Large scale Integrated Primary Care Networks – what lurks beneath the buzz words

You will probably have heard media reports a couple of weeks ago about a new GP contract that will bring 22,000 extra supporting health staff into GP surgeries, as a key part of the government’s NHS Long Term Plan. And it will route £4.5m extra funding into GP practices.

But the mainstream media has not reported that, for this to happen, all GP practices have to get themselves into a Primary Care network by this summer.

They have not explained what Primary Care Networks are, how they will affect both patients and Primary Care staff, or the vast sums that they – and other forms of “integrated care” of which they are a key part – will leach out of the NHS in the form of global corporate profits.

GP practice incomes will be be increasingly reliant on Directed Enhanced Services contracts secured by their Primary Care Network – so basically GP practices are being forced to become part of a Primary Care Network, like it or not.

Retired consultant surgeon Anna Atthow said,

“This deal is a shocking sell- out of the British general practice.

It ends the rights of patients, won in 1948 to see their own GP,  and will lead to the break  of one -to- one continuity of care between GP and patient.

Patients,  seeking a  GP appointment can be diverted away, by a receptionist (or ‘care navigator’) to be seen by a pharmacist or physiotherapist or paramedic or other non- doctor substitute.

These health professionals are not trained as doctors and  will not be able to detect subtle signs and symptoms of disease, thus delaying diagnosis and putting patients’ lives at risk.

Primary care networks, handling 30,000 – 50,000 patients, are being groomed to become the centre of the “new care models”  of so-called ” Integrated Care Systems”.

This deal is a historic betrayal of primary care and must be fought throughout the NHS and Labour and trade union movement.”

It all sounds a bit bonkers. For a start, 70% of GP practices are not in a GP network and they have to get themselves into one by 29th May.

And then there’s the issue pointed out by Nils Christiansen (a solicitor who specialises in primary care), that

“[T]he new network contract will need to be held by an appropriate business vehicle (there is no indication yet of any restrictions on who could hold them) so [GPs] will need to consider who will be the local prime contractor.”

Here’s the link to NHS England info about the new GP primary care network contract.

What is a primary care network?

A primary care network doesn’t just link together a number of GP practices, as you might expect. The imposition of the Primary Care Network contract engineers what the Institute of Healthcare Management calls a once in a lifetime, monumental shift in GP practices.

Instead of caring for a few thousand patients, a primary care network will have anywhere between 30K-70K patients on its list. In order to provide out-of-hospital care, as hospitals are centralised and cut, it will “integrate” a range of services, provided by a “multidisciplinary team”.

NHS England and the BMA define a Primary Care Network as:

“GP practice(s) (and other providers – eg community (including community pharmacy, dentistry, optometry), voluntary, secondary care providers and social care. ) serving an identified ‘Network Area’ with a minimum population of 30,000 people.”

(Source: Network Contract Directed Enhanced Service Contract specification 2019/20 April 2019. Para 3.2 and footnote 6, p10)

One model for the Primary Care Networks is the so-called Primary Care Homes. These group together all the GP practices in a primary care network, together with a range of other NHS, social care and voluntary and community service organisations.

As in this graphic. Confused? You’re not alone.

Primary care clinician: “Feel a bit like they’ve used us as their pawns”

A clinician whose practice is now becoming a Primary Care Home said,

“There will be 4 practices in our “home”, integration with social aspects and closer working with other agencies – which is alluded to as a bottom up approach to shaping health care. We have been allocated £90,000 to shape the care of our population – I think 50,000 population.

There is a new charity role where one worker is to work with 28 patients across the sites to look at the reasons behind why people reattend (sigh !!!) Physio have looked at how many appointments we currently use in hospital and that will now only happen in house and we will design how that works. Mention was made of an initiative to look at loneliness and mental health in schools.

All the words and ideas we are aware of in the NHS Long Term Plan are touched upon – links to “compassionate community”, increase in charity, the links to churches etc.

I’m going to be looking for another job asap

No one has really yet clocked it or what it means – most campaigns are focussing on hospitals cuts, not realising that they go hand in hand with this huge primary/community health care change.

