Kirklees NHS Commissioners are pushing large scale General Practices as part of the hospital cuts and Care Closer to Home plan

Key features of the new large scale primary and community care hubs:

  • A misty belief in technology and innovation as the solution to current GP problems
  • Only complex patients will see a GP in the new large scale out of hospital hubs
  • Behaviour change schemes will drive patients to self care

Over the last year, Greater Huddersfield and North Kirklees Clinical Commissioning Groups have set about big changes to primary care, as a key part of the proposed integrated out of hospital care system that is supposed to replace slashed hospital beds and services.

The Kirklees Primary Care Strategy is to ditch traditional family doctor GP practices and replace them with large GP hubs that will provide integrated primary and community services for 30-50k people, based on the Primary Care Home model.

The first new building projects for the new large scale Kirklees GP Practices are:

  • a new Huddersfield Town Centre primary care centre for 10K Central Huddersfield patients, for 4 GP practices to share, with a “blend of hospital services and care closer to home”
  • a new Lindley Group/Village Development at Thorncliffe Street
  • Slaithwaite/Colne Valley Family Doctors move to new premises at Globe Mills.
NHS England’s GP Forward View – a £2.4m misspend

The basis for the Kirklees Primary Care Strategy is NHS England’s GP Forward View – which GP Margaret McCartney has condemned as a £2.4m misspend.

She points out that it relies on the

“misty belief that more technology and innovation will save General Practice”.

But technology can increase demand for health services, while doing nothing for the quality of care.

And NHS England’s GP Forward View fails to meet the urgent need to stop doing things that don’t work – like taking GPs away from patients to act as NHS commissioners, and requiring them to do masses of box ticking for unnecessary health screenings, dementia checks and advance care plans.

Margaret McCartney points out that

“Doctors spending more time on bureaucracy, while clinical care is done by less qualified people, is not the change we need” (BMJ 2016;353:i2366).

Unless you have a complex illness,  you won’t see a GP any more

GPs’ jobs are being redefined as Primary Care Consultants and they will supervise a range of primary and community care staff.

Once these new “at scale” GP networks have set up, you won’t see a doctor in primary care any more, unless you have a complex illness.

And you will stay out of hospital too, given the massive Mid Yorks hospital bed cuts that have already been made, and the proposed massive Calderdale and Huddersfield hospital bed cuts – currently the subject of  a 3 month review by local NHS organisations and Calderdale and Kirklees Joint Health Scrutiny Committee, ordered by the Secretary of State and his Independent Reconfiguration Pane.

As Greater Huddersfield Clinical Commissioning Group stated some years ago in a document I obtained through a Freedom Of Information request, these plans involve the “big challenge” of:

“Realigning the mindsets of individuals, their carers and their health professionals…”

They now call it:

“empowering patients to self-care”.

To make this “realignment” or “empowerment” happen, West Yorkshire and Harrogate Sustainability and Transformation Partnership (now Integrated Care System) is building an:

“interesting and exciting relationship with behavioural science experts”

from the Yorkshire and Humber Academic Health Sciences Network – a company licensed by NHS England to drive Life Sciences innovation in the region. The aim is

“to change the relationship between people and organisations,”

That was the message from Matt Walsh (Calderdale Clinical Commissioning Group Chief Officer and West Yorkshire and Harrogate Integrated Care System lead for standardising elective care) at the March 2018 Joint Clinical Commissioners meeting.

Patient behaviour change programmes open up huge business opportunities in Life Sciences industries – patients are becoming a source of profit for life sciences and digitech companies.

Far from being healthcare driven by patient needs (and provided at lower cost), Accountable/Integrated Care is about replacing skilled, qualified health care labour with corporate capital in the shape of Big Pharma, biomedical and digitech products, all the better to extract profits from patients.

This is the main theme of the recent Darzi/Institute for Public Policy Research plan for health and social care in the 2020s.

Jeremy Bentham’s Panopticon and Darzi’s Panopticon
Introducing “non traditional roles to release GP time”

Greater Huddersfield Clinical Commissioning Group is working with the Huddersfield GP Federation, My Health Huddersfield, to introduce

“non traditional roles to release GP time”

Starting with Clinical Pharmacists, who will provide specialist advice about medication for patients, particularly the elderly and those with multiple conditions. This is supposed to free up GPs for other appointments and so reduce the numbers of people pitching up at A&E departments. But a clinician in a GP practice outside Kirklees said,

“We are seeing projects rolled out indiscriminately as though there is no need to consider factors in different places that will influence reproducibility . Our practice had a pharmacist working in surgery for a short while – I’m not entirely sure what their remit was, but it seemed to involve medication reviews as opposed to any sort of patient contact.”

