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Hospitals ready themselves for primary care takeover

Trusts are showing a ‘huge appetite’ for creating new GP practices, Sofia Lind finds

January issue 2015 - hospital trusts takeover

GPs’ independent contractor status ‘risks being destroyed’ as hospital trusts make plans to take over vast chunks of primary care. 

Pulse has learned of a ‘huge appetite’ among trusts for establishing new GP practices with their own registered list, as recommended for the first time in NHS England’s Five Year Forward View.

Management consultants are already circling, with PwC reporting an ‘extraordinary level of interest’ among trusts in setting up so-called ‘Primary and Acute Care Systems’ (PACS), during seminars held by the firm to explore trusts’ appetite for new models of care.

Providers are already making their feelings known at the highest level, with NHS England chief executive Simon Stevens saying he has held discussions with some 15 trusts that have expressed interest in the PACS model.

NHS England believes the move will better integrate care, but GP leaders warn a landgrab by hospital trusts would hold risks for GPs as it would allow trusts to ‘take over the world’.

Dr Robert Morley, chair of the GPC contracts and regulation subcommittee, says GPs’ independent contractor status already provides ‘holistic’ care and ‘medical leadership… at fantastic value for money for the NHS and the taxpayer’.

He warns: ‘This now risks being destroyed by a system based on managerially led vertical integration, which would inevitably have a salaried workforce beholden to their foundation trust employers. Patients would be the biggest losers in such a system.’

Quick guide: The new models of primary care

• NHS England’s five-year view outlined plans for ‘Multi-specialty Community Providers’ (MCPs), with GPs employing consultants and integrating with mental health, social care and community services.

• The Government’s Autumn Statement pledged £200m to pilot MCPs. An additional £1.2bn over four years to revamp GP premises will also support the creation of this new model of care.

• NHS England chief executive Simon Stevens has suggested the MCPs will be expected to offer extended hours access, while health secretary Jeremy Hunt has said they could even provide chemotherapy and dialysis.

• NHS England will consult commissioners early this year to decide how to prioritise funding for the MCPs.

• The MCPs differ from the ‘Primary and Acute Care Systems’ in that they will be primary care-led, while the PACS will be run by hospital trusts – and will be concentrated in areas where general practice is ‘under strain’.

The warning follows NHS England’s Five Year Forward View, which has received a £200m Government ‘transformation fund’ to begin the work. It puts forward two competing models of primary care: GP practices setting up multi-speciality community providers (MCPs) that would integrate more closely with secondary care, mental health services and community services; and hospitals setting up GP providers under PACS.

NHS England has said PACS would only be allowed in certain circumstances, such as in areas where general practice is ‘under strain’, but says they could eventually become the equivalent of the US ‘accountable care organisations’, which have responsibility for all patient care under a capitated budget.

Dr Tim Wilson, a partner in the PwC health sector team, tells Pulse trusts recognise that there is money to be made from taking on GP practice lists: ‘For many hospitals looking down the barrels of a deficit, this offers an option to do some good work and benefit financially.’

Zeitgeist

Dr Wilson says PwC has begun holding meetings for potential providers of both models, saying NHS England’s plans had ‘tapped into the zeitgeist of the NHS’.

He says: ‘These meetings were a natural next step to help organisations interested in providing better outcomes for patients in a more sustainable fashion to work out what they need to do next.

‘There is an extraordinary level of interest among providers and commissioners. I think the Five Year Forward View has tapped into the zeitgeist of the NHS, and indeed social care. I think when these models were promoted, people were saying: “Yes, that is exactly what we have been wanting for the last few years”. There is a huge appetite from trusts, GPs, social workers, community providers and commissioners.’

Recalling a conversation with a trust chief executive, Dr Wilson says: ‘The client told me, “the problem I’ve got is that we’re getting better and better at looking after older people. I’ve got a team going round A&E, they spot older people and stop them going into hospital. They go in and are able to get them out early – but every time I do that I lose money”. He wants to be a PACS for the money – to be able to do more preventive work.’

Dr Wilson says he expects the new models to go live within two to three years. 

In London, the local area team has already set out its plans to transform primary care in the capital, spearheaded by former RCGP chair Professor Clare Gerada. It will incentivise practices to merge or federate as MCPs, which will provide a range of enhanced services, and could lead to some providers opting out of the national GMS contract in favour of a hybrid of APMS and the NHS Standard Contract.

The document says offering this new ‘specification’ for general practice in London will cost up to £810m a year, representing a 5.36% shift in the overall health care budget, plus an unspecified amount of ‘transition’ funding.

Professor Gerada predicts that GP partnerships will vanish altogether from London within a decade.

But Dr Morley laments NHS England’s thinking on primary care: ‘It’s sad and ironic that, now general practice has been brought to its knees by a decade of destructive polices based on starvation of adequate funding, the solution is seen to be a takeover by trusts using surpluses they have accumulated through the divisive payment-by-results funding system, which has seen them suck in money at the expense of GP care.’

Expert view: ‘Hospitals may see this as an opportunity to take over the world’

Dr Michael Dixon

There’s a real danger that the outcome of a secondary care-dominated model is that general practice will become largely salaried, with many GPs losing their status as independent contractors.

We could end up with a system that falls into place simply because of the current dynamics and power-sharing of the health service, which is still a secondary care-centric, overmedicalised service where hospital specialists are the ‘senior’ service.

My fear is that some hospitals will see this as an opportunity to take over the world. There would be good reasons for hospitals to take on general practice: they could make sure that local practices only referred to that hospital, and they could also bump up their income.

The danger is that this will create further flow of money into secondary care away from primary care. With very large hospital trusts, there’s a danger GPs could become the drones, rather than being at the centre of the system providing patients with continuity of care.

