NHS England recently announced that it is “looking very actively” at how it can make Clinical Commissioning Groups get involved in commissioning primary care.
From September 2014, NHS England will hand over a role in commissioning primary care to Clinical Commissioning Groups. This handover is related to setting up a new system of integrated primary and community health and social care – just like the new system that the Calderdale and Greater Huddersfield Strategic Outline Case plans to set up.
It doesn’t seem to bother NHS England that this would create a clear conflict of interest for Clinical Commissioning Groups (CCGs), which are groups of local GPs; or that the GPs’ trade union, the British Medical Association, had just a week earlier said it opposed CCGs commissioning or decommissioning GP contracts because of conflict of interest.
As Greater Huddersfield CCG Clinical Lead Dr Steve Ollerton said yesterday at a Kirklees Healthwatch public meeting, it wouldn’t be right for the CCG to commission GP services, because it would mean he would be deciding how much to pay himself. GP contracts are currently made with NHS England.
GP Online reported that Birmingham Local Medical Committee secretary Dr Robert Morley said:
‘The idea … is absolutely nonsensical, it’s barmy, it’s lunatic, it’s barking mad.’
Calderdale CCG sees dialogue with NHS England as way to make sure that existing GP contracts don’t stop investment in new locality-based teams
Since GPs say it’s wrong and barking mad, why is NHS England suggesting it? The Calderdale Clinical Commissioning Group (CCG) Draft 5 Year Strategic Plan 2014/15-2018/19 includes a section on risks associated with delivery of the Strategic 5 Year Plan. One of the risks is:
“The rigidity of primary care contractual models impact on delivery of new integrated community provision”.
It identifies “emerging dialogue with NHS England” as a way of reducing that risk.
“New integrated community provision” is central to the Strategic Outline Case for transforming NHS and social care in Calderdale and Huddersfield.
Calderdale CCG’s Strategic 5 Year plan is very much about how to put this SOC into action (where it isn’t already well underway).
Section 6.1g in the Strategic 5 year plan says that Calderdale CCG aims to save money by reducing A&E admissions and also by reducing “non-elective spend and activity” to “deliver a shift from non-elective care” and “reduce time spent in hospital”.
This translates to reducing the number of beds at CRH to 80.
Locality-based primary and community care teams
The Strategic 5 year plan aims to reinvest a large proportion of the savings from reducing “non-elective spend and activity” and A&E admissions into “new integrated community provision.”
This will be based on new “locality-based” teams that will include GPs and a range of other health care services, to replace hospital care.
You can see that this is going to require big changes in GP contracts and the services they provide. They might – perish the thought – be a bit “rigid” about this.
So it seems kind of surprising that the GP-led Calderdale CCG has let this go through in the Strategic 5 year plan.
I’ve tried to ask Hebden Bridge Group Practice what they think of all this, but the Practice Manager has failed to return my 4 or 5 calls. I know he must be busy, but I think it would be good if they put their side of the story here.
NHS England’s plan to get CCGS “actively involved” in commissioning primary care will surely be completely unworkable in practice, if CCCG sticks to its conflict of interest rules. These make it plain that any GPs or other members of the Governing Body with a conflict of interest have to declare them at the meeting and are then unable to discuss, debate or decide on anything that relates to their conflict of interest.
Since all GPs on the Calderdale CCG Governing Body have a conflict of interest when it comes to commissioning primary care, that leaves lay members and Calderdale CCG employees to make the decisions. So much for GP-led decisions about what’s best for Calderdale NHS.
Privatising primary and community NHS services
GP Online magazine on 11 March 2014 carried an article by Neil Roberts that says NHS England’s recent report “ Improving General Practice – Phase One emerging findings report” includes:
“plans to tender for new providers and new models of general practice in areas of poor quality or under-provision.
APMS contracts could be used, with contracts extended beyond existing five-year terms to promote stability.
Small practices will face increasing pressure in the face of NHS England’s belief that general practice needs to ‘operate at greater scale and in greater collaboration’ in future.”
APMS contracts are “Alternative Provider Medical Services” contracts. They were introduced by the New Labour government and enabled private health company Care UK to set up two walk-in centres in Calderdale, and Virgin Care to set up 3 GP practices in Calderdale.
Unlike regular GP practices, where the contracts are negotiated nationally, APMS contracts are negotiated locally and usually with with non-NHS bodies, such as voluntary or commercial sector providers.
Historically, APMS contracts have been way more expensive than GP contracts and have not provided good services. This is well documented and I will dig out the links if anyone’s interested.
