16.06.2022

At whose service?

Reform of primary care should not be trusted to the likes of Policy Exchange, writes James Linney. This ‘independent’ think tank was set up by Tories to serve the Tory agenda of cost-saving and profit-making

On March 4, Policy Exchange published its vision for the future of primary care, entitled ‘At your service: a proposal to reform general practice and enable digital healthcare at scale’.¹

It did not make much in the way of waves in the media, but its proposals are worth taking a close look at, because, given the extent of influence Policy Exchange has over the government, they act as a peep through the keyhole at how primary care and the national health service in general are likely to be moulded in the coming decade - if, that is, the NHS is left in the abusive hands of a Tory government.

Policy Exchange claims to be the “leading think tank in shaping policy agenda since their birth in 2002”, which is probably true enough: it is certainly the favoured rightwing influencer for the Boris Johnson government. Less true though is its claim to be an independent, non-partisan, educational charity; whose research is “evidence-based and shared with policy makers from all sides of the political spectrum”.² In reality this ‘independent’ think tank was founded in 2002 by the Conservative MPs Francis Maude and Archie Norman, along with Nick Boles, who later also became a Tory MP. Its first chairman was Michael Gove. Policy Exchange plays dress-up as an objective scientific research body, but it is actually a secretly funded lobby group acting in the interests of capital.

It is no surprise then that its ‘At your service’ document is forwarded by the secretary of state for health and social care, Sajid Javid. He evidently fully endorses the proposals, saying he welcomes them as “a pragmatic contribution to the vital debate on the future of the NHS”.

Despite its 98 pages, the document (noticeably lacking evidence, whilst being stuffed full of repetition, empty soundbites and bafflingly unexplained managerial speak) can be boiled down to a few key proposals: namely, the buying out of general practitioner (GP) partnerships and amalgamating them into large super-surgeries, ‘digitalising’ primary care and relying on AI technology for initial clinical triage and diagnosis.

The document at least begins with some sense, with the authors admitting that primary care is in a bad place. Hence we are told:

The status quo is unacceptable to both the GP profession and their patients. Pressures predate the pandemic, but increased demand, combined with acute workforce pressure, has moved GP access to the top tier of public concerns.

In fact this is a great understatement. As anyone who works for or has had recent contact with the NHS knows, it is in a major crisis; GP appointments are extremely hard to come by, accident and emergency departments across the country regularly have waiting times in excess of 10 hours, delays for operations and secondary care clinics are longer than at any other time in NHS history and there are 110,192 job vacancies across the NHS.³

How then did we get into such an unholy mess? The authors go on to explain: “… the fundamental issue is well understood: demand outstrips supply.” No mention here then of the decade-long Tory attack on the NHS, their unrelenting defunding, staff pay freezes and privatisation - all of which have been accelerated during the Covid-19 pandemic.

Scaled

Turning to the main proposals, let us first consider their recommendation for a “scaled model of general practice”. This essentially means bringing an end to GP surgeries that care for a few thousand people, where they are able to be familiar with their practice population and build over time a meaningful doctor-patient relationship. Policy Exchange instead prefers ‘super-surgeries’ that have 250,000-500,000 patients under their care, covering very large geographical areas, where presumably a GP or practice nurse would likely never be dealing with the same person’s care twice.

Without falling into the trap of nostalgically recalling a time of jolly village GPs, available for home visits 24 hours a day, there is, however, a lot to be said for the continuity of care and it is an essential part of what makes primary care such a satisfying and rewarding job; additionally there is a well-established body of evidence that such continuity leads to better experiences of healthcare and better outcomes for patients.⁴

Why then should we abandon this valuable, central characteristic of primary care? Policy Exchange claims there are “considerable agglomeration benefits” and continues:

Scale presents the opportunity to align primary care more effectively with secondary and community services and, in doing so, the means to ensure general practice has a stronger voice within integrated care systems … Independent provision will continue to have a central role in primary care. Driving innovation at scale and enhancing service offerings for consumers, independent providers should be essential to primary care service provision. Commissioning and procuring services at a larger scale will allow for the purchasing power of the NHS to be felt, delivering improved value for the taxpayer.

