A bizarre experiment is being acted out in North West London. Its Integrated Care Board, covering the third largest population of all 42 ICBs in England was discovered at the end of January to be embarking on a scheme to fundamentally change primary care services by April 1 – with no plan for consultation with GPs, patients or the wider public.
Their plan was a root and branch reorganisation that would replace the role of GP practices in handling calls seeking a same-day consultation. Instead of practice staff passing calls on to their GPs, North West London’s boroughs would be carved up into a smaller number of “hubs,” each covering one or more of the 45 Primary Care Networks.
According to the ICB’s model, hub call handlers would divert almost all calls (93 percent) to staff other than GPs, leaving a token GP to “supervise” the handling of calls – and speak to the remaining 7 percent of patients. The role of the GP in each hub would be reduced to call centre supervisor, with other GPs left dealing only with complex cases and chronic sick and non-urgent care.
Had some of the confidential documents outlining the scheme not been “leaked” into the right hands, many GPs and their patients would have been effectively faced with an ambush, with little chance to resist.
That was clearly the intention, and ICB leaders have tried to bully, offer phony apologies, and claim to be ‘following orders’ as the scale of opposition to their plans has become clear.
Only when the opposition became more vocal did the ICB reluctantly agree to hold back on implementation and make vague promises to try “co-production” instead of confrontation.
So who has asked for these changes?
Nobody at all. The proposals have so far only been supported by the ICB chair, chief executive, directors, and their own immediate camp followers, while local GPs have been furious both at the plans themselves and at the way the ICB attempted to force them through without consultation.
GPs, patient groups and campaigners have hit back, linking up with local politicians and MPs to organise briefings, meetings and protests.
While the ICB chiefs point to some public pressure for more speedy access to GPs, they ignore the fact that North West London is already one of the best-performing areas for swift access to GPs, and many local GPs already have very good levels of accessibility.
Moreover, there has been no equivalent public pressure or campaign asking for appointments with the much less experienced and less qualified “Additional Roles” staff, such as Physician Associates, who would be taking most calls under the NW London plan.
So who is driving the experiment?
The chair of NW London ICB is Penny Dash, who until 2021 was a senior partner of management consultancy McKinsey. The ICB has also brought in another major consultancy firm, KPMG to assist in rolling out their plan for complete reorganisation of primary care.
As the plan was revealed, and the growing anger of public and GPs became obvious, various ICB leaders tried different ways to defuse the situation. Chief Executive Rob Hurd insisted that the changes were “determined nationally” by NHS England, leaving the ICB no scope to conduct a formal consultation.
Yet there is no national programme. Only NW London and one other ICB (Buckinghamshire, Oxfordshire and West Berkshire) have been pushing through similar proposals. The idea they may be implementing a national plan was cruelly shot down … by NHS England, whose primary care director Amanda Doyle said she wanted to “step back” – and allow local systems to get on with their own proposals.
Hurd also claimed to be following the directions of the 2022 ‘Fuller Stocktake’ (an extensive NHS-backed report undertaken by Professor Claire Fuller): but few of the report’s proposals have been implemented anywhere.
As that argument also fell flat, the ICB got desperate and tried to argue that opponents of the scheme were irresponsibly frightening patients – when in fact what was frightening them was the ICB’s plan (which is perhaps why it was kept secret).
Unaware of the irony, the ICB’s Primary Care Director Dr Genevieve Small told GPs:
“The bit that’s keeping me awake at night is that we have made our patients incredibly anxious. And they have felt that general practice as they know it is ending on the 1st April and that they won’t be able to see their GP any more.”
This was of course what many patients DID think of the ICB plan. And there was a simple solution: drop the plan and start talking instead to GPs and to patients about how to generalise best practice to make services more accessible.
Since then even more evidence has emerged to confirm that NW London ICB is in no way following rigid national instruction: NHS England has backed a project involving seven ICBs who will test new “operating models” for GP provision – over the next two years. It’s not clear whether any of the models will be anything like the one at the centre of the NW London row.
But if NHS England is happy to allow an extended study like this they are clearly not cracking the whip over North West London ICB bosses demanding they drive through their plan for hubs.
What do the plan’s supporters want to achieve?
It appears that NWLICB’s main focus is securing a share of NHS England’s £1.4 billion kitty for the “Additional Roles Reimbursement Scheme”, which can be used to cover the full cost of employing 17 different types of staff to work in primary care – but NOT to employ the staff patients most want to see: GPs or nurses.
NHS England has stipulated that to be eligible for funding under ARRS, each PA has to “provide a first point of contact care for patients presenting with undifferentiated, undiagnosed problems.” (page 91)
Around the country, this has produced the ridiculous situation that fully qualified GPs are unable to find locum and full-time posts, or are being made unemployed, with their work being increasingly done by less qualified staff – who are cheaper, or in many cases effectively free to employ.
