Big GP changes in 2024 – how will they affect Calderdale patients and staff?

This will probably take around 10-15 minutes to read.

GP practices must become part of new Integrated Neighbourhood Teams by 2024. There seems to be little clarity about what this “rapid transformation” means – apart from the fact that the government and its quango NHS England may talk the talk, but have not come up with the money to make it happen.

Following a recommendation in NHS England’s May 2022 Fuller Report on Next Steps for Integrating Primary Care, NHS England is pushing,

“integrated neighbourhood teams that move beyond Primary Care Networks as a fundamental building block of an integrated care system…the aim of Integrated Neighbourhood Teams is to significantly reduce growth in hospital demand and shift away from a hospital-centric model of care.” (Fuller Report, p13)

At its November 2022 meeting, the West Yorkshire Integrated Care Board duly agreed,

“an ambitious … vision for integrated neighbourhood teams working together to join up services [and] to…support transformation towards integrated primary care and community health services.”

But West Yorkshire Integrated Care Board also warned that,

“The West Yorkshire primary care allocation of £4.5m is insufficient to support the scale of investment required for infrastructure (estates and digital) to aid the rapid transformation for service delivery.”

Calderdale Council’s Detailed Review of General Practice has little to say about any of this, although one of its key objectives is

“to develop a shared understanding of the role of… the role of Primary Care Networks and the requirements placed on PCNs by NHS England and how General Practice will be commissioned under the Health and Care Act 2022 .”

The House of Commons Public Accounts Committee is unimpressed. It recently reported that,

“It is not clear what tangible benefits for patients will arise from the move to Integrated Care Systems, nor is it clear by how much or by when things will improve.”

Integrated Neighbourhood Teams will need “alternative and novel sources of capital funding” for primary care estates “transformation”

West Yorkshire Integrated Care Board noted that its “ambitious vision” for integrated neighbourhood teams needs,

“a clear and robust approach to delivery, which is backed up through sufficient resources…, particularly for leadership and neighbourhood team development, recruitment to address shared neighbourhood workforce shortages. Workforce, digital and estates transformation are critical enablers.”

However, as noted above, these resources are not currently available. So the Integrated Care Board proposes,

“to identify alternative and novel sources of capital funding which may include such as via 3PD and Local Authority capital in addition to ensuring we can make full use of all our system estate, not limited to General Practice.”

3PD is third party development – ie commercial investment – is this another Private Finance Initiative?

NHS Property Services say,

“Where there is insufficient NHS funding available for a property development project, we can explore alternative funding sources individually or in combination, such as third-party developer capital.

“To take this option forward, NHSPS must agree the extent of the land required, the rent payable under this arrangement, the service model and schedule of accommodation. These considerations would be required by a commercial development to enable the scheme, including details of the funding routes.”

This continues the direction of travel over the last five years, when private sector investment in reshaping the NHS Estate has been taking place through implementation of the Naylor Review – which proposed £10bn of investment: one-third from land sales, one-third from the private sector and one-third from the government.

A key aim of this investment, according to the government’s response to the Naylor Review, is to change the NHS estate so that it accommodates the new models of care set out in the Five Year Forward View – such as those to be delivered by Integrated Neighbourhood Teams.

As the Devil’s Dictionary of Healthcare explains, the corporate gaze has now shifted to primary and community care:

“Community services are already pretty much under the control of private companies and it’s only a short step to link such services with primary care under the banner of integration.”

NHS England’s Cavell Centre Programme seems to be piloting the primary and community care estates transformation for Integrated Neighbourhood Teams – but has apparently got stuck for want of funding. In Plymouth, Devon Integrated Care Board and Plymouth Citiy Council seem to have been sent on a 3 year wild goose chase by NHS England to develop the Plymouth Cavell Centre, only to be told by the then-Health Minister Robert Jenrick that there was no national NHS funding available and that the Devon Integrated Care Board should sort out the funding from its inadequate £250m 3 year capital budget.

But still West Yorkshire Integrated Care Board is proposing commercial third party investment and Local Authority capital as a source of capital for Integrated Neighbourhood Team “hub” buildings.

What are the Primary Care Networks, that Integrated Neighbourhood Teams are to replace?