All the stuff we’ve been told about has previously proved not to have the intended impact. Why on earth will this be different? It won’t – it will simply give care over to charitable status. I really can’t believe we are incapable of seeing what lurks beneath all the buzz words

Feel a bit like they have used us as their pawns.”

Locality hubs

A number of primary care networks will be linked to a “locality hub”. There are various versions of what this is, but the British Medical Association has endorsed locality hubs as “ alternative mechanisms to meet the urgent needs of patients when local practices have reached capacity”

(The number of integrated primary care networks to a hub in this diagram is indicative.)

A BMJ graphic shows other activities taking place at Locality Hubs, as well as handling GP “overspill”.

Bradford Primary Care Home Locality Hubs apparently provide:

  • Speech and Language Therapy
  • Dieticians
  • Specialist Nurses for eg dementia, end of life, diabetes, heart failure, respiratory and paediatrics
  • Secondary care (ie hospital) outreach services
  • Diagnostics
  • Reablement services
  • (G)PwSis – which means (general) practitioners with specialist interests. (This is about GPs providing services that hospitals currently provide, with the aim of cutting costs. Although there’s no reliable evidence that this will be cheaper.)

It seems that Bedfordshire locality hubs are to include CAMHS and perinatal services as well as recovery services.

Staffing

As Anna Atthow’s pointed out, the new large scale GP networks will be largely staffed by new grades of less skilled clinical staff – the 22,000 extra supporting health staff for GP surgeries that the media trumpeted recently. The new Primary Care Network contract provides extra funding for Social Prescribing Link Workers and Clinical Pharmacists.

Some of the new grades of allied health professionals, such as physician associates, are copied from the USA’s Accountable Care Organisations workforce.

The aim of introducing less skilled clinical staff is to cut 1m GP appointments a year – and to cut the numbers of GPs needed to care for patients.

Only patients with complex needs will see GPs

Many GPs are not at all happy about this fundamental change to their role.

The way it works is that a care navigator signposts patients to other services, with no reliance on GPs. This has already been happening in GP surgeries for some time and as all GPs are forced to join Integrated Primary Care Networks, it will now become the norm.

Patients with complex needs – who are at risk of admission to hospital through A&E – will be identified through a process of “risk stratification” which segments patients into various categories.

Risk stratification requires the use of digital health technology (so called telehealth and telecare) and shared electronic patient records.

The aim is to prevent emergency hospitalisation of these patients. But where such “risk stratification” has already been carried out, for example in “Vanguard” pilots, it has had the opposite effect and increased hospital admissions.

The concern of primary care networks is to cut the costs of the most expensive categories of patients

These are broadly:

  • Frail elderly with complex health problems
  • Mothers and babies
  • People suffering from the “modern epidemics” of obesity, diabetes, heart and respiratory problems
  • People with disabilities

However there is no real evidence that the “care models” designed to treat these categories of patients cut costs. Or give them better care.

GP Dr Bob Gill said,

“Isn’t it time we developed a collective spine and stood up to all this sh*t? Obedience to malign authority is complicity. I have had enough of our profession’s self-selecting, entrepreneurial, short-sighted muppets who are led by the nose to access any funding irrespective of its long term impact
We are on the brink of transition to a US, dumbed-down, dysfunctional, worse-performing and perverse healthcare system. It seems so many GPs are sleep walking into destroying their own profession and selling out patients.”

Compromising doctors’ ethics of Do No Harm

Cutting most patients’ access to GPs will have extremely damaging effects on patients who need a Further Medical Examination for benefit claims, because they need access to a doctor to write letters. Without a Further Medical Examination, a disabled person won’t be able to claim benefits. This is about the destruction of the welfare state. It’s about taking rights away.

The DWP now have people in mental distress top of their target list to get back to work. Which is where Universal Credit will really come into play with this.

The mental health charity MIND won the Individual Placement Support contract – part of the DWP/NHS Health and Work Programme. Individual Placement Support is about the ‘health and work conversation’: Work is good for Anxiety and Depression. What barriers are there to you working?

