June 2019
GPs are central to the NHS system, and are being railroaded into signing a legally binding document without full understanding of the implications.
NOT signing the new GP contract, and NOT signing up to a ‘Primary Care Network’ is essential if we are to resist the conversion of our National Health Service into a system shaped by health insurance industry preferences.
Please read on to understand how and why this is being done, and why conscientious GPs who have signed will regret it in the long term.
What is the “integrated care model”?
This “new model of care” for the NHS is an import from the American private sector; the Health Maintenance Organization/Accountable Care Organization (HMO/ACO).
It is not fundamentally about providing care to UK residents in the way that the NHS has traditionally provided universal healthcare.
Instead the new model is designed to facilitate the siphoning of money allocated for patient care, out of the NHS and into private sector profits. This new model results in poorer care for patientsi,ii,iii.
Poorer care for patients: how patients and professionalism will be put at risk
GPs are now being asked to agree to a professional contract which actively puts patients in danger, because the new arrangement:
-
Conflicts
with medical ethics:
the new contract personally rewards GPs financially when they avoid referring patients to hospital care, regardless of whether the omission harms the patient;
-
Imposes
new and unnecessary constraints:
these reduce the individual GP’s ability to make decisions on the clinical care of patients on the basis of their independent professional judgement;
-
Instead
passes ultimate control over their patient list to leaders in a
“network”:
clinical judgements will increasingly be based on the algorithms contained within insurance industry software which is currently being embedded as the new skeleton of the NHS infrastructure, with GPs’ own diagnostic procedures and prescription choices overridden;
- Presumes, bizarrely, that doctors diagnosing without seeing a patient in person is safe and ethical: early efforts are not working out well and widespread take-up would destabilise NHS funding to conventional GP services for all patientsiv.This bad model is nevertheless being energetically promoted at government levelv.
- Puts patients in danger by allowing inadequately qualified staff the authority to make clinical decisions: patients want and deserve medical care from fully qualified doctors, but this relatively expensive arrangement is under threat from these changes to primary care.
Signing up is voluntary for a GP. However due to the changes it introduces the longer a GP stays in a Primary Care Network, the harder it will become to exit the arrangement.
It can be expected that GPs who participate will also over time see the value of their core GMS contract diminish and the money source for the Primary Care Network increase as the service transitions to the American model.
Background to the 2019 GP contract and Primary Care Networks: corporate infiltration
The extent to which the biggest US health insurer UnitedHealth Group has already infiltrated the NHS and is embedded, with its UK subsidiary Optum, to re-orientate the NHS has been overlooked, underestimated and under-reported.
This is the “elephant in the room” in official coverage of the NHSvi.
UnitedHealth and Mr Simon Stevens
UnitedHealth Group was able to place its Executive Vice President and head of global expansion Simon Stevens into the top position as Chief Executive Officer of NHS England in April 2014vii. Stevens had led UnitedHealth’s push for NHS involvement for many yearsviii.
UnitedHealth Group took on Simon Stevens directly from his position as Senior Health Adviser to Tony Blair’s Government in 2004. The Cabinet Secretary at that time intervened to block Stevens, in his new post, from immediately lobbying for UnitedHealth to win NHS contracts. ix
- In 2011, as President of Global Health for UnitedHealth Group, Simon Stevens was spokesman for an industry lobby group advocating taking the US healthcare model overseas.x
- In the same year he had won a major piece of new business for UnitedHealth, a contract to develop the new Clinical Commissioning Groups in the UK’s NHSxi.
- During this period, when his job was to develop the global business of UnitedHealth Group, he was also a Trustee on two UK thinktanks influential in promoting integrated care: The King’s Fund 2007 – 2011, and the Nuffield Trust 2012 – 2014xii.
Since Stevens was appointed CEO of NHS England in 2014, UnitedHealth Group’s subsidiary Optum has been given key contracts in a “support role” which allow it to further shape the structure of a new NHS from inside the system, for instance via carrying out commissioning support functions for Clinical Commissioning Groupsxiii.
UnitedHealth Group has a long track record of legal action and fines for profit-incentivised malpractice, which include denial of patient care:
- In March 2019, a federal court found that UnitedHealth Group’s subsidiary United Behavioral Health (UBH) rejected insurance claims of tens of thousands of people seeking mental health and addiction treatment based on defective medical review criteria, “wrongly influenced by a financial incentive to suppress costs”xiv.
- The company was fined $400mxv in 2009 for installing computer systems with biased algorithms, the state investigator termed this “deception, manipulation of data and outright fraud”xvi.
