GPs’ role as family doctors is under sustained attack

The essence of NHS England’s GP Forward View is a drive to commercialise GP practices, push out traditional family doctors and bring in large super practices that will operate through a new “care model” that is compatible with the  Accountable Care Organisations that NHS England intends will run NHS and social care as a public/private partnership – like the Private Finance Initiative, but for health and social care services as well as buildings.

GPs in primary care are at the centre of the NHS.

But funding for general practice has fallen in real terms compared to secondary care – even though the government is pressing for treatment to move out of hospital.

There is a national picture of GP burnout, early retirement, exponential rise in GPs wishing to go to Australia or Canada, and a fall in applications for training places.

As part of the National Health Activists Network (NAN) 2016 Testimony on the Destruction of the NHS , Gaynor Lord presented information about how this is panning out where she lives, in Brent.

It is pretty much the same everywhere else too.

Brent in NW London has suffered from being part of the NW London “Shaping a Healthier Future” hospital reconfiguration, which has been commissioned with the involvement of local GPs on the Clinical Commissioning Group (CCG) who have demonstrated clear conflicts of interest.

Shaping a Healther Future (SaHF) is a project to reconfigure the major hospital provision in N W London; its first “casualties” were the A&E closures at Hammersmith and Central Middlesex.

It also requires the transfer of hospital services into the community, with an opportunity for contracting that feeds the development of large scale GP “locality companies” and furthers the destruction of the concept of GP practices that operate as family doctors.

Major “reconfiguration” of primary care with no public consultation

Without consultation on such a major reconfiguration, the latest plan for primary care seems to be that a locality 18 – 64 age range will be catered for by the overall network, with the elderly and children within “their” practice’s care. Where responsibility for individual patient care will sit with any GP is anyone’s guess.

This idea of “mass cover” chimes in with NHS England’s new promotion of 30,000 patients lists (with an exception made for rural practices, no doubt as a result of contributions by Sarah Wollaston). Patients generally have no awareness of this.

All of my generation will have had examples of seeing our familiar GP who, knowing us, will pick up on our health issues and at least have a background knowledge of us without having to trawl through the summary notes on the computer in very short appointments. There was a rationale for having a family doctor. No longer.

Of course these kind of changes cannot take place without flexible contracts. My own very personal experience of my very popular excellent GPs, who have served us for over 12 years, is a case in point.

Originally employees of the local Primary Care Trust, then tendered out, after a nine-year patient backed campaign that took advantage of the Labour government’s ‘Right to Request’ legislation, in April 2013 the practice became a social enterprise.

Without warning or consultation or indeed abiding by its own procedures for managing time-limited contracts, 2 1/2 years into the contract NHS England are tendering us out again as part of “Tranche 4” Alternative Provider of Medical Services (APMS) contracts, ignoring vigorous patient complaints, petitions and well attended patient meetings.

Alternative Provider of Medical Services contracts were introduced by the New Labour government in 2004, to open up primary care to ‘new providers’. They were used to procure the Labour government’s ill-fated ‘Darzi’ centres across the country.  A 2009 GP Magazine article says:

“APMS contracts are the private sector’s gateway to providing primary health care to NHS patients.”

They don’t require a GP practice to be run by medical people, and they are very controllable, time limited and driven by Key Performance Indicators (KPIs).

(Allyson Pollock’s 2013 article on the Commercialisation of GP services is relevant.)

As if according to the “defund, run down, privatise” plan, after more than 500 GP practices had closed between 2009/10 and 31 August 2014, at an accelerating rate, NHS England – invoking competition law – said it would open up all new GP contracts to bids from the private sector, and only use the time-limited Alternative Provider of Medical Services (APMS) contract, not General Medical Services or Personal Medical Services contracts.

Following the BMA General Practitioners Committee’s challenge to the legality of this, NHS England watered down its plan – but, as the General Practitioners Committee said at the time, this would only make a difference if NHS England put its revised plan into action.

Re-tendering existing GP practices is directed at large private companies – some of them “locality” companies run by CCG-member GPs

NHS England now says it is bound by competition regulation to tender out our GP service, but its own guidance says this is not true. As a practice patient participation group, we continue to debate the case – but up against an intransigent NHS England, what hope is there?

It is clear this tendering is directed at the larger providers. The “market engagement event” for this describes the process:

“The first three tranches of the programme have resulted in the successful procurement of ten APMS contracts using the standard London contract and methodology. We are about to start Tranche 4 which will offer the greatest number of opportunities to potential providers so far. We would therefore like to offer you a fresh chance to obtain an overview of the programme as a whole, and of the opportunities offered by Tranche 4 in particular.”

We have a list of those who attended the event (our GP’s had to be in surgery that Wednesday afternoon) – the potential bidders for the 16 London practices in Tranche 4 include Virgin, a US based venture capitalist body misleadingly called the Practice Group, the Hurley group which holds various practices across London (with one of its partners recently appointed Head of Primary care services in NHS England – another is Clare Gerada), and one of the locality companies mentioned above.

Bidders for Tranche 4 complete Pre Qualification Questionnaires without saying which practices they want; the bidding process is essentially anonymous – so, even if our GP practice makes it to the next stage, it will not being able to set out its own popularity and success (growing from 5500 to 8500 patients in under 2 1/2 years and holding the local phlebotomy walk-in contract as well as the hub services for the locality for out of hours appointments).

And of course our doctors – already busy and actually seeing patients – will have to spend their time and money from the social enterprise funds in order to undertake all the legal processes as a result of this tendering.

The size of the practice makes it very attractive and our patients feel they have become a juicy commodity to be traded.

If GPs do not get the practice, since at least one of them is not local, that GP will be lost to the area.

This commissioning – part of a joint Clinical Commissioning Group/NHS England commissioning of primary care services – has gone ahead without Brent Clinical Commissioning Group raising any objection to the destabilisation of my practice and other local practices. Nor have these GPs had any support from their local Local Medical Committee rep, who simply waved them in the direction of the overall London-wide General Medical Council.

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