Commercialisation of GP Practices through Alternative Provider of Medical Services contract may be key to Integrated Care Systems

As Integrated Care Systems scramble to implement the Fuller Review recommendations for NHS General Practice – which indicate that by 2023 or 2024 at the latest, Primary Care Networks should become part of larger scale Integrated Neighbourhood Teams that bring all providers in a PCN footprint together we wonder what NHS England’s push for more Alternative Provider of Medical Services GPs has to do with this.

Unlike GP practices with General Medical Service or Personal Medical Service contracts, GP practices holding Alternative Provider of Medical Services contracts are private providers of NHS primary health care.

Opening NHS GP Practices to commercial companies was the reason for the contract’s introduction in 2004 by the New Labour government.

Alternative Provider Medical Services (APMS) contracts are the only general practice contracts that can be entirely owned by those who are not NHS GPs, such as private commercial organisations. They seem to be the main mechanism for corporate takeover of GP practices. They allow for profits to be taken out of the practices.

And perhaps more significantly – given limited opportunities for extracting profit from GP practices – they allow corporations to take controlling positions in the new Integrated Care Systems and to access the goldmine of NHS patient data.

There seems to be an NHS England policy that any new GP practice contracts that are put out to tender have to be Alternative Provider Medical Services

However, under pressure from the General Medical Council in 2014 the quango watered down this policy by agreeing to review practice closures on a ‘case-by-case’ basis, rather than the previous blanket policy of using APMS for all new GP contracts as ‘best practice’. 

This has not stopped NHS England from continuing to push Alternative Provider Medical Services contracts. The “blanket policy” seems to have returned, judging from a 30th September 2022 statement on the East Riding of Yorkshire Clinical Commissioning Group website, ‘Improving primary care services in Bridlington’ ,

“No new GMS contracts can be offered by NHS England/Improvement. Instead, APMS contracts are used under Directions of the Secretary of State for Health and provide the opportunity for locally negotiated contracts with non-NHS bodies, such as voluntary or commercial sector providers, or with GMS/PMS practices to supply enhanced and additional primary medical services.”

In 2020, NHS England set in motion a programme to award APMS contracts lasting 20 years to digital-first providers in under-doctored areas. An NHS briefing note said the contracts could be set up in 27 CCGs across the country. Although GP leaders warned the move could ‘destabilise’ practices, leading to closures, NHS England went ahead with discussions with under-doctored CCGs.

Procurement for the programme via a ‘dynamic purchasing system’ was proposed to follow, and it seems that this is it: APMS Contracts – GP Services Purchasing System, 23 January 2020 – an online purchasing system where pre-approved GP providers can apply to join a list of approved suppliers of APMS GP practices, that “can…be invited by local commissioners to bid to provide APMS services when local needs arise.”

London Local Medical Committees were not best pleased.

What’s the real reason for NHS England’s push for Alternative Provider Medical Services contracts?

There are limits to profitability from general practice. It has been historically underfunded and continues to be so and there is only so much you can cut back on staff (numbers and skill mix) without seriously impacting performance (as measured by CQC) and engendering patient dissatisfaction. There will eventually come a limit to how much a practice can cut back like that and survive.

For instance, the North Central London Integrated Care Board recently refused to renew two of Centene/ Operose Health GP practice contracts in Islington, as evidence accumulated of a decline in standards of health care since Centene’s takeover of the contracts from AT Medics Ltd in early 2021.

The lack of profitability is shown by Babylon Healthcare’s controversial “digital first” GP at Hand service, with over 100,000 NHS patients. In May 2022, Babylon Healthcare chief executive Ali Parsa said that although the company was ‘overwhelmed with demand’ for GP services in the UK, it lost money for every patient it gained. At the end of November 2022, Babylon will ditch its 5,000 patients in Birmingham, when it closes its GP at Hand clinic since it is “no longer financially sustainable.”

Given this inherent lack of profitability, it seems likely that companies like Centene’s UK subsidiary Operose Health have other aims in getting involved in UK primary care, and that these coincide with NHS England’s agenda in pushing Alternative Provider Medical Services contracts.

For a start, since companies like Centene, via its UK subsidiaries, also own key community healthcare services and private hospitals, ownership of GP practices potentially enables them to control the healthcare provision for an entire population of a given area.

This is in line with NHS England’s agenda of fully integrating GP practices in what would essentially be an Accountable Care Organisation /Integrated Care Provider contract, to provide the entire range of health and social care services for a given area.

Alternative Provider Medical Services contract holders to run primary care Integrated Neighbourhood Teams?

If one of NHS England’s key Accountable Care Vanguard schemes – the 2017 Nottingham and Notts Principia Vanguard Accountable Care System – is anything to go by, such a contract holder would be a system integrator, responsible for effectively controlling the whole public/private managed care system for the relevant area.