This is where social prescribing link workers come into play – where they look at barriers to you working. And then prescribe self management. Self care. Via a behaviour change scheme most likely run by a cash-strapped 3rd sector organisation with no therapeutic skills.

The “work is a health outcome” programme – a dangerous partnership between DWP and the NHS – is creating a toxic environment that is compromising doctors’ ethics of Do No Harm.

This link between the DWP and the NHS needs to be broken once and for all.

But the NHS Long Term Plan has no such intention. It name checks Sheffield City Region’s “Working Win” large scale research trial.

Funded by a £4.4m contract for 2.25 years to 2020, this is a partnership with NHS England, the Work and Health Unit and 5 local Clinical Commissioning Groups in the South Yorkshire and Bassetlaw Integrated Care System. It focusses on using a new type of Individual Placement Support to get people with mental health and musculoskeletal conditions into employment. (These are the two main conditions that prevent people from working.)

Credit: Brian Hilton, Mental Health Resistance Network

“Prevention” and population health management – ignoring the corporate determinants of ill health

The large scale primary care networks will rely considerably on charities, third sector organisations and private companies to “help” patients to self-care and follow large scale “preventative” behaviour change programmes.

Many GP patients will be handed “social prescriptions” to go and join a community group, contracted for the purpose by the local Clinical Commissioning Group, Local Authority or more likely both of them together through some kind of joint/integrated commissioning arrangement.

The idea is to help “risk stratified” patients to sort out non-medical problems that are damaging their physical or mental health.

A social prescribing link worker in Bristol outlines how he approaches patients as part of a citywide public health initiative in the areas of deprivation.

No matter that “modern epidemics” of non-communicable illnesses are caused by government policy failures to regulate corporations and to create the conditions for economic, social and environmental justice. It’s apparently our individual responsibility – under the guidance of voluntary organisations and private companies – to make good the damage to public health – both physical and mental – that’s caused in large part by deregulated corporations.

This is intended to improve the “population health”. Contract payments to the Primary Care Network seem likely to include incentives for getting patients signed up to these schemes, and improving population health.

The chief officer of Calderdale Clinical Commissioning Group calls this:

‘moving away from the dependency model of healthcare.’

It’s worrying that the the neoliberal wind seems to be blowing the NHS down the conditionality route – dividing people into deserving and undeserving sick: If you don’t take part in behaviour change programmes, you’re to blame for your illness, so don’t expect care from us.

Companies getting in on the behaviour change act

Nuffield Health is getting in on the act via its fitness and wellbeing clubs. Over half of them include emotional wellbeing clinics. Nuffield Health opened these clinics in 2018 and aims for all its clubs to have them by the end of 2020.

Together with the British Psychological Society, Nuffield Health is developing a “pilot of best practice for integrating physical and emotional health care” – to be delivered in its fitness and wellbeing clubs.

Nuffield Health says this will help them influence the gym industry in the approach to emotional wellbeing.

What lurks beneath the buzzwords?

Primary care networks – also called General Practice at scale – are central to the government’s project of opening up the NHS to the global corporatocracy of health insurance, life sciences, digital technology and health management companies.

A key sector of what Soshana Zuboff calls Surveillance Capitalism

This is evident from following the money. Integrated Primary Care Networks depend on the disruptive use of digital technology, to:

  • deliver remote care to patients and to monitor their self-care and self management,
  • capture the actual costs of each patient – as in an insurance-based healthcare system, and
  • identify the outcomes of treatment, as the basis for payment to the Primary Care Network.

Together with the wider Integrated Care Systems, they also depend on other categories (or Lots) of “health services support”. Here’s the list:

This list is in NHS England’s new Health Services Support Framework, which identifies approved suppliers that NHS commissioners and providers can hire to tell them how change to the way they work in order to fit the global corporate model of healthcare.

Privatisation of NHS commissioning

This amounts to the privatisation of NHS Commissioning, as Commissioners are required to pay private companies to do the work for them. NHS Commissioners lack the skills and resources to set up and use a commercial insurance-based model within the NHS shell of Integrated Care Systems.

And in case hiring companies on the Health Services Support Framework isn’t enough to enable them to do this job, NHS England has “invited” scores of Clinical Commissioning Groups to work with Optum and PWC to change their commissioning processes in line with USA accountable care organisations’ methods.