The scaling up of primary care is not a new idea. Many will remember the poly-clinic ‘Darzi centres’ of 2008 that gained traction when Labour health minister Ara Darzi proposed them as a way of modernising primary care; notably they were an extremely expensive failure, with many closing in subsequent years. More recently Primary Care Networks (PCNs), introduced in 2019, are also essentially an exercise in scaling up - this time GP surgeries were instructed by NHS England to form partnerships with several other surgeries in their area, most serving 30,000-50,000 patients.

One of the PCN’s roles has been to recruit and integrate additional clinical staff, such as physiotherapists, clinical pharmacists or dietitians: the so-called additional roles reimbursement scheme (ARRS). But ARRS has been so underfunded that it has probably resulted in more work for GP surgeries, with any new additional clinic staff being spread so thinly as to be completely ineffectual. For example, the PCN will be responsible for recruiting, training and mentoring a junior pharmacist, who then has the impossible job of providing care for up to 50,000 patients. Meanwhile mostly well-meaning senior primary care staff have become increasingly tied up in running PCNs, their role mostly boiling down to absorbing the bureaucratic burden on micromanaging the devastating cuts being enforced from above.

The authors of ‘At your service’ do not seem to be put off by the lack of evidence for, or the past failures of, upscaling in primary care. An explanation for their disregard is clearly the claim that scaled-up super-surgeries will be cheaper - almost certainly having to spread even more thinly already scarce healthcare workers. At the same time, they will represent a lucrative proposition for potential third-party (private) companies. These independent providers have much more to gain securing a deal to sell their products to a surgery caring for half a million ‘consumers’. Another even more damaging implication contained here is that these ‘super-surgeries’ would be managed and owned by various independent providers: a very attractive proposal for many financial or private healthcare companies, whose directors will, I am sure, be reading this document with great interest.

Profit first

In order to achieve these super-surgeries, Policy Exchange here propose a £6 billion buy-out of the current GP partnerships, subsequently offering all GPs full employment in a standardised salaried role. This in itself could be a progressive idea - potentially a sort of nationalisation of primary care. Since the NHS was established, GPs have held a unique place within it - with each surgery, consisting of GP partners (or sometimes a single GP), essentially being a small business owner, who is paid by the government to provide certain services and ensure their patients meet set health targets.

Historically the financial compensation for these services was more generous, but a decade of Tory rule has seen primary care made to do more and more work, for less pay - to the point where many GP surgeries are struggling to remain open and staff are worked to the point of burnout.⁵ However, there remains an obvious conflict of interest: GP partners have a responsibility to their own businesses above everything else. To bring all GPs under the same salaried contracts could remove this conflict of interest, whilst at the same time helping to break down the separation of primary and secondary care, allowing better cooperation rather than them having to compete for already scarce resources.

I am not, of course, suggesting that Policy Exchange is aiming for the nationalisation of primary care. Instead what will happen is that primary care will be run on the cheap for the benefit of shareholders and CEOs. A vision of this was presented a few days ago in a BBC Panorama programme that revealed how Operose Health (owned by US healthcare giant Centene Corporation), which runs 70 GP surgeries around England, was using physician associates to do that. Physician associates are less experienced and less well paid, normally working under the close supervision of a GP. But for this patient population of over 600,000 they were being made to take the place of GPs, putting patients health at risk for the sake of profit.

One of the other emphases of the Policy Exchange document is what it calls “delivering digital-first primary care”. People would no longer call up their own GP surgery to book an appointment: they would instead initially use an app and be directed to an AI symptom-checker tool. This ‘chatbot’ would triage, diagnose and advise the patient. If deemed appropriate, the person might gain access to a video consultation with an actual clinician. Policy Exchange would like this clinician to be based anywhere - possibly abroad, with priority countries including Australia, Canada, New Zealand and South Africa.

This is essentially a proposal to impose the Babylon Health, ‘GP at Hand’ model of primary care on the entire NHS, with all the enormous profit benefits for private tech companies that this would obviously entail. As I have stated in a previous article,⁶ the use of AI for diagnosing illness is far from a proven, safe way of caring for patients and, despite Policy Exchange here wanting a national rollout, it offers no new evidence for its safety or improved clinical outcomes.

