Doctors have raised concerns over the future of GP services for thousands of vulnerable patients after a CCG reduced funding and tendered for a new provider – despite having failed in several previous procurement processes – in one of the areas of the country worst hit by the second wave of the coronavirus pandemic.
NHS Nottingham and Nottinghamshire CCG is looking for a new provider to run the GP services currently offered by NEMS Community Benefit Services at the Platform One GP practice, rated outstanding by the CQC, which is on the site of Nottingham train station (pictured above) in the heart of the city, and provides care for nearly 11,000 patients.
The CCG’s contract with NEMS comes to a natural end on March 31, 2021, and local health leaders have decided to decrease funding on offer to the provider of the service. A GP at the practice told The Doctor the current funding amounted to around £190 per patient and a letter from the CCG suggests the new funding will be set at around £110 per patient.
The CCG has asked local GPs to ‘innovate’ to provide the solution themselves
The existing provider, NEMS, which has run the service for 11 years, has ruled itself out of bidding for the contract and told The Doctor they felt the funding on offer would mean they were unable to continue to provide ‘the same model of care’ for its complex patients – many of whom are homeless, live in probation hostels and rehabilitation centres, are asylum seekers, have mental health problems and substance misuse issues as well as many with dual or triple diagnoses across mental and physical health.
However, The Doctor has seen a series of CCG letters and a confidential briefing video which reveal that local health leaders have already gone through three competitive procurement processes in the last four years, all of which have failed to find a new provider, and that an open market procurement process this time around also found no bidders.
Now, the CCG has asked local GPs to ‘innovate’ to provide the solution themselves – despite lower funding levels for a complex patient group, there currently being no building for services to be provided from and a stark demand that services must be at most 0.5 miles from the city’s Old Market Square hub. The CCG has also unilaterally reduced the practice’s list size by 3,000 patients - sending those patients whose postcodes are outside the city boundary to other practices with limited consultation or support, according to local GPs, and without asking patients if they wanted to remain with the practice.
One Nottingham GP described the process as a ‘very controversial way forward’.
A GP working at the practice, who asked The Doctor to protect his identity, said at least half of the patients at the practice are very vulnerable and many of them are being dispersed.
They said: ‘The reality is that one of our patients might be equal to five or ten patients in another GP practice in terms of demand on the service. I have patients who have consultations every two or three days and have done for years.
‘This is a very significant cut and it was worked out that if NEMS kept the contract and the staff they would lose £400,000 to £500,000 a year.’
They added: ‘We had no engagement over these patients. Some of those being dispersed are very vulnerable. If they had come to us in advance maybe we could have worked with them. I don’t think they understand the sort of patients we have. I have a patient who has agoraphobia – he hasn’t left his house for years. We do home visits and visits over the phone, he won’t seek help from anywhere else and he has lots of medical problems. We are trying to manage him as best as possible. The staff he has a good rapport with are leaving. This is going to destabilise him.’
We talk about a patient-centred approach – but where are the patients being looked after in this?GP Kalindi Tumurugoti
GPs at the practice have written to the CCG urging them to consider the impact these changes will have on vulnerable patients and to allow those who wish to stay at the practice but have been dispersed to do so.
It all comes despite a member of CCG staff telling GPs previous efforts to find a new provider failed due, particularly, to reduced funding and lack of premises – two issues which have not changed and may even be worsened during a time of unprecedented pressure for healthcare.
The process has raised a host of concerns among frontline staff and doctors’ representatives in the city – with staff worried about vulnerable patients being left behind, particularly during a global pandemic and with a potential vaccine on the way. Doctors have also raised concerns about the CCG’s handling of the process and additional workload for other practices forced to take new patients on. The Doctor understands patients have already been told about the changes and some practice staff have left or already begun looking for other roles – raising questions about the future of services should the CCG’s latest attempts prove unsuccessful again.
BMA East Midlands regional council deputy chair and Nottinghamshire GP Kalindi Tumurugoti said the situation was ‘appalling’.
‘This is what happens when CCGs and other leaders discuss things at a high level. What about the patients? NEMS has an excellent record and history of looking after these patients with good access and reputation. Still no news about the new provider or the bidding process. I’m not sure whether or not there’ll be lot of bids and interest in this area because of the complex patients, location and the issue with premises. It’s going to be a difficult task to find an alternative provider,’ he said.
