On Wednesday 8 May The Guardian published an article by Dr Paul Williams MP ‘As a doctor, I say it’s time to nationalise GP surgeries’. As a patient, Public Matters’ Deborah Harrington here writes an open letter to her doctor, explaining the pitfalls and the risks to patients and doctors alike from the Primary Care Networks which Dr Williams promotes in such glowing terms. In his original piece Dr Williams references The Inverse Care Law in support of his case, but avoids mentioning the all-important bit which argues that market forces always adversely affect provision of patient care to those who need it most. Dr Paul Williams is an MP, a member of the House of Commons Health & Social Care Select Committee and was the chief executive officer of Hartlepool and Stockton Health GP Federation which oversees 37 practices in Hartlepool and Stockton.
URGENT: Re Primary Care Network contracts due to be signed by tomorrow Wednesday 15 May
You will know that I am facing a difficult day tomorrow. I have my ‘two week referral’ appointment you made for me at the hospital. You told me to try not to worry.
But I have another worry about Wednesday that I can’t discuss in an appointment with you. It’s about the new NHS Long Term Plan and new GP Primary Care Network contract. The implementation of these plans across the country is creating cuts and closures to District General Hospitals with a stated aim of putting much of their work, including the transfer of responsibility for about 30 million outpatients a year, into primary care.
I have read the background to this issue and although it is clear that care in the community (where well resourced and funded) can improve people’s wellbeing, there is little or poor evidence that it reduces the need for inpatient care. We already have one of the rich nations’ lowest bed:patient ratio and it is not safe to lose any more. The opposite side of the coin to ‘too many patients’ is ‘not enough beds’. There is also an assumption that you, as a GP, routinely and indiscriminately refer patients to hospital. This is despite the fact that, according to the Nuffield Trust, an estimated 95% of general practice consultations are completed without referral to other services.
As part of the changes, GP referral services are being used to double-check any treatments you request for me. Am I not to trust your judgement any more? I am doubly worried to know that some of those referral services are provided by Optum, a subsidiary of US health insurance giant United Health.
At the same time we are seeing what have traditionally been our locally based GPs in their family practices either disappearing or merging into new organisational forms. These are supposed to be resourced in such a way as to provide the enhanced community support required in the Long Term Plan, but the reality is there’s neither the money nor the staff to meet such aspirations. This is the reason for my letter to you, as the final phase of mergers is being brought in with the Primary Care Network contracts which are to be signed by you on the same day as my appointment.
I believe that there are two separate but equally important issues to be addressed and I would like to raise them with you and have your view on them.
Firstly these plans are changing and increasing the responsibilities of GPs in the NHS at a time when GP numbers are seriously depleted and due to become even more so in the next 5-10 years as a large cohort is expected to take early retirement. To make major changes at a time of such stretched resources seems very foolhardy if not dangerous. Major structural changes require a lot of work. “It is a real challenge to get across the valley of death from where we are now to the sun-lit uplands where it all works” as Nigel Edwards, Chief Executive of the Nuffield Trust, described the situation in a Health Select Committee oral evidence session. As a patient I find it distressing to hear such a phrase.
Research has shown time and time again that early diagnosis of serious disease is most effective when there is GP-patient continuity of care. It makes sense to me as a patient too. On the other hand they have no evidence that the ‘sunny uplands where it all works’ even exist. As one GP responded to MP Paul William’s article in the Guardian supporting the PCNs, “The amount of work a GP practice can agree to take on is limitless. But is it right to say yes to all this extra work when there aren’t enough GPs to do the core work? At a time when GPs are in short supply it’s better for everybody if they concentrate on being accessible to their patients and providing appointments for sick people rather than rushing around like blue arsed flies trying to do everything.”
Which brings me to the second point: the way that GP services are being restructured – and restricted – and how that affects my ability to access an appointment with a doctor as my first port of call if I am worried about my health beyond the point where a paracetamol, OTC remedy from the pharmacy, or a day under the duvet will make me feel better. Large scale GP organisations have been around for a few years now and are growing in number but, as I understand it, all the remaining family practices will be obliged to sign up this Wednesday and, in effect, the family practice where I can go and see ‘my’ GP will become a thing of the past. Under the GP Forward View and now the 10 Year Plan, access to doctors is being restricted and GPs will be required to mostly see patients with complex needs. Surgeries (or polyclinics, or other facilities) are increasingly ‘GP-led” rather than a place you go to see a GP, with a “care navigator” directing you to ‘services’ such as ‘self-care’ – which isn’t a service. Our practice website where I can book on-line for an appointment some weeks in the future tries hard to deflect me away from even considering seeing you.
I appreciate that PCNs are seen by some GPs as a way of avoiding being swallowed up by super-practices, or some of the other company structures. They are seen as more ‘NHS’ than these corporate entities. But I am concerned that the whole process of change in the NHS away from the very locally based services the 1946 Act was designed to create and provide is incremental. What may appear like a line of resistance to the encroaching privatisation and corporatisation of the NHS may well not be. In July 2016 the Nuffield Trust did a survey of the effectiveness of the GP large-scale organisations and found that they really only make their savings from merging their ‘backroom’ functions. One of the largest super-practices, Modality, has been made custodian of funds to create the PCNs. Modality works in partnership with Optum. Surely having a US insurance giant influencing or running the decision making process for anything in our NHS is most patients’ worst nightmare?
I am well aware that there are real arguments among GPs and other health experts about whether the private contractor family-practice model should continue. But its particular form has allowed NHS patients since 1946 the extraordinary right to see a highly trained doctor – and to maintain a long term patient relationship with them – virtually on their own doorstep. All the new and existing large scale organisations erode or remove that right. If there is to be a new model, it must have that relationship at its core if the NHS is to maintain or improve health outcomes. Furthermore, from your point of view as a practitioner, the Nuffield Trust’s report found that in the new large-scale organisations, “Salaried GPs were least satisfied with their freedom to choose their own method of working and practice managers were most satisfied with their freedom, which raises questions that we could not explore further about whether standardisation of work processes affects clinicians more than other staff groups. Salaried GPs were also least satisfied with their hours of work.”
We are moving to a system where neither you nor I will be as happy with the service or the doctor-patient relationship as we have been in the past. It’s a system re-designed on the way healthcare is delivered in the US, the Accountable Care model. There’s been a 30 year love affair between the NHS’ medical establishment (supported by MPs on all sides of parliament) and the US style of healthcare (not that you’d know it, it gets little publicity and many denials). And after all the change and stress there is no evidence that health outcomes will be improved or lives saved. Indeed, looking at the US experience, the opposite is true.
Is there any resistance among GPs to what is happening? Do you have time to lift your eyes from the mountain of paperwork on your desk to even think about it? I would very much hope so. Otherwise my children and grandchildren are unlikely to have the same access in the future to the service which has cared for me and all the generations since 1946 so well. I would really like to hear your views. Along with many others I am relying on resistance from within the medical profession to the changes that are ‘transforming’ our NHS beyond recognition to its and our detriment.
With very best wishes