NHS England is adding “Innovation Greenhouse” lot to the list

Update 9.9.19 In order to provide faster routes for Integrated Care Systems to buy “tried and tested innovations for patients, populations and NHS staff”, NHS England is planning to add a new lot to the Health Services Support Framework, according to documents issued to suppliers. (This info comes from the NHS Procurement website. There is also a Digital Health report here.)

Unsurprisingly the approved suppliers on the Health Support Services Framework include all the usual suspects and then some:

Primary Care Networks – global corporations’ route to commercially valuable patient data

Primary care networks not only help feed global corporations a goodly share of the NHS’s vast stream of public funding – they also help them access the NHS’s invaluable 70 years worth of medical data that covers the whole population.

How did this happen?

The government and its quango NHS England – official name NHS Commissioning Board – have engineered this by drastically cutting primary care funding and driving hundreds of GP practices into bankruptcy, while GPs in droves have been taking early retirement or emigrating to places like Australia where the GP workload is far more manageable.

GP practices are folding at the rate of one a week. In the last year, tens of thousands of patients have found themselves losing a practice, or having it merged with some random practice more or less in the same neighbourhood.

Simon Stevens, the NHS England Chief Exec, has been saying for years that the corner shop version of family doctors has to go, to be replaced by a supermarket version of large scale integrated primary, community health and social care services.

Now he is making that happen.

Of course, the spin tells a very different story

The justification is that the frail elderly with complex health problems cost the NHS a disproportionate amount of money. And that this is “unsustainable”. Big wow.

Obviously the time that most people most need the NHS is when they are dying and giving birth. And luckily, most people die after reaching old age.

Why should we suddenly get excited about that and use it as an excuse to segment the population and set one demographic cohort against another?

Of course successive governments with their punitive agenda of spending public money on corporate welfare, not public services, want to cut the costs of services for these expensive patients. Particularly since – unlike some other treatments such as planned care surgery – they offer little opportunity to make profits.

That is, until now. Juicy profits accrue to the companies that sell the software and consultancy advice to segment the population, and to link the patient-linked costs and data about outcomes of treatments to the risk and reward contract payments to the primary care networks.

The stated aims of this major redisorganisation are to achieve “clinical and financial sustainability”. The real aim is to benefit the corporatocracy by allowing them to siphon off a constant stream of profits from our public wealth.

In order to achieve this transfer of public wealth to corporate profits, the whole GP system of family doctors that we know and love is being destroyed.

But the government, its minions in the NHS quangos set up by the Coalition government’s 2012 Health and Social Care Act, and its flunkies in the press cover this up by assuring us that Integreated Care is about removing competition from the NHS and replacing it with collaboration.

The House of Commons Health and Social Care Committee has fallen for the spin. So have 38 Degrees with their recent petition. So has Polly Toynbee.


11 comments

  1. Since early last year, my practice has had a minute long ‘introduction’ in the decision tree appointment selection, which is recorded by the senior practice owner. It states that by his authority, the receptionist will ask you for a brief description of your symptoms and may direct you to another healthcare professional, who may be outside the surgery. Pharmacists are named as places where you can get help with minor conditions.

    In the last 6 months I have been examined by someone at the surgery, who confused the words, leg and foot. While I recognise that some languages may not have different words for these things, English does and I was concerned afterwards as to what had been written on my notes!

    I am therefore concerned that early diagnosis of such things as cancer, will be thwarted by these measures. Cancer symptoms are as different as individuals and bodies are not as compliant as to register low enough haemoglobin test results to automatically trigger an investigation, however far advanced the cancer is!

    Liked by 1 person

  2. Can the blogger please get in touch with me As I’m currently doing a series of blogs and would like permission to use some of this material

    Like

    • Everything on ck999 blog is covered by a Non-Commercial, Sharealike, Attribution Creative Commons Licence. Details are in the blog footer. As long as your blog is non commercial and you follow all the terms of the licence, you are welcome to reuse anything on the ck999 blog. Thanks for asking.