GP Receptionists’ “active signposting” of patients

For some types of health and social care, GP receptionists working as “Care Navigators” will now “actively signpost” you to

“the most appropriate source of help [including] a range of local health and wellbeing services, both within and outside primary care.”

The following types of health and social care are the ones you reach through with “Care Navigation”:

GP receptionists’ “active signposting” is “not triage” but “empower[s] patient choice.” It

“frees up GPs’ time… and supports the self care agenda.”

Receptionists’ training for their new role includes services available, referral criteria, when referral is appropriate and:

“critically when it is not appropriate.”

Let’s just hope patients’ minds have been successfully “realigned”, otherwise this might not go down too well.

Clerical staff – rather than clinical staff – are now processing incoming hospital documents about patients, including entering details into the patients’ records and arranging any follow up action. It is expected 80-90% of documents can be processed without involving GPs.

The Clinical Commissioning Groups are also working with GP practices to identify which ones are able to take on international GPs recruited by West Yorks & Harrogate  Integrated Care System.

“High impact actions to free up GP time” include online consultation – despite evidence that this doesn’t save GP time and there are clinical safety problems with online consulting

West Yorks & Harrogate  Integrated Care System has funding for a project team that will work with GP practices to stimulate more of them to buy and use online consultation systems.

N Kirklees practices have been struggling with an NHS England target for e consultations and this is costing NK Clinical Commissioning Group money. Clinicians say that it takes more time to respond to e consultations,  and telehealth use was limited as GPs often need to examine the patient to make clinical decisions. (NK Primary Care Commissioning Committee, 17 Jan 2018)

This doesn’t seem to be a problem limited to N Kirklees. Pulse Online, a GPs’ magazine, report that several studies have been released in recent months, calling into question the safety of online consultations and presenting evidence  that they don’t lessen GP workload.

And GP Margaret McCartney also points out a lack of evidence on effectiveness and safety of Skype consultations. One pilot found that these took about as much time as face to face consultations. (BMJ 2016;353:i2366).

A study by Trisha Greenhalgh of virtual online consultations found that there is no firm evidence that they work. (BMJ Open 2016;6:e009388).

A 2017 University of Exeter Medical School Study of WebGP online consulting in 6 Devon practices found that WebGP uptake during the evaluation was small. GPs judged that 72% of online consultations required a phone or face to face consultation. (BMJ Open 2018;8:e018688)

However, this hasn’t impeded a rash of technology companies and GP superpractices like the Hurley Group, which is behind the econsult programme, from peddling their costly wares, or stood in the way of NHS England’s Estates and Technology Fund schemes, which  include N Kirklees Clinical Commissioning Group’s Locality Hub and Spoke Scheme and Greater Hudds Clinical Commissioning Group’s GP Web eConsult scheme.

Greater Huddersfield Clinical Commissioning Group is working with self-selected GP practices to bid for NHS England Transformation Funding for online consultation systems. One Greater Huddersfield GP practice already has an online consultation system in place.

Social enterprise Local Care Direct is “at scale” provider for extended access

Where evening and weekend GP access has been piloted, patients have not used it much, so it seems a bit daft to roll it out everywhere.

However, on NHS England’s instructions, Greater Huddersfield Clinical Commissioning Group has contracted with Local Care Direct to “lead provision” of Greater Huddersfield GPs evening and weekend extended hours, from March 31st 2018.

Local Care Direct is an urgent care social enterprise  and a member of Urgent Health UK  (a federation of social enterprises that provide out of hours healthcare).

A Health Services Journal article on 8th June reported that social enterprises, which now dominate the GP out of hours sector, receive the lowest amount of funding per patient, compared to NHS organisations and commercial providers also delivering out of hours services.

Perhaps this is related to the fact that, as one senior source within the sector told HSJ, it does not use agenda for change contracts as they are

“too expensive and…perverse” and have “automatic uplifts when our contracts do not.”

This raises the possiblity that commissioners may be awarding contracts on the basis of the cheapest bids rather than the best quality.

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