For the new model to work, hospitals and local primary care should come together as equals, with equal representation and equal respect, not just as part of a secondary care takeover of primary care.

Dr Michael Dixon is chair of the NHS Alliance



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Readers' comments (12)

  • Can the general public take a minute to think why GPs hate this idea?
    They are making so much noise not because they would be out of work (in fact GPs would still be needed to deliver that service), but obviously for the people they care the most- patients!!!!

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  • "I’ve got a team going round A&E, they spot older people and stop them going into hospital. They go in and are able to get them out early – but every time I do that I lose money”. But thats the problem with GP land it isnt activity payment based. Such surgeries will be filled with salaried GPs who last a few months at a time, there will be no continuity of care and admission rates will be high - or is this what they are after????????????

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  • Bob Hodges

    Hospital Trusts patently struggle to run hospitals properly, so what they can do with primary care I'll never now.

    They'll certainly be absolutely no good at providing chronic disease management for the complex and elderly, which is where the main efficiency of GPs lies and the biggest single risk to the integrity of the NHS as a whole.

    I suggest they try running hospitals first, they organising festivities in breweries, THEN trying their hand at GP.

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  • We have the cheapest and best Health Care[ Commonwealth fund report 2014], because doctors and others work long hours for little reward. My take home pay per Consultation is £2.60 and the highest paid GP in the country will not make more £ 3.50 take home. That is extra-ordinarily cheap and not known nor recognised. Introduce market forces and see the price of Health care soar.
    If trusts want to run it - good luck to them. This is the 14th re-organisation of the NHS. The DOH has no concept of the selfless and poorly paid work that is done. Dr Sassa's prize winning BMA article - a microcosm of the NHS Universe- wherein she does a 80 hour weekend with 4 hours sleep, delineates the NHS.
    Unfortunately, the mandarins have no idea that a new Universe of Health and safety, human rights and duty of care is here.
    I, for one, would be happy for trusts to take over or anyone for that matter, but I cannot see £2.60 being bettered.
    They are in for a shock, and about time.

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  • A Mid Staffs in primary care in the making...

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  • My take home pay after staff, petrol, car, clothes, food, books, indemnity, holiday, tax, pension, holidays, amazon, spotify is 22p.

    Honestly anonymous at 1.05pm needs to stop muddying the valid argument about our underfunding with nonsense like that. At £2.60 per consultation he/she needs to close the practice and do some locum work. Thus seeing 20,000 patients to bring home £50k would be more like 6,000 or fewer patient per year.
    Unless he counts each patient contact (letter, script) as £2.60, which is disingenuous and unhelpful.

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  • It should be no surprise that in a system where medical training is over represented by hospital specialisms, where funding goes disproportionately to secondary care and where star struck politicians with a top down micro managment bent, who cant see past the doors of the hospital and the A&E department, bring in 'clever' young wiz kids from a managment consultancy firm (who if they have mates in medicine are likly working as Junior Drs in hospital) and they come to the 'smart' conclusion that we need hospitals to run primary care.

    Read the news papers, switch on the TV, when the NHS is mentioned the discussion is about heroic secondary care and failing primary care. The fact that around 90% of all NHS work is done in primary care is never mentioned. The fact that all this work is done on around 7.5% (and shrinking) of the NHS budget isn't considered either.

    In this climate of disinformation and down right basic ignorance, that the proposed solution of 'hospitals and managment' to the rescue shouldn't be a surprise to anyone.

    It will be more expensive, secondary care biased (i.e. expensive)...over managed and inefficient.

    To me the whole process of the destruction of primary care is a metaphor for the way the UK in general destroys anything that is generally good, farms it out to other people and pays too much attention to incompetent managment overly dominated by an unrepresentative corrupt and elitist political/media establishment.

    We don't own our own car industry, we had to get others to run it for us. We don't do anything much in this country other than shuffle other peoples money in finance in the city.

    We still (just about) have an excellent home grown health care system...but here we go dismantling it. We cant trust our own Drs to run primary any more, so we starve it of funding then get managment consultants to advise its taken over by fund holding hospitals and no doubt eventually large American health care companies...for the benefit of shareholders in the city of london.

    Its fairly simple basically. Primary care is actually and excellent and efficient system if funded appropriately. But it isn't. The answer is to fund it properly ...not dismantle it and replace it with a secondary care led monster.

    Its illustrative of a fundamental problem with the managment of the United Kingdom in general and another reason to emigrate, leave this country and work elsewhere.

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  • Medway CCG tried to force a vote so that GPs could chose from 3 options
    1. Do nothing - wait and watch
    2. Team up with NHSE and have more influence on decision making ( though in the fine text it read- CCG will comply with what NHSE say, so virtually CCG is stuffed and so are we)
    3. Team up with NHSE and hospitals - that's where you agree to being managed by Hospitals, I presume.
    These options were questioned and now we head for a vote in January.
    The problem is that an email circulated by the CCG sent last week to all GPs states clearly : Despite the outcome of the vote, CCG will have the right to choose Option 1 or 2 !!!
    Thank you, it's very clear - CCG's have their own interests - they are not listening to or representing GPs anymore. The Medway GP vote has already been put down as a farce which will materialize on 18.01.2015

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  • This plan just isn't going to work. See slide 13 http://www.slideshare.net/mobile/DrWilliamBehan/presentations
    Its all about administrators taking more control and patients losing out

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  • This is a real threat to primary care particularly in areas where practices are struggling. There is an alternative model in the NHS England Five Year Forward (the Multi-Speciality Community Provider) but it needs primary care engaging rapidly and wanting to try something new - otherwise I suspect the hospitals will get there way

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