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.’
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’
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
01 December 2023
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