Airedale 38 Degrees members with urgent questions about GP services in their area were shocked at the self-congratulatory nature of the Airedale, Wharfedale and Craven Clinical Commissioning Group Annual General Meeting on 28 September. It culminated in an awards ceremony which was referred to as if that was why everyone was there. But members of the public attended in order to get answers to worrying questions about the future of the area’s NHS.
They came away empty handed.
Of particular concern is the apparent chaos of proposals for the future of primary care under the cost-cutting West Yorkshire and Harrogate Sustainability and Transformation Partnership.
New Modality Partnership Super Practice
Judith Joy asked why there had been no mention of the important change to 1/3 of their 16 GP practices, which have recently set up a new Modality Super practice. This is made up of 6 GP Practices that have joined the Midlands-based Modality Partnership (which has now extended into 5 Sustainability and Transformation Partnerships across England).
The Clinical Commissioning Group said that was nothing to do with them. But it is. The Clinical Commissioning Group are planning to set up an Accountable Care Organisation to run NHS and social care services in the Airedale, Wharfedale and Craven area. Modality aims to be the lead provider in Accountable Care Organisations and is already working on this in West Birmingham and Sandwell.
Formerly known as the Vitality Partnership, the organisation told the Kings Fund in 2014 that it was a ‘GP managed care organisation’. This is a reference to the Health Management Organisations that preceded Medicare’s Accountable Care Organisations in the USA and were notorious for cherry picking patients and limiting available treatments in order to cut costs.
As they commission GP services, and are responsible for managing GP contracts to provide these services, the Clinical Commissioning Group should really accept its responsibility for making sure that the Modality Partnership super practice provides appropriate care to its patients.
Is it ok that most Modality patients do not see a GP? Because the Modality executive director, Dr Naresh Rati, told Pulse magazine, that the super practice’s solution to the GP shortage was to employ a range of less skilled, less qualified staff, so most patients would not necessarily see a GP. Instead, Modality GPs focus on “proactive care looking after… complex cases.” This is about trying to reduce hospital admissions of people with long term illnesses, although there is little or no evidence that this works.
Dr Rati also said that 80% of patient contacts were conducted remotely, through their app, or over the phone. A West Yorkshire health professional commented:
“Would you want your own mother registered there? Great if you are young and busy with a sore throat – they could always prescribe antibiotics (you don’t need) over the phone. Not so great if you are actually ill but have a million and one symptoms that just don’t seem to fit very well together.”
Naresh Rati was frank in his interview that patients didn’t like these arrangements. He said,
“…we are getting ‘push back’ from our patients, who are used to the traditional general practice model, but I think as more and more GPs start to adopt that sort of model, hopefully, society will start to shift as well.”
The West Yorkshire health care professional commented,
“This is a money driven agenda – it forces unimaginative conformity – we will make sure one size ‘will’ fit all. The net will be wide enough and regimented enough to catch the main bits. Those that slip through the net? Well, can’t be all things for all people. It’s bloody awful – a recipe for inequality and health poverty. Nice for anyone lucky enough to have a nice neat little long term condition to manage, not so great if you have something rare or are on the slope to a diagnosis.”
Judith Joy emphasised that despite the Annual General Meeting’s focus on the importance of communication with the public, the patients affected by the merger with Modality had not been contacted regarding this change. She reported to the AGM that a lady asked about it at her practice (one of the six), was told nobody there knew the answer and that they would contact her – which has not yet happened.
Dr Thomas, the Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG) Governing Body Chair, interrupted that this was a matter for individual practices and not the CCG.
Dr Thomas’s response sounds like a major cop out, given that the creation of a GP super practice is in line with NHS England’s Five Year Forward View, and the Sustainability and Transformation Partnerships that have been set up to carry it out, fast. The end goal seems to be a reduction in the number of GP practices in England from 7,500 to 1,500.
Clear answers from the Clinical Commissioning Group are urgently needed
In West Birmingham and Sandwell, Modality Partnership aims to be the lead provider in an Accountable Care Organisation, responsible for managing the budget for the area’s primary care and community health services. In order to do this it has:
“established a partnership with the US health services company, Optum, which provides health analytics, actuarial support, data tools, decision-support tools, and other services.”