UnitedHealth Group/Optum and the foundations for Primary Care Networks
The principles of Primary Care Networks are strikingly similar to ‘Patient-Centered Medical Homes’ which have been developed and promoted by UnitedHealth Group in the US since at least 2007xvii.
In 2012 Simon Stevens explained that UnitedHealth had been “testing that model with a number of primary care practices and the early results are quite promising showing a two-to-one return on investment”xviii.
Is profitability really the most important thing in GP practice?
UnitedHealth Group’s subsidiary Optum was chosen as corporate support partner for the first ‘Primary Care Network’ in England, which was founded by the National Association of Primary Care (NAPC). Simon Stevens formally launched the model in 2015, known then as the ‘Primary Care Home’xix.
- UnitedHealth has had close links with the National Association of Primary Care since 2006, including producing a joint publication in 2010 advising GPs on how to do commissioningxx.
- Optum was until very recently listed as a partner of the NAPCxxi and UnitedHealth/Optum had personnel on the NAPC Council in 2018xxii, prior to the announcement of the NHS Long-Term Plan in early 2019.
Conflict of interests – or conjoined interests? Optum and NHS England
Who is driving and shaping this redesign of GP practice?
People in powerful positions overseeing the transformation of Primary Care in the NHS are in a business relationship with UnitedHealth Group.
NHS England’s former Senior Clinical Advisor for Workforce Design in the New Models of Care programme xxiii was involved in the development of the NHS Long Term Plan which involves conversion to integrated carexxiv. As Chair of the National Association of Primary Care (2014 to 2018) he was “architect” of the first Primary Care Network (the Primary Care Home) which had UnitedHealth’s subsidiary Optum as its “corporate support partner”xxv ,xxvi.
The “co-author” of the Primary Care Home is the current President of the National Association of Primary Carexxvii. He and the former Chair are the National Leads for the Primary Care Homexxviii.xxix.
Both these developers of the Primary Care Home are also directors of a private consultancy founded in 2013 focusing on primary care development, which works with private sector health companiesxxx.
NHS England’s Senior Clinical Advisor for Integrated Care Systems and New Models of Care Evaluatorxxxi:
- Was the founder of one of the largest “GP Superpartnerships” in England, Modality Partnership, which is partnered with Optumxxxii and has reportedly expressed ambitions to be an Accountable Care Organisationxxxiii.
- Is a member of a limited liability partnership (LLP) created in 2015 which co-owns a nascent Accountable Care Organisation company with Optumxxxiv,xxxv.
- His fellow LLP members include the current CEO of Modality Partnership along with others on their national Boardxxxvi,xxxvii. Modality Partnership is spreading across the country, now covering around 400,000 patients xxxviii.
The CQC‘s Chief Inspector of GPs from October 2013 until March 2019xxxix.
- Was an LLP member during the years 2015 to 2017 of the same LLP Partnership which owns a nascent ACO company with Optumxl.
- Was reportedly a Modality Partnership GP until at least 2018xli.
UnitedHealth/Optum’s ongoing role in NHS systems, redesign and Leadership training
Optum was hired in 2018 by NHS England and NHS Improvement to shape and train NHS leaders of the new “Integrated Care Systems”.
Optum is now carrying out NHS-funded programmes under a “major capabilities building program” launched by NHS England and NHS Improvement in January 2018, to accelerate the development toward “Accountable Care Systems”.xlii As part of these programmes, Optum is paid from our taxes for:
- training “leaders” in governance and financexliii
- training them on “population health”xliv
- tuition on strategyxlv
- “focus on care redesign”xlvi
- “focussing on contractual issues”xlvii
Optum is also training new GPs on the NHS England-funded programme called “Next Generation GP”xlviii,xlix, and supporting “integrated community services”, also called Out of Hospital Programmesl.
Optum is already closely involved in the restructure of the NHS in many areas of the country. Through their software and consultancy, Optum is now reframing how UK health professionals see healthcare and interact with their patients.
Simon Stevens was promoted to UH’s President of Global Health in the same year that UnitedHealth acquired decision support software Scriptswitchli, which is widespread in GP surgeries across the NHSlii.
Following Stevens’ appointment as CEO of NHS England in 2014, Optum has been placed on special NHS frameworks that have given them increased access to contracts which allow them to carry out key functions of the NHSliii,liv,lv.
Those functions include referrals and prior approvalslvi, procurement and management of contractslvii, data processing lviii, CCG communications and FOI requestslix , medicines managementlx, and even control of access to confidential patient recordslxi. The referrals task also gives them access to individual patients’ medical records whenever secondary care is prescribed by the GP, as the referral gateway will allocate or refuse NHS money for that care, and the referral cannot occur without the permission of the organisation which carries out this task.