The pandemic has, of course, been a catalyst throughout the NHS (and particularly in primary care) for changes in the way care is offered, including greater use of digital technology. Despite the fact that we are mostly back to seeing people face to face, GP telephone consultations are now more routinely offered and we also have the option of video consultations (and photos of rashes, etc, too can be requested from patients via secure apps).

These digital options, though at times helpful, have hardly produced a revolutionary transformation. For example, from personal experience, video consultations have been of very little benefit: often the clarity of the video is poor, but more generally there is not much additional clinical information a video offers above a telephone consultation. Both can often lead to duplication and more work, because often a telephone or video consultation leads to the need to arrange to see the patient in person anyway. Obviously remote consultations have their benefits in certain situations and can be convenient, but most medical presentations are dealt with more safely and effectively face to face.

The increased requirement to use digital technology has begun to create more of a barrier to accessing healthcare for many of those who often need it the most; ie, some of the more vulnerable and/or elderly, or people who simply cannot afford a smart phone.

Let me be clear: I think the NHS should have available to it the most cutting-edge IT and technology, but this should be safe and proven to benefit patients. Once again the Policy Exchange document does not engage in any serious discussion or presentation of evidence in favour of complete reliance on digital technology for clinical decisions, telling us instead:

Lessons can be learnt from best practice in the banking sector, where in the space of a decade online services have become commonplace, with initiatives introduced to effectively support the digitally excluded.

By this time a common theme has well and truly emerged - the pretence of reforming and innovating primary care is actually a guise for cutting corners and making privatisation much easier. No doubt this all makes for happy reading for certain tech companies that are very keen, I am sure, to land these enormously profitable contracts - whilst simultaneously gaining access to some very marketable data.

Damage

So far we have seen how Policy Exchange wants to restructure primary care, but what this document fails to do in any meaningful way is attempt to tackle the two major challenges facing the NHS currently: the lack of funding and the staffing deficit. Since the government made its pledge to recruit 6,000 more GPs by 2024, the number has actually fallen - it will take a miracle to meet that target now. There are 1,622 fewer fully qualified GPs today than there were in 2015, while each practice has on average 2,026 more patients than in 2015. The UK now has fewer practising doctors per 1,000 inhabitants than any other Organisation for Economic Cooperation and Development state apart from Poland.⁷ As the British Medical Association highlights,

There are now just 0.45 fully qualified GPs per 1,000 patients in England - down from 0.52 in 2015. For the GPs that remain, this means increasing numbers of patients to take care of. The average number of patients each GP is responsible for has increased by around 300 - or 16% - since 2015.⁸

Meanwhile the UK spends far less on healthcare as a share of gross domestic product than comparable OECD countries (0.27% of GDP on capital in healthcare compared to an OECD average of 0.51%).

Yet the ‘At your service’ document, for all its 98 pages, has very little to say about the staffing crisis - and even less about how the NHS has been intentionally starved of funding. These omissions are consistent with recent statements by Sajid Javid, who said: “The NHS now has locked in the resources it needs. It doesn’t need any more money. What it needs to deliver for more people is not money. It needs reform.”

These omissions are further evidence that this Policy Exchange document is not concerned with any serious discussion of the crisis of primary care nor the solutions to it. To reveal its real intentions we need only return again to the question of who Policy Exchange are, who they have political ties with and who funds them. If the proposals above are introduced and the crisis of funding and staffing continues, the result will be disastrous for the NHS, which may never be able to recover.

Policy Exchange reassures us that it is committed to “upholding the founding principles of the NHS” by keeping services free at the point of use. But there is more than one way to skin a cat. As we have seen, it is perfectly possible to privatise the NHS whilst keeping it free of direct charges; taxes just flow from government to the ‘independent providers’ hiding behind an NHS logo - a kind of nationally sponsored form of money-laundering. This was demonstrated numerous times by the Tory government during the Covid-19 pandemic. Take, for example, the £39 billion (20% of the NHS’s entire annual budget) spent on the failed ‘test and trace’ system, which provides the likes of Serco with record profits.

There emerges from the pages of this document the picture of a bleak future for the NHS if the Tory government has its way. Scratching beneath the surface reveals that Policy Exchange would have us ignore the fundamental crises threatening the very existence of the NHS in favour of actually harmful reforms that are solely ‘at the service’ of private health and tech companies.