Calderdale CCCG is spending £2.75m on voluntary and community sector to make it business-ready
Calderdale CCG’s Strategic 5 year plan says that it will invest £2m in third sector capacity and capability building in 2013-14. This is obviously in line with the Strategic Outline Case proposal that voluntary and third sector organisations will to do a lot of the work of supporting home-based NHS and social care in the new “locality-based” integrated teams.
Calderdale CCG’s 2012-13 Statement of Involvement, presented to the 14th Nov 2013 Calderdale CCG Governing Body meeting, shows that in 2012/13 Calderdale CCG gave a £750K grant to the third sector to set up a ‘Health Connections” umbrella project to support the voluntary and community sector to
“sustain and capacity build itself over the next 3 years…to develop a sector which is business-ready.”
Voluntary Action Calderdale runs both Calderdale Healthwatch and the CCCG-funded Health Connections Calderdale
A visit to the Health Connections Calderdale website shows that both the organisation and the website are run by Voluntary Action Calderdale.
Voluntary Action Calderdale (VAC) also has the contract to run Calderdale Healthwatch services for
- Influencing – helping people get involved in the planning of local health and social care services
- Signposting – giving people the right information at the right time to support them to make a choice about services they may need.
Calderdale Healthwatch is holding public meetings to allow “consultation” about the Strategic Outline Case for transforming NHS and social care in Calderdale and Huddersfield.
Calderdale Health Connections is signing up voluntary and community organisations to be “engagement champions” for Calderdale CCG and WSYB Commissioning Support Unit.
A downloadable document on the VAC/Health Connections website says:
“VAC are seeking members of VCS groups to train as Engagement Champions
The Health Connections Team, in partnership with the West and South Yorkshire and Bassetlaw Commissioning Support Unit (WSYBCSU) and Calderdale Clinical Commissioning Group are seeking Voluntary/Community groups to participate in a project to train staff and volunteers to deliver engagement activities on behalf of the NHS.
- Participation in a package of free training
- Eligibility to go on an approved provider list for future commissioning opportunities from the NHS
- Skills development for individuals”
At no point (as far as I’m aware and please correct me if I’m wrong) has Calderdale Healthwatch declared at its public meetings that:
- it is run by an organisation, VAC, with a vested interest in the implementation of the Strategic Outline Case, through its contract to run Health Connections Calderdale.
- Or that this organisation is running training activities for “engagement champions” for Calderdale CCG and WSYB Commissioning Support Unit,
- or that attendance at these activities means organisations can go on a provider list for Calderdale CCG/WSYB Commissioning Support Unit commissions that, as the Calderdale CCG Strategic 5 Year Plan shows, are part of the Strategic Outline Case programme.
Blood on the CCG floor come September?
The SOC/ Calderdale CCG Strategic 5 year plan to reduce hospital care across the board and increase health and social care in locality-based teams across Calderdale will have big effects on working terms and conditions for NHS staff. The Strategic Outline Case notes that there will be significant costs in “reprofiling” the workforce, which is about changing people’s job descriptions as NHS services move out of the hospital into the community.
According to the GP Online 11/3/2014 article, NHS England’s report, laughably entitled “Improving General Practice…” says that where small practices close, or are shut down over quality concerns:
‘we will, where possible, make arrangements for an existing provider to take over the practice on a permanent basis, in line with our view that general practice is more likely to deliver high quality, cost effective services when operating at greater scale’.
Come September 2014, when Calderdale CCG will acquire the power to “co-commission” GP services alongside NHS England, I predict blood on the CCG floor.
September 2014 is when NHS England will publish a national framework for joint commissioning in September.
The NHS England report “Improving (sic) General Practice…” also says that practices could receive increased funding where money allocated by CCGs to support care for over 75s successfully reduce emergency admissions.
NHS England has already told CCGs to make £5 per patient in funding available to support care of over-75s, with the funding payable directly to practices or other organisations working around them.
A small fight about this broke out at the 14 March 2014 Calderdale CCG meeting, with the Chair Dr Brook saying this money had to go to GPs and the Calderdale Council head of public health saying it should go to deprived areas, since there was greater ill health and far shorter life expectancy in these areas.
He revealed the shocking fact that in two of Calderdale’s most deprived areas, life expectancy was lower than 75 so they clearly needed the money most. The mini-brawl was only cut short by someone saying this could be discussed later.
Joint and shared commissioning = £bns of private health company contracts
The drive towards more joint and shared commissioning is tied up with changes like those proposed in the Calderdale and Huddersfield NHS Foundation Trust’s Strategic Review and its Strategic Outline Case (SOC).
These changes are all about:
- centralisation and specialisation of hospitals
- cutting hospital beds and reducing hospital admissions
- providing more integrated NHS and social care in the community as a way of keeping people out of hospital
The way the Calderdale and Huddersfield SOC plans could well pan out can be seen by looking at Staffordshire and Stoke-on-Trent Transforming Cancer and End-of-Life Care Programme.