UnitedHealth has been given access to patients’ confidential data in some areas beyond the reach of the national opt-outlxii,lxiii , and an increasing number of patients referred by their NHS GP are having their treatment approved (or disallowed) by America’s largest health insurerlxiv.
Medical notes are thus being examined by Optum personnel doing commissioning support tasks; their primary professional loyalty is to UnitedHealth Group. This is a profound conflict of interest and would horrify many patients, who have trusted their GP’s assurances of confidentiality in disclosing personally sensitive information which is now in the hands of insurance industry personnel.
UnitedHealth/Optum personnel can now be found in many other positions of importance in NHS STPs, CCGs and NHS Trusts, sometimes having individuals in more than one of these roles concurrently. For example an Optum consultant who is non-executive Director on Barnet Enfield and Haringey Mental Health NHS Trust also runs the Herefordshire and Worcestershire STPlxv.
The swift and increasing infiltration of UnitedHealth Group across the system, facilitated by NHS England, threatens to lead to a dominant market position in primary care in this country, which is currently illegal under existing competition lawslxvi.
NHS England now proposes the repeal of the competition requirements of the Health and Social Care Act 2012, a step which will legalise a dominant market position.
An “anti-privatisation” strategy to repeal the competition clause s75 is being actively marketed to NHS activists and NHS staff, by Stevens and others, as the solution to the NHS’s privatisation threatlxvii. This strategy furthers the interests of UnitedHealth Group by legalising a takeover of control of the NHS and of the administration of primary care.
In addition to restructuring the system to redirect money to itself, if UnitedHealth Group can run down the NHS service enough, US-style private health insurance will finally take off in this country with UnitedHealth in a prime position to exploit the ‘market’ it has been a part of creating.
“Integrated care” will repurpose the NHS from public service to insurer’s income stream
Are the new changes to the NHS less to do with improving the delivery of medical care and more to do with the business growth plan of America’s largest health insurer?
- UnitedHealth Group’s subsidiary Optum has, bizarrely and without formal explanation, seamlessly come to be imbued with “expert” status in the new NHS. It is deeply involved in the conversion of the system away from the welfare state model and toward the integrated care model that insurers prefer.
- Traditionally the NHS logically prioritised treating the sickest first – this is being inverted. If the NHS reforms are allowed to complete as plannedlxviii, eventually it is the most ill who will be most likely to be excluded from treatment, as occurs in the USA.
- GPs are being misled into signing up to a system which will make access to care in the NHS increasingly limitedlxix.
- If patients choose, or through denial of NHS care feel they have no choice but to choose, to go outside the NHS via private insurance, they will find their healthcare expensive, limited by exclusions for pre-existing conditions and restricted according to premiums paid.
- Those who can afford to pay for care without insurance are exposed to the risk of profit-led overtreatment whose side-effects may be very dangerous.
- Inappropriate interests are being served by this change to our NHS; it will put decent GPs under immense pressure to behave unethically, it will harm their patients, and it will harm those who ought to be their patients and would have been under the traditional NHS model.
- It appears that the GP role is intended to reduce in the near future to providing a medically qualified fig leaf for insurance industry profitmaking, if they can hold the budget for Primary Care and keep the money rather than spend it on patients.
Why a fully-informed and conscientious GP would resist this contract
The potential conversion of the NHS from universal public sector healthcare provider to UnitedHealth Group income stream will convert GPs from “family doctors” to “demand managers” whose main job responsibility is to reduce the cost of care.
The trust between you and your patients is at risk once they know that you will keep a proportion of the NHS budget that is saved from paying for their care. When budget restrictions start to bite and Optum’s referral gateways start to deny care on a large scale as a consequence, you will find your decisions challenged on the grounds of the new contractual conflict of interest you have signed into.
Signing the GP contract amounts to acquiescing to this situation, which will:
- harm your patients in the long term
- cause you ethical conflicts sooner or later
- reduce your personal income in the medium to long-term, unless you are among the “entrepreneurial” GPs who do not mind denying needed care to their patients in order to boost their own personal income
This reshaping of our primary care system to align with health insurance industry preferences is contrary to the public service spirit of the NHS you joined, and will contribute to its destruction.
Please start asking questions about why this is being imposed and to whose benefit it is. GPs who cooperate now will regret doing so in the long term.
What to do now
If GPs have signed up to Primary Care Networks they should withdraw from the contract immediately.