In the case of the Principia Vanguard, the system integrator was the US Centene corporation.

In the messy and confusing privatisation and transformation of primary and community care that is currently underway, as already mentioned the Fuller Report published earlier this year signalled that Primary Care Networks should become Integrated Neighbourhood Teams by 2023 or 2024 at the latest. An Integrated Neighbourhood Team is seen as a multidisciplinary “team of teams”, requiring:

“full alignment of clinical and operational workforce from community health providers to neighbourhood ‘footprints’, working alongside dedicated, named specialist teams from acute and mental health trusts, particularly their community mental health teams.”

Integrated Neighbourhood Teams seem to be for patients with complex health and social care needs that can be met out of hospital, but need the input of many different services. Such patients would be referred into the Integrated Neighbourhood Team.

SInce this was what Primary Care Networks were supposed to do, why scale them up into Integrated Neighbourhood Teams?

Are Integrated Neighbourhood Teams a takeover of Primary Care Networks by the Integrated Care System?

According to the Fuller report, there has been a perceived lack of progress with Primary Care Networks because of “a lack of infrastructure and support (which) has held them back from achieving more ambitious change” (p6).  This ignores the fact that many GPs are unconvinced of the value of Primary Care Networks. It looks like an attempt to shove them into action, regardless.

One commentator asks,

“Does this mean, effectively, a takeover of Primary Care Networks by the system, i.e. that the practices in the Primary Care Networks become one partner of this new system, that has its own infrastructure, leadership and (potentially) place within an existing organisation? Maybe. Local interpretation means that if a local Integrated Care Sytem wants to interpret it like this it probably can.”

The Fuller report is clear that support for the new Integrated Neighbourhood Teams (HR, quality improvement, organisational development, data and analytics, finance etc) will need to come from ‘larger providers such as GP federations, supra-PCNs, NHS trusts’ and not from within Primary Care Networks themselves. 

This looks very much like the system integrator function trialled by Centene in the Principia Vanguard. And in its reference to ‘large providers’, there seems to be more than a nod to Alternative Provider Medical System contract holders. As a Health Leader report points out,

“Whoever takes on the role of providing this support [for the new Integrated Neighbourhood Teams] will become hugely important for general practice.  As more and more of the funding is channelled through INTs it is highly likely this type of support will also be provided to practices in future. 
“The risk for general practice is that if it has no vehicle for providing (or at least coordinating) this support, then it will default to being provided by alternative provider organisations.  This in turn means much of general practice funding will come to practices via these organisations.” 

There is more information here about Integrated Care Boards’ new role in a public/private primary care service, based on large hubs that co-locate community services, outpatients, diagnostics and other NHS health services, in addition to third sector and Local Authority services (for example, social care and housing support).

The newish Calderdale Collaborative Community Partnership Board – a bunch of hospital, mental health, community health, pharmacy and primary care services providers, formerly known as the Calderdale Care Closer to Home programme. – aims to create at ‘place’ level,

“One single workforce across all community/primary care.”

Transforming Community Services, para 5 page 5

And there is more info here about the population health management outcomes-based contracts that define the purpose of these new Integrated Care System public/private primary care services.

As GP Dr Louise Irvine advocates,

“If we want to reclaim and regenerate General Practice as a service based on public service, rather than commercial values, the first step is to abolish APMS practices and end the ability of practices to be owned, bought and sold by private companies.”

Whether these companies are the wholly owned subsidiaries of NHS hospitals, like Somerset Symphony Healthcare, or the UK subsidiary of Centene Corporation.

2 comments

  1. PRIVATIZATION BY THE TORY’S HAS ALWAYS BEEN THE PLAN AND THIS IS THE WAY THEY WILL DO IT. OH AND BY THE WAY MY SISTER CONREACTED POLIO IN 1952 AND OUR GREAT N H S GP GOT HE INTO HOSPITAL PROMPTLY SHE WAS CURED FROM A LIFE IN A WHEELCHAIR BU ”OUR N H S ” MY FATHER SAID TO ME THAT BEFOR THE LABOUR PARTY IN CONJUNCTION WITH THE TRADE UNIONS FOUGHT TO GET THE NHS PUT IN PLACE ,HE WOULD NEVER BEEN ABLE TO HAVE TAKEN MY SISTER TO A PRIVATE DOCTOR FOR HELP ,EVEN THOUGHE HE WAS A EXPRESS TRAIN DRIVER ON SILLY MONEY .THIS TORY NASTY PARTY HAS ALWAYS BEEN HELL BEENT ON PRIVATIZIN ”OUR NHS ” AS OF COURSE THEY ALL HAVE SHAERS IN THE PRIVATE HOSPITALS AND MEDICAL INSURANCE COMPANIES . CARE FOR FELLOW HUMAND IS NOT IN THE MANEFESTO SADLY

    Liked by 1 person

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