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Can primary care rescue our failing NHS?

A big ask and funds are certainly needed up front as following the last few years of neglect, there is a serious service wide workforce crisis. Workforce shortages apply equally to primary care despite the previous secretary of state frequently berating GPs. Indubitably there is a short term NHS crisis to tackle but essentially there is need for both a short and longer term strategy and resultant plan. Usually the short term absorbs all the energy, but many NHS problems are perennial and cannot all be blamed on the current world wide economic and social malaise, severe though it is.

david colin thome

By Professor David Colin-Thome, OBE, chair of PCC and formerly a GP for 36 years, the National Clinical Director of Primary, Dept of Health England 2001- 10 and visiting Professor Manchester and Durham Universities.

If a rescue is to be sustained it must be built from primary care. General Practice Forward View 2016 (The most recent comprehensive GP review)- ‘General practice is undeniably the bedrock of NHS care providing over 300 million patient consultations each year, compared to 23 million A&E visits and have one of the highest public satisfaction ratings of any public service. So if general practice fails, the NHS fails. Yet a year’s worth of GP care per patient costs less than two A&E visits, and we spend less on general practice than on hospital outpatients. For the past decade funding for hospitals has been growing around twice as fast as for family doctor services’.

Beyond even such impressive facts, primary care offers so much more. I quote the late and great Prof Barbara Starfield- ‘‘That aspect of a health service that assures person focussed care over time to a defined population, accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only rare or unusual manifestations of ill health are referred elsewhere, and coordination of care such that all facets of care (wherever received) are integrated“. My own vision which we delivered in the general practice of which I was a partner- to primarily continue to develop and extend primary care provision, but also reshape aspects of hospital based provision and take a population responsibility for the health of its public. Our success led to my originating the Primary Care Home, brilliantly developed by The National Association for Primary Care, supported strongly by former NHS chief executive Simon Stevens culminating in national primary care networks (PCNs).

In the current NHS it primarily falls to PCNs to lead, of course in partnerships with at least their innovative providers. The trigger for me to write this piece arose as recently out of the blue, the academic unit the King’s Fund wished to interview me for a research study commissioned by the Department of Health and Social Care about approaches to reduce waiting times and lists for elective care. I had worked on such issues over some years but last published 10 years ago. Nothing much seems to have changed in the intervening years. The reshaping of hospital care is an essential part of that vision and some general practices over the years have delivered on it, as did many of the pilot Primary Care Homes. PCNs need to enable and where necessary deliver aspects for all. Specifically for elective referral, GPs and the wider clinical team including on occasion virtual specialist support, can potentially obviate the need for many referrals. As for hospital follow up appointments which incredibly account for two thirds of outpatient appointments, many are arranged automatically are unnecessary and account for literally billions of pounds. One of Prof Muir Gray’s many aphorisms- ‘NHS outpatient care is a relic of nineteenth century medicine’. So primary care needs to be incentivised to reshape the otherwise burgeoning hospital sector. There are other aspects of current hospital activity that can be similarly reshaped for example shortened lengths of stay, admission direct to surgical intervention and many aspects of long term conditions care. All for optimal effect should involve primary care often working in imaginative partnerships beyond primary care.

Primary care is the only NHS provider that has a population responsibility for healthcare and its population’s health, and as described the ability to make the NHS more cost effective. Self evidently, an essential leader in the NHS especially as our traditionally led NHS is failing. Beyond the excellent Fuller Stocktake, we need to have fresh thinking on leadership, management and governance or our NHS will continue to fail even if extra monies are found. More of the same will condemn the NHS to the madness described reputedly by Einstein. Essential governance prerequisites are the acceptance of subsidiarity, two way accountability between NHS organisations rather than the ‘top down’ obsession of the NHS and fundamentally devolution of some NHS budgets

There have been two significant NHS reforms involving primary care. Both were only partially successful as the emphasis was on general practices as commissioners. Where success occurred was primary care acting in their quintessential role as providers, and as such can better utilise incentives such as devolved budgets in leading change from a community focus. The money should follow where the activity occurs.

Internationally in health care outcomes we continually lack behind our western European neighbours, now magnified by the severe access difficulties. Money alone will not suffice as demonstrated when the Blair administration hugely increased NHS budgets. Never waste a crisis. Can our severe problems portend a new primary care leadership?

Last Updated on 27 September 2022