Please spread the word about the significance of this contract and of the change from traditional GP care to insurance-industry-inspired integrated care as widely as you can.
We can act together locally to block these changes to protect your own families and your patients, and we can and must fight nationally to save NHS medical care from this parasitism and profiteering.
And as colleagues and NHS patients, we beg you not to sign that contract.
i https://www.youtube.com/watch?v=3qpLVTbVHnU
ii https://www.bmj.com/content/335/7630/1126.abstract
iii https://www.bmj.com/content/345/bmj.e5015.full
iv https://www.fletcherssolicitors.co.uk/news/over-25-of-patients-leave-gp-at-hand-digital-service/
v https://www.telegraph.co.uk/news/2018/10/02/nhs-must-follow-lead-driverless-cars-embrace-technology-even/
vi http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
vii https://leftfootforward.org/2014/04/4-things-you-should-know-about-new-nhs-england-chief-simon-stevens/
viii https://www.theguardian.com/politics/2007/nov/11/uk.publicservices
ix https://www.theguardian.com/uk/2004/sep/30/freedomofinformation.nhs
x http://www.startribune.com/medtronic-unitedhealth-group-want-to-export-u-s-health-care/130604608/
xi https://www.theguardian.com/healthcare-network/2011/jan/14/kpmg-nhs-london-gp-commissioning-unitedhealth
xii https://www.linkedin.com/in/simon-stevens-403a0622
xiii https://www.opendemocracy.net/en/ournhs/why-are-gps-being-told-to-hand-decisions-to-private-health-firms-and-their-lobbyists/
xiv https://www.prnewswire.com/news-releases/the-kennedy-forum-spotlights-landmark-decision-unitedhealthcare-used-defective-criteria-to-reject-coverage-for-mental-health-and-addiction-treatment-services-federal-court-finds-300807270.html
xv http://www.startribune.com/unitedhealth-settles-ingenix-suit/37638584/
xvi http://www.startribune.com/unitedhealth-accused-of-shortchanging-patients/15588882/
xvii https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2012/UNH-Working-Paper-8.pdf
xviii https://www.youtube.com/watch?v=e9CM6vkjHbc (see at 7:00)
xix https://web.archive.org/web/20160905125723/http://www.napc.co.uk:80/pch-story (scroll down for Optum)
xx https://www.england.nhs.uk/wp-content/uploads/2012/06/NAPC-and-UHUKs-essential-guide-to-GP-commissioning.pdf
xxi https://web.archive.org/web/20180926175746/http://napc.co.uk/about-us/partners/
xxii https://web.archive.org/web/20180620081326/http://napc.co.uk/about-us/napc-council/ (John Myatt, Vice President External Affairs, UnitedHealth Group)
xxiii https://healthinnovationnetwork.com/system/membership_reports/reports/000/000/011/original/South_London_Membership_Council_Report_June_2016.pdf (Page 4)
xxiv https://napc.co.uk/nhs-long-term-plan2/
xxv http://www.pulsetoday.co.uk/news/hot-topics/pulse-power-50-2018/38-dr-nav-chana/20037290.article
xxvi http://www.optum.co.uk/content/dam/optum/resources/brochures/Optum_Supporting_PCHs.pdf
xxvii https://napc.co.uk/about-us/napc-council/
xxviii https://www.england.nhs.uk/author/dr-nav-chana/
xxix https://www.england.nhs.uk/author/dr-james-kingsland-obe/
xxx http://waringhealth.com/about-us
xxxi https://www.england.nhs.uk/rightcare/2018/08/14/professor-nick-harding-obe-joins-nhs-rightcare/
xxxii https://www.kingsfund.org.uk/projects/supporting-new-nhs-care-models/modality-partnership-sandwell-and-west-birmingham
xxxiii https://www.nuffieldtrust.org.uk/media/naresh-rati-vitality-partnership-s-vision-for-patient-care
xxxiv https://beta.companieshouse.gov.uk/company/09764707/persons-with-significant-control
xxxv https://beta.companieshouse.gov.uk/officers/9qT6JXoPR4uMRkDEzrNsb2gzRmU/appointments
xxxvi https://beta.companieshouse.gov.uk/company/OC403467/officers
xxxvii https://modalitypartnership.nhs.uk/about-us/our-national-board
xxxviii https://www.hsj.co.uk/technology-and-innovation/major-gp-provider-partners-with-push-doctor-app/7023329.article