      Liked by 1 person

  3. I have complex health needs: advanced liver disease, heart disease, spinal problems, Barrett’s oesophagus and depression. In an attempt to get support at home in, maybe, the run-up to a possible liver transplant at present I am having to deal with: GP, Winchester hospital, Southampton hospital liver specialist, National transplant centre @ Cambridge, Southern Health for some community services, South Central Ambulance Service for patient transport, DoH CHC funding unit, Hampshire County social services, and private healthcare provider. That’s 9 different organisations none of which seem to talk/share medical records properly with each other. And within half of those organisations there are multiple teams – 16 in total – who also don’t co-ordinate. It’s very hard to find out what services are available, how to access them and obtain the results of diagnostic tests when/if they are finally done – usually after a long wait for even “urgent” referrals. No single person/organisation is responsible for co-ordinating my care.

    It is clear to me that this chaotic system has been deliberately created to ration access to services both at home and within hospitals. I suspect there is a huge waste of money going on here as doubtless each organisation and team requires its own admin support, accountants, managers, etc. Money which could be spent on ensuring the ward I’m currently languishing on .(because ‘they’ can’t organise appropriate suport at home and the discharge process is unnecessarily complicated) is properly staffed with nurses. Patient centred treatment is already a joke as all the systems and processes are designed with the convenience of staff first, built-in delays to ration care (people die or just give up fighting a “computer says NO.” Culture and too many decisions are delegated to non-medical staff in call centres or prescribed in stone in rigid hierarchical systems that disempower both nurses and patients. introducing yet more profit-making organisations is only going to make matters worse.

    We need a genuinely integrated healthcare system that is properly resourced and delivers services in patients homes or local hospitals and not via huge, remote regional centres or impersonal telecare. It should focussed first on prevention, but when people do fall ill there should be a named case worker responsible for co-ordinating all aspects of their healthcare with professionals as well as the patient. Healthcare should be delivered at home if possible avoiding unplanned admissions and lengthy discharge procedures. Where hospitalisation is needed, keeping the patient informed should be the first priority not an optional add-on. 5 mins with a consultant/registrar is not adequate. This is NOT rocket science!

    Like

  4. My chronic lymphocytic leukaemia would not have been picked up if I had not seen a GP who knew me, and insisted on three consecutive blood tests before having enough evidence to refer me to a hospital specialist. A locum GP made me feel very small for coming to the surgery with a small cut which would not heal. I knew it was not normal for me, but it took my own GP to go to the trouble of asking me to do repeat blood tests, for white cell count, at monthly intervals. A receptionist wouldn’t have known me or the possible meaning of my presenting symptom. This stinks.

    A paramedic visit can also put people into hospital, whence it is hard to escape. My recent experience of my husband’s hospital care led me to believe that one might, in certain events, be lucky to escape hospital alive, with basics such as drinking and eating not being recorded properly to allow for patterns to emerge through shift changes. There were plenty of expensive computers on wheels doing the rounds. The staff were good, too, but there was a lack of proper communication as someone was moved from one specialty to another, and again, as above, failures in joining up care between hospital discharge and ‘community care’. Heaven help the carer, and, even more, someone who has no carer to speak for them.

    Like

    • Chlimes with my own experiences in both my local hospital and the Addenbrooke’s liver transplant unit where I was being assessed for eligibility for a transplant. Food was pretty dire, the docs weren’t very good at communicating what treatments were being given and why. I’d add that I needed to repeat both basic info and my previous and current symptoms on numerous occasions. I’m fairly articulate and clued up, but even I struggled sometimes. Lastly, the discharge processes were ridiculously slow, with doctors taking ages to write the paperwork and the pharmacy taking hours to issue leaving supplies The nurses mostly do their best, but there aren’ enough to properly staff the wards – especially at night. I rarely seem able to speak on the phone, let alone see, my own GP – though the duty docs usually do call back quickly, but getting a locum out at night is like getting blood from a stone! My local pharmacy (in Sainsbury’s but run by Lloyds) frequently makes mistakes in dispensing, can’ fulfil all the items or deal with urgent requests

      And all This before Brexit and all the “reforms” to the NHS!

      Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.