‘We talk about a patient-centred approach – but where are the patients being looked after in this? I don’t think they will ever find a provider who can provide the same access and care for that funding. It is the wrong time to do this.’
Another Nottinghamshire GP, who wished to remain anonymous, told The Doctor that the decisions ‘struck of cost-cutting and needed exposing’.
He said: ‘The vulnerable patients are the ones that will suffer, particularly during the COVID crisis.’
‘It appears a strange way for the CCG to manage things,’ he added.
And a spokesperson for the Nottinghamshire LMC (local medical committee) said: ‘As an LMC we would support those concerns and seek reassurances over how such practices with “atypical” populations are supported. We have had preliminary talks with the CCG and a few practices in the inner city about the need for extra CCG resource as outlined in national papers, but need to see more action and commitments.’
The Doctor has been told practice staff have concerns about the distribution of patients – many of whom in difficult personal circumstances will have built relationships with the NEMS staff during the last decade – and GPs told The Doctor staff feel scared to speak out about the process.
The GP working at the surgery said: ‘The staff morale is very low. Two nurses have already resigned. We had agreed to appoint two more GPs but we can’t do that now. It’s a sinking ship but I don’t want to leave because I feel some of these patients need us. If people start resigning now then we won’t be able carry it on through to April.’
‘It is a terrible time to do this – they should have given us an extension for a year or something.’
The city’s health scrutiny committee will meet on Thursday (19 November) to discuss the process and whether it should make any comments or recommendations to the CCG. The questions members will ask are whether the process has been properly consulted, public interest taken account of and whether it is in the interests of local health services.
Dr Tumurugoti added: ‘There should be more consultation when things like this happen. The public are never properly informed and staff and patients are told at the last minute. Where is the engagement?’
Nottingham South MP Lilian Greenwood said she had raised concerns with the CCG and was pleased the city council’s health scrutiny committee would be considering the issue.
Ms Greenwood said: ‘The situation for patients registered with the Platform One practice is a real concern. According to the CCG, 3,000 of the existing patients will be reallocated to other GP surgeries in the city but it’s not clear whether those practices have the resources to cope with a large number of new patients. The CCG have yet to identify a new provider for the remaining 7,800 patients. As a city centre practice, Platform One was established to serve a population including higher than average numbers of vulnerable and transient patients and it’s worrying that their care could be disrupted, particularly during the current health crisis.’
One Nottingham GP told The Doctor he had concerns that the developments could mean a private healthcare firm ends up taking over another service in Nottingham. The UK healthcare arm of American private healthcare insurance firm Centene, Operose Health, has in recent months won contracts to provide GP services in Nottinghamshire.
A spokesman for Healthwatch Nottingham and Nottinghamshire, which represents patients in the area, said a ‘number of concerns’ had been raised to the organisation and that its leaders had written to the CCG to question if service users had been asked how they would be impacted and if steps had been taken to ensure alternate practices have capacity, resource and expertise. The organisation has also queried if the specialist expertise of staff currently at the practice will be protected.
He said: ‘Healthwatch will continue to seek assurances that commissioned services are in line with the Nottingham City Integrated Care Partnership’s priority work area “Supporting people who face multiple disadvantages to live longer and healthier lives”.’
Nottingham and Nottinghamshire CCG said it had made the decision in order to ‘commission equitable services for all patients’ across the county. It said discussions had been held with primary care networks to ‘ensure there is sufficient capacity’ to accept additional patients. And when pressed that the commissioning process does not seem to have run smoothly, a spokesperson said: ‘We anticipate that it will conclude within agreed timescales for de-mobilisation of the current provider who have agreed to ensure a smooth transition.’
The spokesperson added: ‘The CCG recognises the specific needs of some of the patients registered at Platform One Practice and will work with the new provider once identified to ensure their needs are met and that they continue to receive high-quality care. Once a new provider is identified, the current provider NEMS will also work closely with them with support from the CCG to transfer primary care staff where possible so talent and experience can be retained within the NHS locally.’