Serious questions are being raised on social media about the use of PAs and other ARRS staff in single-handed GP practices – which almost by definition cannot supervise them properly – and other GP settings without adequate medical supervision.
There would have been much less opposition if NW London ICB had promised to ensure that experienced GPs would be the ones to ‘triage’ patients in each new hub, and decide which cases were sufficiently straightforward for PAs and other staff to play a useful role. Cost restraint and the substitution of GPs with PAs appear to be the main drivers of the policy.
How can Physician Associates best be used to improve NHS care?
Physician associates – who are they and why are they in the media
Is there good evidence to support the NW London proposals?
No. Important recent studies point in the opposite direction. GP magazine Pulse has highlighted recent research in Leicestershire showing that patients live longer when they have access to fully qualified GPs, continuity of care and better funding GP practices.
Data published by the National Institute for Health and Care Research in November 2022 shows that while adding doctors and nurses improves results and patient satisfaction, trying to make do with the various alternative staff has quite the opposite effect.
It is less efficient, less satisfying for GPs, less popular with patients, more likely to wind up increasing use of A&E – and far from saving money, it winds up costing more:
“Employing clinicians who are not GPs did not reduce GPs’ workload or improve their job satisfaction, research found. In the short-term at least, new roles in general practice for other clinicians, such as paramedics and physician associates, increased the time GPs spent delegating tasks and supervising.”
The same study notes that some additional roles – notably pharmacists – can deliver benefits, but:
“The highest quality of care (as measured by the Quality and Outcomes Framework) was seen with more GPs. Higher quality prescribing and lower prescribing costs were seen with more pharmacists. Higher overall NHS costs were seen with overall higher numbers of healthcare professionals, but employing more non-GPs was only slightly cheaper than employing GPs.”
Perhaps even more worrying was the warning that: “Higher numbers of other clinicians (apart from nurses and GPs) were associated with more accident and emergency attendances.”
More savvy GPs will also have taken heed of the implications for them of a recent GMC ruling that suspended a hospital doctor for giving “inadequate supervision” to a PA – on the basis that he had allowed the PA to examine the patient and take their history, and not repeated those for himself before authorising treatment.
The ruling not only underlines the risk to GPs if they are found to have given PAs too much scope to work alone – but also questions the usefulness of PAs in this type of assessment, if everything they do has to be done again by the doctor supervising them. Some GP practices are implementing the BMA’s recent “scope of practice” recommendations defining the appropriate support role of PAs. Some GPs are going even further – and simply refusing to take on supervision of PAs because of the extra workload required to do it properly.
What’s the evidence from the pilot studies?
Any findings from the ten PCNs that have tested out the ‘hub’ proposals have been kept tightly under wraps, despite demands for information by London-wide LMCs. There has been no explanation of why the ICB, having established the pilots last autumn, has more recently tried denying that they existed, and is now arguing that there has been ‘no time’ to evaluate the results.
Of course, we can be sure that if the results were any vindication of the policy they would have been brandished and published far and wide. [BOLD PLEASE]
Instead one Patient Participation Group has managed to elicit an admission that their local hub’s effectiveness as a pilot depended upon a fully qualified GP taking the first call, rather than a Physician Associate or other non-doctor.
This is indeed the basic premise of “triage,” in which the more serious cases are separated out from the less serious and allocated more intensive treatment. Since it was first employed on the battlefields of the Napoleonic wars it has relied on using the most experienced doctor to decide on the patients’ needs.
Is there any agreement in sight?
So far, no. The Local Medical Committees remain opposed, and councillors from various boroughs have joined the resistance to what is not only a rotten plan, but a complete negation of any genuine partnership working between NHS and local government.
Despite the promise of “co-production” there is no indication the ICB has plans to work seriously with or listen to anyone who does not accept their original proposals.
There has been a long history of arrogant NHS bosses trying to bully and wrangle their policies through in North West London.
Campaigners had to battle for eight hard years from 2011 before finally, with support from Labour-led councils they managed to discredit the so called “Shaping a Healthier Future” plans to close Charing Cross and Ealing Hospitals, which was eventually knocked on the head by then Health secretary Matt Hancock.
Already analogies are being drawn between the current threat to primary care services and that threat to acute hospital services. Then a powerful alliance was built between campaigners and councils, especially Hammersmith and Fulham and Ealing.
With ICBs now formally linking the NHS and local government it seems that type of alliance will again be the key to facing down Penny Dash and her acolytes – and defending the primary care model that has been so key to the success of the NHS since 1948.
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