stop patients attending hospital, promoted by an Impact and Investment Fund.

It includes urgent out of hospital care services in the community or patient’s home performed by a network multidisciplinary team of various staff and could involve home visits or referrals to an Urgent Treatment Centre. Arrangements would be set up by the Networks to minimise patient admissions to hospital such as GP streaming at the front door of A&E, patients being seen in the ambulatory care sections of A&E so that they do not have to be admitted, Same Day Emergency Care (SDEC), early discharges from hospital, big reduction in referrals to hospital outpatients, emergency visits to care homes including out-of-hours to prevent the need for hospital admission.

• enhanced care in care homes, involving regular visits of a named GP and nurse. • extended access clinics e.g in the morning, evening and weekends. • digital consultations with patients. Patients are to have a new right to get a digital appointment by 2021.

• the Comprehensive Model of Personalised care may involve inviting the patient to have a Personal Health Budget, which could be spent on community activities. A social prescribing link worker could be employed by a voluntary body, and could recommend such care to the patient. Their pay would be 100% reimbursed by the network funding stream.

• Anticipatory Care involves seeking out the most vulnerable patients and aiming to treat them pre emptively to avoid hospital attendance. • structured medication reviews.

In addition, the GP would have to agree to new ways of working – such as working with a Network multidisciplinary team (MDT) with other community staff such as community nurses, community geriatricians, dementia workers, podiatrists/chiropodists and others who would be working according to network protocols and care pathways and LT Plan priorities.

Some ‘new role’ non-doctors have been given what were formally doctors’ powers – to take a history, examine, make a diagnosis, organise tests, produce a care plan, prescribe and do procedures, eg first contact Advanced Practice Physiotherapists and paramedics.

They are not medically trained like a GP (5 yrs medical school, 5 years GP training). They are told they are autonomous. 111 would be given the power to slot some new patients into GP clinics directly.

Receptionists are being given powers to suggest patients see ‘new role’ staff rather than the GP, – a pharmacist instead of the GP for example – and to organise a digital consultation instead of a physical one. As a consequence of the rapid augmentation of the workforce by such ‘other roles’ not supervised by the GP, the traditional pre-eminent clinical position of the GP in the provision of NHS primary care to patients is in danger of being eroded. The patient’s chances of seeing the doctor could be reduced.

The traditional advocacy role, in which the GP prioritises the optimum medical care for that patient, is now hemmed in by Network priorities to save money and avoid hospital care. Likewise, GP clinical autonomy could be curtailed by the necessity to always work to network managed pathways.

Traditionally the GP had the gatekeeper role, with the power to refer to hospital or other services and to prescribe medicines. Now new prescribing powers are being given to clinical pharmacists, who will be doing medicine reviews and clinics, to physiotherapists and to higher paramedics.

There is to be a new emphasis on electronic data collection and data analytics to minutely monitor performance metrics. The GP contract holder, having signed the Network Contract, would be regarded as having joined the ‘Wider Primary Care Network,’ which would provide the primary care element of the ICS.

The wider Primary Care Network is defined as an ‘investment and delivery vehicle’, (para 4.4 P 25) and it can decide its delivery form, whether it is to be through a GP federation, a lead practice, an NHS provider or social enterprise partner (para 4.1 P 31). The terminology is business language.

The Network Contract, demands that the GP works alongside providers of community services, mental health care, social care and others which could be public or privately run, but would be part of the ‘wider Network PCN and the ICS.’ They could be bound by local alliance contracts… or lead provider responsibility (Para 1.54 P 30).

‘Each ICS will be required to implement integral services that prevent avoidable hospitalisation ( para 1.54. P 30). ‘A new “accountable Clinical Director” (CD) would be a GP compensated with extra money, accountable to theSustainability and Transformation Partnership (STP) or ICS. His job would be to make sure the network delivered on the local plans of the ICS/STP and the national plans of the NHS Long Term Plan.

‘The CD would take part in the redesign strategy of the PCN and decisions on the skill mix of the workforce employed. ‘The wider PCNs, of 30,000 to 50,000 registered patients, would form the basis of the ICS, which would also provide community care, social care, mental health care and some secondary care, e.g. from a geriatrician (or could involve an Urgent Treatment Centre or local hospital according to the LT Plan). This is called “integrated care” although private providers could subcontract to provide parts of it.

‘The idea is that there would be joint commissioner and provider committees, eg, of Clinical Commissioning Groups and trusts, in every ICS, which could operate as a publicly accountable Partnership Board. ‘The aim is to deliver primary care and community services on a single, ICP contract in the future.’

We are told that each STP is to morph into an ICS. We can therefore expect 44 ICSs in England with registered patient numbers of around one to two million each. There is to be one CCG per ICS. Several networks of 50,000 or so patients will be signing up with one CCG.

The myth is peddled that Integrated Care Systems, ‘integrate joined up care round the patient’, primary and secondary, physical and mental and health and social care.
But in fact, the integration is around the commercial style contract, and in particular around the principle of ‘shared savings’.

NHSE is offering extra funding to those PCNs that fulfill their targets to reduce hospital utilisation. This is money for hospital care denied not care supplied, and is the driving motive of the US Accountable Care Organisatons and Health Maintenance Organisations, on which ICSs are modeled.

The other side of this contract is the effect on patients. Huge Integrated Care Systems (ICSs) for one to two million patients each are being imposed to provide ‘integrated health and social care’ and, no doubt, in the course of time are designed to attract private corporations to run them as huge public private partnerships.

The new GP contract coerces GP contract holders to become part of these ICSs and work in them in return for guaranteed increased practice and network funds for five years and other attractive features like the state funding of indemnity for GPs and all network staff, from now on.

However, in return, it is obvious that the traditional doctor-patient relationship would be sacrificed as the proportion of GPs falls and primary care is augmented with 20,000-plus Allied Health Professionals employed by networks and told they are now the main ‘support’ for primary care.

The GP will no longer be the sole gate keeper to hospital referral, diagnostic tests, and prescribing of drugs. The continuity of care so prized in British General Practice would be diluted. If practice contract-holders don’t sign up to a wider Network Contract, their patients will be registered with it anyway, we are told!

The rationale is that the so-called ‘expanded network services’ and ‘improvements’ must be allowed to ‘benefit’ those patients of practices that refuse to sign. With its emphasis on diverting patients away from seeing their GP and the fixation on reducing hospital care there is no benefit to patients in these changes.

In conclusion, this new GP contract ties GP practices up to a network/ICP contract motivated primarily by the drive to save money and cut costs, deny hospital care and reduce skill mix, preparing it for for-profit healthcare. It must be exposed and opposed.
No GP should sign up to it.

The whole BMA membership and all doctors must be informed of what this means, as well as the other unions and the public. All GPs, salaried and locums should have a vote on it.

It is a blueprint for withdrawing even more specialist hospital care, elective and emergency, and ending our traditional NHS GP-led primary medical care, the latter destined to be replaced over the period of this double running of two contracts, with cheaper medical and community care provided in corporate hubs for big business ICSs. This increases the urgency to throw out this Tory government and get rid of capitalism and replace it with a workers’ government and socialism, to restore our public NHS on founding principles.
 
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