The role of Primary Care Networks is contentious. It seems to be to meet NHS England’s requirements to bring together GP Practices and other health and social care providers in an area with a population of 30k-50k, to deliver cost-cutting “new care models” for out-of-hospital services – without requiring the providers to sign up to the contested Accountable/Integrated Care Provider contract, which NHS England/Improvement seems to have put on the back burner after it was challenged in two Judicial Reviews.

The new care models were introduced through NHS England’s “Vanguard” programme from 2015-2019, as part of the the managed decline of the NHS since 2010. Their aim was to shift services out of hospitals into “the community,” where health and care services would be provided by area-based multidisciplinary teams, often working remotely from the patients, through the use of digital gizmos and so-called “virtual wards.”

NHS England’s 2015 GP Forward View said that by 2020, General Practice would be transformed. So how’s that panned out?

The new care models have been associated with significant hospital cuts and centralisation, as well as generally unpopular and overwhelming changes to GPs and patients’ roles. GPs have suffered moral injury, been leaving in droves, some have committed suicide, and patients’ satisfaction with their GP practices has fallen.

West Yorkshire Integrated Care Board’s November 2022 report, Focus on Primary Medical Services and Integrated Primary Care in West Yorkshire, said,

“The GP Patient Survey shows that across West Yorkshire 71% of responders rate their experience of their practice as good or better and 13% rate it as poor or worse. These numbers were 83% and 7% in the previous year… This is the largest reduction in patient satisfaction since this information was recorded.”

It seems to be a kind of reflex to blame covid for the collapse of the NHS – but it is clear that General Practice was radically underfunded, understaffed and under pressure well before the pandemic.

To bind together the multiple providers of these new care models and make them bear the risk of overspending a limited, flat rate, population budget, NHS England tried to introduce a new Accountable Care Organisation contract – quickly renamed the Integrated Care Provider contract to avoid the connotations of the USA’s health care system.

The legal challenges were basically on the grounds that the contract was a radical departure from the foundational principles of the NHS: that treatment was universal, comprehensive, publicly funded and provided and based on clinical need not financial considerations.

The role of Primary Care Networks in setting up the cost-cutting new care models, without having to deploy the contentious Accountable/Integrated Care contract, seems clear from a November 2017 NHS Improvement meeting which discussed the 999 Call for the NHS Judicial Review and concluded the new care models were more important than the contractual structures to deliver them.

However NHS England has updated the Integrated Care Provider contract – although the latest online version is only for 2019/20. It’s apparently available, for

“commissioners to award a single contract to a provider that is responsible for the integrated provision of general practice, wider NHS and potentially local authority services.”

What has NHS England required of Primary Care Networks?

NHS England seems to have two main requirements.

A redesign of GP practices’ workforce, through the Primary Care Network “Directed Enhanced Services” contract

This pays groups of GP Practices serving 30K-50K populations to redesign their workforce by employing “additional roles” to work in Primary Care Network “neighbourhood multidisciplinary teams” alongside other NHS, social care and public health providers in their area. The multidisciplinary teams provide out-of-hospital services, with the overriding aims of cutting unplanned hospital admissions and A&E attendance, while also improving the poor health of people living in deprived communities, through various targeted screening, medication and behaviour change programmes.

The use of USA ‘population health management’ data platforms, data analytics and contracting methods

This is in order to segment the patient population by health and economic/social status; target services to the various population segments; and track patient outcomes, costs and returns on investment.

Population Health Management is basically the use of aggregated health and social data to plan, contract, provide and monitor the outcome of new “integrated care” models delivered by risk bearing primary care networks. West Yorkshire Integrated Care Board’s November 2022 report, Focus on Primary Medical Services and Integrated Primary Care, says

“population health management approaches to proactively identify and support people in their communities…requires radical transformation from existing practice.”

For example, on the basis of analysis of our personal health and care data, as patients we are now being defined and segmented into specific population groups. There are three main patient segments:

• The most vulnerable and complex patients
• Patients from economically deprived communities with relatively poor health
• Patients with basically good health whose health issues are more straightforward.

Which patient segment the ‘population health management’ data analysis assigns us to will affect what we can expect from our General Practice.