This sets alarm bells ringing on two counts – both to do with obvious conflicts of interest and departure from the Nolan standards of integrity in public life.
One is that Optum is part of United Health, the US health company that is the previous employer of the NHS England Chief Exec. Simon Stevens. The other is that Optum also provides growing numbers of community health services for the NHS in England. This means that Modality’s partnership with Optum, as lead provider in an Integrated or Accountable Care System/Organisation, puts Optum in the position of advising Modality to award community service contracts to Optum.
Confusing proposals for future of primary care
Airedale, Wharfedale and Craven Clinical Commissioning Group’s proposals for the future of primary care are very confusing.
The 12th Sept 2017 meeting of the Committees in Common of the 3 Clinical Commissioning Groups (Airedale, Wharfedale & Craven, Bradford City & Bradford District) heard that:
“Work continues with Airedale, Wharfedale & Craven CCG Primary Care Commissioning strategy … It is in its final stages and we have asked practices to discuss with their patients and PPGs to ensure patient participation.”
But none of the patients at the AGM had heard about this.
Also from that 12th Sept 2017 meeting of the Committees in Common of the 3 Clinical Commissioning Groups:
Through our accountable care system in AWC [Airedale, Wharfedale & Craven] the Care Model Development group has developed key work streams to ensure realisation of a system approach to care. One of these work streams is beginning to take shape in primary and community care with the development of “3 communities in 1 system” approach across AWC population. Further information will be provided as these develop but it is really exciting to hear their initial discussions and work plans, which are clearly being driven by the communities for their health and care needs and aspirations.”
What does this mean? And how come members of the public at the AGM know nothing about communities driving work plans for an Accountable Care System?
“Accountable Care” – imposing a health insurance system on the NHS
Imported from other countries where healthcare is provided through public/private partnerships or state-funded insurance schemes like Obamacare for people who are unable to get private health insurance, Accountable Care Organisations are funded by the state on the basis of a restricted budget to cover the managed health care needs of an area’s population (or at least, those who can’t afford private health insurance).
“Managed” health care is about providing a one-size-fits-all care pathway for a given disease or illness, with the interests of a health insurer overriding the interests of patients. It reduces health care to tick box routines, and so allows less qualified, lower skilled staff to carry out the work.
This restricted “whole population” budget is supposed to incentivise efficiency, as the Accountable Care Organisation is allowed to keep the difference between the money it receives and the money it spends; but the evidence is that it incentivises cherry- picking patients who will be cheapest to treat and whose treatment is seen as the best value for money, in terms of the outcome of the treatment. What about patients with expensive clinical needs who are not going to have outcomes that are good value for money?
Neither the Airedale, Wharedale and Craven Accountable Care Board nor the Bradford City and District Clinicial Commissioning Groups’ Accountable Care Board can explain what Accountable Care is, according to Helen Hirst’s Accountable Care update to the 12th Sept 2017 Committees in Common meeting of the 3 Clinicial Commissioning Groups Governing Bodies.
So why are they setting up Accountable Care Organisations? (Apart from the fact that NHSE has directed them to.)
“Accountable Care” is driven by workforce and funding shortages
Helen Hirst’s Accountable Care Update does say that workforce shortages now and in the future are:
“One of the drivers…and new care models need to mitigate this.”
One way the Modality Partnership GP super practice aims to get round primary and community care staff shortages is through piloting GOQii’s UK launch of a platform and app for “managing” diabetes, hypertension and dyslipidemia. GOQii calls its app:
“a smart preventive health care solution”.
GP and author Margaret McCartney has criticised the un-evidenced roll out of apps for GP patients.
An Accountable Care Organisation may not even be an NHS organisation
An Accountable Care Organisation may not even be an NHS organisation, as shown in this slide from the recent UK Health Show 2017.
This is borne out by this NHS Improvement New Care Models update, which says that NHS Improvement is considering how it would need to adapt its licence conditions for an ACO which is a non- NHS provider.
Airedale, Wharfedale and Craven Clinical Commissioning Group have many questions to answer. They had their chance at the AGM – and blew it.