Summary for Hebden Royd Town Councillors: The Primary Care Network contract and the redisorganisation of Calderdale and Kirklees NHS

As agreed at the May 22nd Hebden Royd Town Council meeting, here is Calderdale and Kirklees 999 Call for the NHS campaign group’s summary of information for Town Councillors about the new Primary Care Network contract and the Calderdale Care Closer To Home Commissioning Prospectus.

Primary Care Network contract

NHS England has rushed in the contentious new Primary Care Network Contract with little notice to GPs or the public. It is due to go live on 1 July 2019.

From conversations with Practice Managers as we hand-delivered letters to GP practices, shortly before the deadline for them to become part of a Primary Care Network, we learned that most GPs hadn’t had time to discuss the contract and many hadn’t informed their patient participation groups.

But the Institute of Healthcare Management calls this contract a once in a lifetime monumental shift in GP practices.

In terms of what this monumental shift will mean for patients, there are good reasons to think that:

  • Apart from a small percentage of patients deemed at a high risk of unplanned hospital admission, most patients’ right to consultations with their named GP’s will effectively end.
  • Patients’ access to elective services will be further restricted.
  • Access to NHS continuing care will be restricted through the shift to self-care and increased reliance on families and volunteers, in a departure from what Calderdale CCG has labelled in a derogatory way as the “dependency model of healthcare”.
  • It introduces surveillance medicine – whereby NHS care risks becoming conditional on compliance with “industrial scale” behaviour change schemes – on the assumption that “lifestyle changes” can prevent modern epidemics of illnesses, which in reality are largely determined by poverty and deprivation. Simultaneously, patients’ privacy is violated through digital surveillance and potentially unconsented data collection and sharing.

For these reasons, the Primary Care Network contract looks like a withdrawal from the core NHS principle of a universal, comprehensive health service that is free at the point of use and based on clinical need.

GP workload

The general practice crisis is due to chronic underfunding and understaffing, and the Primary Care Network contract will not solve these problems.

Successive governments’ spending cuts have led to closure of many public services that people rely on. As a result, GPs’ workload has become so overwhelming that over 1,000 have quit over the last 3 years. For example, last year Hebden Bridge Group Practice lost 5 GPs. It has since replaced them with Advanced Practitioners and GP locums.

Loss of patients’ right to see their named GP

Much of the extra funding attached to the Primary Care Network contract is earmarked for the employment of less skilled auxiliary healthcare staff. Of course, these are trained professionals who enhance the work of primary care teams. The problem is that Primary Care Network contract is not about employing them to add value, but to substitute for GPs – an entirely different kettle of fish. The pace and scale is a worry, as is the ratio of GPs to allied Health Professionals.

The Primary Care Network contract requires risk stratification of patients. Risk stratification attempts to predict which patients are most at risk of unplanned hospital admission; the related intention seems to be to limit GP consultations to such patients (who form a very small proportion of the population) in order to prevent the need for their hospitalisation.

Restricting access

While the new Primary Care Network contract does not formally require GPs to restrict patients’ access to NHS elective care, the extra money it brings into GP practices is tied to specifications that require reductions in the use of the NHS (as well as the employment of less skilled auxiliary health care staff). The contract contains an irresponsible and potentially detrimental incentive for GPs to make fewer referrals, and GPs are unlikely to ignore this incentive.

Other factors also create a strong likelihood that GP referrals to hospitals for many treatments will be a thing of the past: as well as complying with ‘commissioning for value’, Primary Care Networks will have to comply with commissioner restrictions to growing numbers of elective care treatments.

Hospitals cuts and centralisation depend on 14 Primary Care Networks

We think that social equity and the provision of effective NHS care require that both Halifax and Huddersfield retain their full District General Hospitals. For years now, Calderdale and Kirklees 999 Call for the NHS and other groups have been campaigning to stop and reverse the hospital cuts and centralisation plans for Calderdale and Kirklees.

These plans involve moving many services out of hospital into the “community” – aka Care Closer to Home. This means GPs will no longer be able to send many of their patients to hospital, and GP practices will have to do lots of things that used to be done in hospital.

The overall intention is to cut costs and restrict patients’ use of the NHS.

On top of 5 years of savage so-called “efficiency cuts” to the Halifax and Huddersfield hospitals’ spending, this financial year the hospitals trust must make further “efficiency” cuts of £11m, in order to reduce the deficit from £43.1m in 2018/19 to £9.7m in 2019/20. (In reality, what they call the ‘deficit’ is a funding shortfall.)

These financial plans depend on the hospitals trust meeting the 2019/20 ‘control total’ of £37.9m. If it doesn’t do this, it will lose £28.2m of funding. To meet this control total, the revised Strategic Outline Case says transformation of services is essential.

To make these changes, the new Primary Care Network contract will formally tie GP practices into 14 Primary Care Networks that have been set up across Calderdale and Kirklees without any public consultation.

Proposals unfit for the public

At the 15th February meeting of Calderdale and Kirklees Joint Health Scrutiny Committee, Calderdale and Kirklees 999 Call for the NHS, Hands off HRI and Thelma Walker MP all challenged the revised NHS “reconfiguration” proposals as unfit for the public.