For instance, according to the Fuller Report, if the generally healthy patients want a same day urgent appointment, their General Practice surgery will no longer be their first port of call. Instead they will have to learn how to navigate a new NHS urgent care system that’s provided by a combination of:

• the revamped NHS 111 service, with its out-of-hours clinical assessment service (provided by YAS under the 2019 Yorkshire and Humber Integrated Care Service contract)
• community pharmacies
• a same day GP appointment made by the revamped NHS 111 service, online advice and – ultimate course of action –
• a walk-in to an A&E

Population Health Management obviously carries considerable data protection risks

West Yorkshire Integrated Care Board is the Data Controller for West Yorkshire population health management data. The Data Services for Commissioners Regional Office are providing West Yorkshire Integrated Care Board with de-identified patient data for population health management across the West Yorkshire Integrated Care System.

The data controller lines for population health management data seem to be blurred as Data Services for Commissioners Regional Office was formerly a sub-group of NHS Digital, which has now been reabsorbed into NHS England.

It specialises in converting patient information, within a secure environment, into a format commissioners can legally use: anonymised patient level information.

Although there is legitimate doubt about whether the patient level data is really securely anonymised and patients’ opt outs are respected.

The NHS Digital Data Release Register shows that West Yorkshire Integrated Care Board unsafely disseminated 26 data files in total (information about files used safely is missing for TRE/”system access” projects), during Data Sharing Agreement runs starting 2021-08-01 (sorry I made a typo when I copied the end date and can’t now find the source to correct the typo, so can’t supply the end date for this data run).

The Register shows that the objectives of the data runs were:

• Invoice validation by Clinical Commissioning Groups, to ensure that the activity claimed for each patient is their responsibility and to advise the Clinical Commissioning Groups whether payment for invoices can be made or not. Invoice Validation is conducted by North of England Commissioning Support Unit and Liaison Financial Services Ltd.
• Risk stratification of patients carried out by Wakefield Clinical Commissioning Group. An algorithm is applied to patient identifiable Secondary User Services (SUS+) data linked with Primary Care data (from GPs), to produce patient risk scores. This data contains both clinical and financial information that commissioners use “to prepare plans for both individual and groups of vulnerable patients.” Pseudonymised data is used in “Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs”

How has all this played out in Calderdale?

The shift of services out of hospital in Calderdale has gone under the name of Care Closer to Home, since the programme was set up 2014 by the then Calderdale Clinical Commissioning Group.

In 2019, Dr Nigel Taylor told a Hebden Royd Town Council meeting that part of the reason for the increased ‘demand’ for GP appointments, that the Practice was unable to meet, was that GPs were already delivering services previously provided in hospital.

Eight years on from the start of the Care Closer to Home programme, the Detailed Review section on Pressures Within the System (p 11) reports that “ initiatives to move care from hospitals into the community” are one factor in the “significant pressure” that General Practice is under, according to the Chair of Calderdale Local Medical Committee, Dr Khan.

Over the winter, Calderdale General Practice reported OPEL 4 for the first time. This is a black alert, or serious incident, and means General Practice was unable to deliver comprehensive care and patient safety was potentially at risk. The Chief Exec, Robin Tuddenham told the January Calderdale Cares Partnership Board meeting that,

“the pressures are now the new norm, rather than relating to winter, all parts of the health and care system experiencing intense demand and hospital bed pressures continuing all year with no seasonal variation.”

The pressure to shift services out of hospital seems likely to increase, since last year Calderdale and Huddersfield hospitals trust was judged in need of “significant support” from the NHS England regional team, because of the hospitals Trust’s “deficit position”. The “support” takes the form of “a series of deep dives” and “a challenging cost improvement scheme” in 2023″ (ie spending cuts) but this will still leave an “underlying deficit.”

When is the government going to fund our Calderdale and Huddersfield hospitals adequately? This cuts and underfunding saga has been going on for the best part of a decade!

As things stand, it doesn’t look as if the provision of Care Closer to Home as a key means of reducing A&E attendance and unplanned hospital admissions is working as planned. Certainly Calderdale Clinical Commissioning Group (as was) has been unable to provide evidence of this to Calderdale and Kirklees Joint Health Scrutiny Committee.

Regardless, the aim of Integrated Neighbourhood Teams is to significantly reduce growth in hospital demand and shift away from a hospital-centric model of care, according to the Fuller Report.

Why are Integrated Neighbourhood Teams replacing Primary Care Networks?

Basically, it looks as if Primary Care Networks have gone as far as they can in setting up accountable/managed care models that transfer financial risks to the providers, and so conclusively “incentivise” them to “manage demand”, without a contract that creates a single accountable organisation.