This “partnership”, between Macmillan Cancer Support, five Clinical Commissioning Groups in Staffordshire and Stoke-on-Trent and two social care commissioners, is one of the Department of Health’s 14 national pioneer sites for integrating health and social care.
The Magnificent 7 involved in the Calderdale and Huddersfield Strategic Outline Case seem to be tagging along behind the pioneers.
A couple of weeks ago Staffordshire and Stoke-on-Trent Transforming Cancer and End-of-Life Care Programme put an advertisement on the Supply2Health Website saying they were looking to commission £1.2bn of contracts for cancer and end of life care. These contracts are all about providing integrated health and social care for people with cancer and people who are at the end of their lives.
The Staffordshire and Stoke on Trent Transforming…Care Programme says its
core aim is,
“to transform the commissioning process, from the current system of commissioning intervention or services, to commissioning the entire patient journey.
This will ultimately lead to one sole provider being responsible for the whole cancer/ end of life pathways from beginning to end, rather than the current system of a number of providers with a series of contracts for each separate part of the care pathway.
It would be for the successful Prime Provider(s) to organise the best model of care across a network of providers, who would be subcontracted to deliver specific services.
Outcomes based service specifications will be used as a framework for this. (p2)”
This sounds pretty much word-for-word the same as proposals in the Calderdale and Huddersfield SOC.
UCV Plain Speaker has already run one article reporting on this new kind of commissioning, which private health companies are reportedly drooling over, according to articles in their trade magazine, Health Investor.
At the Kirklees Healthwatch public meeting yesterday, Greater Huddersfield CCG Clinical Lead Dr Steve Ollerton gave the impression that West Yorkshire is also moving towards larger scale joint commissioning.
He said that decisions about the location of A&E hospitals will ultimately be made at regional level, with the involvement of all 11 West Yorkshire CCGs.
Dr Ollerton said that the Keogh Report (about the future of A&E in England) implied that West Yorkshire could end up with 3 or 4 A&E departments. He said that it’s going to be 4 because if it’s 3 there won’t be any in Kirklees and Calderdale, and “we’’ll lose out.”
In the light of the Staffordshire and Stoke on Trent pioneers and their £1.2bn privatisation contract, I asked the CCCG Governing Body meeting last week whether they were likely to offer their contracts for integrated health and social care to private health companies. I felt the answer I received was a bit sketchy and unclear. Basically, the CCG Chief Officer said that wasn’t their intention. But they would have to comply with procurement and competition rules.
Here is another Supply2Health integrated care contract, this time from a South London CCG advertising a 5 year contract valued between £39.2m and £54.6m, using the same “prime contractor” model, for a Local Care Centre with these clinical objectives:
- “To facilitate the development of integrated services and care pathways that put patient’s needs foremost;
- To provide a comprehensive range of clinically appropriate services that can be safely and economically delivered in a primary/community setting;
- To introduce innovative service provision that embraces technology and new ways of working that facilitate the delivery of high quality, accessible services;
- To provide an efficient and effective working environment for all staff that acts as an enabler for multidisciplinary working practices and service integration; and
- Ensure that the configuration of services has a strategic and clinical fit within the wider network of health and social care
Merton Clinical Commissioning Group (MCCG) is seeking to engage a prime contractor for the provision of a range of clinical services at the Nelson Local Care Centre.
The Nelson Local Care Centre is currently under construction due for completion by Spring 2015. This new facility will be a flagship resource for Merton, offering a range of integrated primary and intermediate care resources that are fit for the delivery of more modern evidence based healthcare. Our overall aim is for patients to experience an improved system of care, avoiding the need for multiple visits, to a one stop shop system, where care is coordinated between services. This in return will help avoid duplication of effort, streamline the pathway and generally increase both efficiency and the overall quality of care.”
Does this sound like what the Calderdale & Hudderfield SOC are calling Locality-Based primary/community care centres? It does to me.
Calderdale and Huddersfield CCGs are both saying they don’t intend to go down the privatisation route. But other CCGs who are further down the “Right Care Right Time Right Place” route that the SOC is based on are putting £bns of contracts out to tender, and Health Investor says that this kind of prime contract is the next big thing. So how do Calderdale and Huddersfield CCGs imagine they’re going to avoid it?
Here is the GP Online article. If you open it in google news you can read all of it, otherwise it’s just the headline and first sentence.
Here is a pdf document by the Staffordshire and Stoke-on-Trent Transforming Cancer and End-of-Life Care Programme.
Here’s a report on the 14 March Calderdale CCG Governing Body meeting.