The local NHS Commissioners failed to answer questions about the impact of the new Primary Care Network contract on Calderdale and Kirklees patients and GP practices.

USA healthcare system import

Primary Care Networks group several GP practices together with acute, mental health, community health, social care and outpatients services, along with companies, volunteers and charities. They each serve 30-50K patients and operate a system of so-called integrated care closer to home imported from the US healthcare company, Kaiser Permanente.

Kaiser Permanente pilots were introduced by the New Labour government after it brought staff from the USA management consultancy company McKinsey and Kaiser Permanente into the Department of Health – around the time of its 2000 Concordat between the NHS and private health care companies. This was an agreement to open up the NHS to private companies.

In his other job as clinical lead at the Health & Social Care Information Centre, Hebden Bridge GP Dr Mark Davies visited Kaiser Permanente along with Jeremy Hunt, then Sec of State for Health.

Calderdale Care Closer to Home Alliance Contract

5 Primary Care Networks have been set up in Calderdale. They will be key to a new Integrated Care Alliance, according to the recently-published Calderdale Care Closer To Home Commissioning Prospectus.

The Prospectus includes the rather baffling statement (p14) that clinical responsibility for all patients within their own homes (including residential and nursing) will no longer sit by default with the patients’ registered general practice.

So who WILL be clinically responsible for patients in their own homes?

The Commissioning Prospectus says that the likely end point of this new Integrated Care Alliance is a 10 year contract. Although the Commissioning Prospectus coyly avoids naming it as such, it describes this contract in terms identical to those that define the contentious Integrated Care Provider contract.

This was formerly known as the Accountable Care Organisation contract, before the government rebranded it in order to distract attention from the origins of Accountable Care in the USA’s Medicare/Medicaid system. This is a limited state-funded health service for those who are too poor or ill to get private health insurance.

Whatever it’s called, Integrated or Accountable Care aims to cut costs and ‘manage demand’ for NHS care by a variety of means – including so-called value-based commissioning. This uses a set of spending benchmarks for different treatments in order to show their economic value.

In a universal public health care system like the NHS, where treatment is based on patients’ clinical need, how is economic value an appropriate criterion to use when deciding whether patients should receive treatment?

Another means of controlling costs is a new contract payment method, based on a fixed per person payment, plus rewards for meeting specific outcomes such as reducing hospital admissions and numbers of people suffering from illnesses like obesity, diabetes etc.

Five years ago, when Calderdale Clinical Commissioning Group started discussing such payment methods for Care Closer to Home contracts, one GP on the Governing Body said it would be important to introduce governance processes that made sure they did not lead to “cherry picking” the cheapest patients to treat. Indeed. But there seems to be no mention of this in the Prospectus

According to Mike Lodge, Calderdale Council’s Scrutiny Officer, Calderdale and Kirklees Joint Health Scrutiny Committee has no view on the Care Closer to Home Prospectus as yet. He anticipates that the Joint Committee will meet in June.

National policy context – NHS cuts and privatisation agenda

A key determinant of the proposed changes is the 2009 McKinsey Report, “Achieving World Class Productivity in the NHS 2009/10 – 2013/14: Detailing the Size of the Opportunity”.

Using the process described by Naomi Klein in her book ‘Shock Doctrine’, the government used the 2008 financial collapse to present drastic changes to the NHS as unavoidable, even though they seemed to imply the end of a high-quality health service equally available to all.

Commissioned by the-then Prime Minister Gordon Brown following the government bail out of the bankers, this report by the American management consultancy company set out NHS cuts proposals. These led to the imposition of £20bn NHS “efficiency savings” over the period 2011/12 to 2014/15, under the ConDem government.

In Calderdale, as elsewhere, this created a massive funding shortfall. This is why Calderdale and Huddersfield hospitals trust is now running a ‘deficit’ – like most other hospitals in England.

Once the 2012 Health and Social Care Act was in place, David Cameron appointed Simon Stevens to run the NHS Commissioning Board quango that was set up to covertly dismantle the NHS as a comprehensive universal health service.

There was NO democratic mandate for the 2012 Health and Social Care Act, as it was not in any political party’s 2010 election manifesto.

Before transferring to the NHS Commissioning Board (more commonly known as NHS England), Stevens was employed by huge global USA health care companies, both as Chair of Optum Institute of Sustainable Health, and Chief Exec for United Health.

Optum, a subsidiary of United Health, now has a substantial role in the NHS, particularly in setting up data analytics and other systems needed to run Primary Care Networks and Integrated Care Systems.

Under Stevens’ direction, the McKinsey-recommended cuts regime continued into NHS England’s 5 Year Forward View (2015-20), based on a further £30bn funding shortfall. This was commuted into a £22bn funding shortfall through the award of an additional £8bn NHS funding to introduce “new care models” that imported versions of the USA’s Accountable Care Organisations on the NHS,

The 5 Year Forward View has been implemented by local Sustainability and Transformation Plans (now evolving into so-called Integrated Care Systems).

The “new” extra NHS funding of 3.4%/year, promised by the government from this financial year, is barely enough to make good the NHS “deficits” that have arisen as a result of the government’s sustained underfunding of the NHS over the best part of a decade.

Calderdale and Kirklees 999 Call for the NHS,
10 June, 2019

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