xxxix https://www.hsj.co.uk/primary-care/exclusive-gp-chief-inspector-to-leave-cqc/7023429.article
xl https://beta.companieshouse.gov.uk/officers/c7fiEikXpmQJIntIakhZZ9EjZnc/appointments
xli https://www.digitalhealth.net/2018/08/babylon-threatened-to-sue-cqc/
xlii http://www.ourhealthiersel.nhs.uk/Downloads/Meetings/OHSEL%20Board-SPG/9%20Nov%202018/Hiii%20-%20NHSE%20ICS%20Development%20Programme%20Terms%20of%20Reference%20SEL%20vF.PDF
xliii https://www.westnorfolkccg.nhs.uk/sites/default/files/Governing%20Body/2018/4th%20July%202018/Item%2018.52%20WNCCG%20Draft%20Minutes%2024%2005%2018%20GB%20040718.pdf (page 4)
xliv https://www.healthierlsc.co.uk/news-and-events/latest-news/population-health-management-accelerated-programme-update
xlv https://www.oxfordshireccg.nhs.uk/documents/meetings/board/2018/11/2018-11-29-Paper-18-66-Chief-Executives-Report.pdf (page 7)
xlvi http://www.northcumbriaccg.nhs.uk/about-us/how-we-make-decisions/Governing-Body-Meetings/2018/2018-december/papers/72-ics-north-cumbria-and-north-east-update.pdf (page 4)
xlvii https://www.herefordshireccg.nhs.uk/who-we-are/publications/governing-body-papers/governing-body-papers-2018/24th-july-2018/1942-item-8-governing-body-ao-report-july-2018/file (page 3)
xlviii http://nextgenerationgp.wixsite.com/2017/faqs
xlix http://nextgenerationgp.wixsite.com/2017/copy-of-nottingham-speaker-profiles
l http://www.lpft.nhs.uk/assets/files/BOD%20meeting%20papers/2018/25-october-2018/4.2-stp-update-october-2018.pdf
li https://www.digitalhealth.net/2009/11/unitedhealth-buys-scriptswitch-for-50m/
lii http://stg-uk.optum.com/how-we-help/scriptswitch.html
liii https://www.out-law.com/en/articles/2015/february/nhs-england-appoints-companies-to-new-preferred-suppliers-procurement-framework/
liv http://www.ehealthnews.eu/development/4609-nhs-set-to-save-millions-on-essential-prescribing-software-through-new-framework
lv https://www.england.nhs.uk/hssf/supplier-lists/
lvi https://www.brightonandhoveccg.nhs.uk/sites/btnccg/files/files/GP%20prior%20approval%20process%20updated%20Nov%2016.pdf
lvii https://www.kentonline.co.uk/kent/news/firm-poised-to-take-on-133450/
lviii https://www.westkentccg.nhs.uk/about-us/access-to-information/fair-processing-notice/
lix https://southwestlincolnshireccg.nhs.uk/about-us/key-documents/freedom-of-information/foi-disclosure-log/medicines/1482-120-medicines-wound-care-formulary-september-2016/file scroll to end
lx https://www.lincolnshirewestccg.nhs.uk/wp-content/uploads/2017/05/ClG014-LWCCG-Patient-Group-Directives-PGD-Policy.pdf pages 5 and 8-13
lxi https://southwestlincolnshireccg.nhs.uk/about-us/policies/information-governance-1/1517-ig22-smartcard-and-identity-card-id-policy-mar-17/file
lxii https://www.england.nhs.uk/ig/in-val/
lxiii https://www.england.nhs.uk/wp-content/uploads/2017/03/20190514-CEfF.pdf Optum is the Controlled Environment for Finance for all eight Kent CCGs in the STP area and for two Lincolnshire CCGs
lxiv https://calderdaleandkirklees999callforthenhs.wordpress.com/2019/01/27/usas-united-health-subsidiary-optum-decides-which-ealing-patients-referred-to-hospital-by-gps-will-have-their-treatments-funded/
lxv https://www.hsj.co.uk/workforce/former-pct-chief-appointed-to-chair-stp/7021310.article
lxvi Competition-Based Reform of the National Health Service in England: A One-Way Street? International Journal of Health Services https://journals.sagepub.com/doi/10.2190/HS.42.2.d?icid=int.sj-abstract.similar-articles.1
lxvii https://www.theguardian.com/society/2019/feb/28/scrap-laws-driving-privatisation-of-health-service-say-nhs-bosses
lxviiiThe NHS reforms were explained as an insurance industry takeover back in 1988, for example in Chapters 4-6 in https://koshh.org/wp-content/uploads/2016/04/The-Health-Of-Nations.pdf
