Almost 11,000 patients at a GP practice in central Nottingham, many of them vulnerable, face disruption to their services and potential reductions in care as Nottingham and Nottinghamshire CCG/ICS imposes hefty cutbacks in funding and puts a major GP practice out to tender – all in the name of equality.

Waiting in the wings is an American company that appears to have no compunction over grabbing a drastically under-funded contract, and slashing back the services to fit.

According to the CCG’s own Equality and Quality Impact Assessment, which has been seen by The Lowdown, the contract on offer would downgrade the enhanced care currently available to the patients on the list of the Platform One GP practice (rated “outstanding” by the CQC) to “core primary care services.”

It’s unlikely any additional care will be provided, since in the name of equality the CCG has decided that once the current contract ends in March 2021 any increase in care to meet needs of one group of patients would also have to be introduced in ALL practices throughout the city and county, claiming: “This reduces inequality amongst the GP practice offer.”

Of course the patients on Platform One’s list are far from equal in status or health needs to the average patient in Nottinghamshire. The CCG has been trying for years to re-tender the service, at a drastically reduced level of funding per patient – reportedly cutting back from £190 per head to just £110, a brutal 43% reduction.

 

So far there have been no takers despite three rounds of tendering. Platform One clinicians (employed by NEMS Community Benefit Services, a not for profit local company that has run out of hours services for over 20 years) have stated they can’t afford to carry on the service at this reduced level of funding, which would leave them with a deficit of £400,000-£500,000 per year. Their contract ends in March 2021.

They have made good use of the additional funding, developing the expertise to deliver enhanced specialist care and support, including mental health and substance abuse treatment, for some of the city’s most vulnerable patients, including over 350 homeless people. The CCG is unable to guarantee any of these enhanced services would continue under a new provider, or that patients transferred to other GPs would receive equivalent levels of treatment.

Two thirds (7,163) of the patients registered with the Platform One GP practice have a mental health diagnosis code from seeking secondary mental health care. A third of these make up a majority of  the 3,000 patients from the Platform One list who are being forcibly transferred to other GP practices in the city and county in an effort to reduce the size and geographical coverage of the practice – and make it more attractive to a private bidder after three abortive efforts at re-tendering.

But the patients have not been consulted. The primary care team have decided to arrange the transfers on patients’ behalf, or as the Equality and Quality Impact Assessment puts it: “The primary care team are to explore allocating patients to practices, rather than writing to patients and asking them to re-register themselves.

Patients facing an imposed transfer out of the practice they have chosen to enrol with, and into a practice chosen for them by the CCG’s rather less than caring primary care team, are not the only ones to be ignored. According to Platform One clinicians:

“As far as we are aware, no consultation has taken place with any stakeholders, members of  the Crime and Drugs Partnership, Substance Misuse Treatment Providers, statutory  bodies or most importantly, with the patients or their representatives.”

The cutbacks and their implications have been covered at length in two articles in the BMA’s The Doctor magazine, which warns that a US company which has already won five contracts for GP services in Nottingham and another 16 elsewhere in England has bid to take over Platform One:

“A UK subsidiary of a multi-billion dollar US healthcare firm is in the running to take over an ‘outstanding’ Nottingham GP practice which looks after thousands of the most vulnerable patients in the city. Operose Health, the UK arm of one of America’s largest healthcare companies Centene, has bid for the contract …”

The parent company Centene was for some time actively involved with CCG bosses in the establishment of what is now grandiosely described as the “Integrated Care System” in Nottingham and Nottinghamshire.  But why an American company should aspire to taking an under-funded contract for a patient list including such a high proportion of vulnerable patients with high levels of need for care and support is unclear. The prospect of making any significant profit is vanishingly small.

Nor can we know what the company’s strategy might be: the other failed practices Operose has already taken over in Nottinghamshire are not attached to Primary Care Networks and according to local GP Dr Irfan Malik they have “gone off the radar.”

“We don’t know how they are run, or what they are expected to achieve compared with other practices.”

Image of Dr Malik

The issue has also been covered by the local press, and the case has been taken up by the local Healthwatch, by Keep Our NHS Public, by local MP Margaret Greenwood and by Nottingham City councillors in addition to Notts Refugee Forum and other groups representing Platform One service users.

On November 19 the CCG was summoned to explain itself to Nottingham City Council’s Health Scrutiny Committee, resulting in a letter from the chair to the CCG noting the lack of any published equality impact statement, asking for the process to be delayed and further information provided to the next scrutiny meeting.

The Equality and Quality Impact Assessment (EQIA), grudgingly published after the scrutiny meeting, makes clear time and again that the CCG’s primary care commissioners had paid little or no attention to the special needs of the Platform One patients while bundling 3,000 of them out to alternative GP practices in a “confidential” process … without their knowledge or consent.  The EQIA states:

“Should the allocation proceed as planned it is anticipated that all patients will be written to during Q4 2020/21 to advise them that their registration has been transferred to a named practice closer to their registered address.”

While Platform One Practice is located in Nottingham City East, the EQIA admits the 3,000 patients will be scattered far and wide: “The 96 receiving practices are located across all ICP areas and across the majority of the 20 Nottingham and Nottinghamshire PCNs.”

The primary care team appear to have made a large number of assumptions that somehow everything will turn out all right, and taken no account of the specifics of the patients whose care they are disrupting. The EQIA states several times “We do not hold demographic information on the patients that are being dispersed and allocated to another GP practice.”

For the transferred patients the EQIA also admits, with no apparent concern: “There may be some negative impacts on continuity of care as patients will be receiving care from a different practice team.”

Later the EQIA also admits it’s likely the changes will have a more severe impact on some minority ethnic  patients: “Where patients are being allocated to an out of City practice, closer to their home, there may be some negative impact if the practice does not have the same level of cultural or language expertise / knowledge.  However this may be mitigated if staff have received cultural awareness training.”

For the 7,000 patients with mental health problems “There may be a negative impact on this patient group for both Phase A (transferred) and Phase B (new provider of Platform One) as these patients may not receive the same service that they have been receiving to date from NEMS e.g. the new provider and other practices may not have dedicated Mental Health Nurses…”

Dr Malik, senior partner of another GP practice 3 miles from Platform One, expressing concern at the knock-on impact on other GP practices, and on emergency hospital and mental health services, told The Lowdown there is no evidence of other GPs arguing for the levelling down of Platform One’s enhanced funding.

“It’s higher because of the higher level of need of its patients. It’s a high quality service that has been built up from scratch: the GPs want to carry on, but the problem is the reduction in funding, meaning the quality of care would have to be reduced.

“Having read recent reports from the BMA and listened to the 3-hour Health Scrutiny Committee questioning of the CCG, my opinion is that funding should be secured for NEMs to continue their excellent work at the surgery.

“The proposed re-tendering and partial list dispersal of 3,000 patients is poorly planned, and the timing during the current pandemic couldn’t be worse. Our main concern should be the vulnerable patients, who often don’t have a voice.”

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