West Yorkshire Integrated Care Board’s “Focus on Primary Medical Services and Integrated Primary Care” report says,

“4.8  It is … clear that existing contractual mechanisms do not necessarily support these integrated models of working…”

The need for a new form of contract is also hinted at in the Detailed Review’s comment on problems integrating GP practices with community health services and urgent response teams:

“Access to district nurses is an issue, with an ageing workforce and inadequate numbers of training places available. PCN’s and general practice are not able to contract district nursing services. There is no opportunity through this current scheme to engage district nursing staff, this is commissioned by the ICB as part of the Community Contract and they are situated in the CHFT Communities Team. District Nurses work alongside the PCN and General Practice Teams, which is positive, but they are not a part of GP practices, they are a part of Calderdale Huddersfield Foundation Trust (CHFT). District nurses are a vital part of community services, there is potential to for them to move into General Practice, this will be made clear in the Government deal which has not been published yet.

“Urgent response teams are also not a part of general practice, they are commissioned within the Calderdale Cares Community Partnership. However, Urgent Response teams do work collaboratively on the ground with General Practice.”

But what is Calderdale Cares Community Partnership?

Baffling cats cradle of informal alliances and non-statutory committees

It seems even Calderdale Council’s Detailed Review of General Practice may be confused, in its reference to Calderdale Cares Community Partnership.

Is this a typo? Or yet another group?

Although not a formal or legally binding contract, the Calderdale Collaborative Community Partners Partnership Agreement was added to the then Calderdale Clinical Commissioning Group’s contracts register.

According to the Calderdale Cares Partnership Agreement, which took effect on 1 April 2022, the Calderdale Collaborative Community Partnership Board is a network/collaborative that is accountable to both Calderdale Cares Partnership Board and the Clinical and Professional Forum.

And of course Calderdale Cares Partnership is accountable to the West Yorkshire Integrated Care Board, and, for some of its functions to the other statutory integrated care system body, West Yorkshire Integrated Care Partnership.

Then there is the complicating factor that Calderdale population health management carried out by its Primary Care Networks is overseen through the Calderdale Community Collaborative Programme Board – not the Calderdale Cares Partnership Board, which is responsible for Primary Care contracting.

How on earth can the public find out who’s making what decisions and why, about GP Practices, Primary Care Networks and Integrated Neighbourhood Teams?

Maybe that’s the point.

In West Yorkshire it seems that Integrated Neighbourhood Teams will be contracted by the local delegated committees of the Integrated Care Board. In Calderdale’s case, that is the Calderdale Cares Partnership Board.

Oddly, Calderdale Cares Partnership Board has no statutory existence.

And its commissioning of the Integrated Neighbourhood Team/s will be under the overall direction of the West Yorkshire Integrated Care System – where the West Yorkshire Integrated Care System Primary and Community Care Programme Board has turned into a Fuller Delivery Board, answerable to the West Yorkshire Integrated Care Partnership, not the Integrated Care Board. They are working out,

“how this interconnects effectively with arrangements at place and with other system boards overseeing wider aspects of integrated care and improving population outcomes.”

What’s the risk that ‘alternative provider’ – ie big corporate – organisations will control GP practices in Integrated Neighbourhood Teams?

The Fuller Report is clear that back-office support for the new Integrated Neighbourhood Teams (such as 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. 

A Pulse article points out,

“Whoever takes on the role of providing this support 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.”

Alternative provider organisations are big companies with Alternative Provider of Medical Services contracts – like Operose Health (the UK subsidiary of US health insurance company Centene), Modality (whose employee Dr James Thomas is Medical Director on the West Yorkshire Integrated Care Board) and SSP Health – part of a complex web of companies in the NorthWest that has assets of over £20 million and “serves” more than 150K patients. Taxpayer (you and me) funded and runs around 37 GP Practices in the region.

It’s long been the government’s plan to replace traditional family doctors with corporate chains of GP surgeries. Calderdale NHS campaigners have been warning about this since around 2016.

Other potential Neighbourhood Integrated Team priorities could be areas such as workload, recruitment and estates – as mentioned above in the section “Integrated Neighbourhood Teams will need “alternative and novel sources of capital funding” for primary care estates “transformation”.

For Calderdale, who is going decide these priorities, how and when? And what’s happened to public transparency and accountability?