Feature

Learning a new way of thinking

Does anyone know what ‘the primary care-led NHS’ really means? David Martin offers an explanation, and searches out a second opinion

When EL(94)79 — Towards a primary care led NHS — appeared in October 1994 many recognised a white paper in disguise. It paved the way for further developments in GP purchasing, with extensions to standard fundholding and the introduction of community fundholding and total purchasing. It spelled out the role of the new HAs in relation to primary care. But in addition to these specifics it carried an elusive message of much greater significance and radicalism — that the NHS was to refashion itself as a service truly driven by and centred on primary care.

It may be that even the authors of the words only half understood them at the time, and many in the NHS who heard the message sensed its gravity without quite knowing what a primary care led NHS would look like. In any event, iterations of the theme quickly followed and then came the crucial but rather sadly named ‘listening exercise’, the powerful provision-related agenda set out in Primary care: the future, and the twin white papers of last autumn, Choice and opportunity and Delivering the future.

The primary care led NHS initiative is not a programme in the sense that the Health of the Nation or the Patients Charter are programmes. Nor is it, like the Working for patients internal market reforms, a defined and systematic revision of the NHS delivery system. It is a state of mind, a way of thinking about things. Programmes and new service delivery mechanisms may flow from it, but its essence is the values, attitudes, and styles of thought that people must share in order to communicate and progress together.

But there is not yet a fully shared view. Some health authority staff still talk about a primary care led NHS as a task to be carried out — something to be done next Wednesday, or after the contracting round... or whenever. Some in acute trusts say it is mere words, a side show, a distraction from the real business at the turnstiles, a mistake and a threat. Nevertheless there does seem to be a general convergence of thinking and acceptance around the central ideas.

People are reconnecting themselves to some basic principles — perhaps things they have believed in for twenty years but which have become ritual incantations. They have remembered what they mean and why they are important.

The primary care policy is a reaffirmation of a broad community care commitment, with three main foundations. The first is the right that individuals have to control what happens to them through informed choice. There is an unstoppable, intersectoral, international trend towards the empowerment of users of services. The initiative is being reclaimed by the public from the professionals as their traditional prestige wanes. And the general trend is accelerating sharply in relation to publicly funded services.

The second is people’s preference for (and therefore, through their right to influence and choose, the entitlement to) care services that are delivered with the minimum interference or intervention that is consistent with effectiveness. This means at home or, if away from home, for the shortest possible time and in the most home-like surroundings that can be contrived.

The third is the right to expect that care services will be ‘seamless’. This means comprehensive (i.e. geared to the whole person in their environment), flexible (i.e. responsive to changes in the person or the environment), and integrated (so that when different agencies are involved their contributions are delivered, through their management action not the vigilance of the consumer, without gaps, overlaps or contradictions).

These themes underpin the concept of community oriented care and, within that, the pivotal position and potential of primary health care.

The primary care led NHS initiative is essentially catalytic in carrying these aims forward. The assumption is that if you put more decisive influence in the hands of GPs as purchasers, and greater freedom and flexibility as providers, they will shape the service in keeping with the basic policy aims. On the face of it this is a reasonable expectation. GPs are generally trusted advocates for their patients (virtually the whole population), and are expected — not least by patients themselves — to reflect their choices and preferences as powerful proxies. They are also in a good position to see the whole person, to know about changes in his or her circumstances, and increasingly to play a big part in co-ordinating health with other services. They are in and of the local communities around the needs of which services should be fashioned, not the institutions which have traditionally been the driving forces.

Of course there would be tremendous challenges even if everyone were pulling in the same direction — which is not yet the case. How is the variety of performance and quality in general practice to be accommodated — or, where appropriate, diminished? How are the limitlessly diverse service developments that the white papers will release to be described and managed within a single administrative structure? How are accountability and financial control to be maintained? How is the individual patient perspective to be reconciled with the population perspective? How is appropriate, effective and evidence-based practice to be promoted in a context of great variety and local discretion?

If this is the direction of travel, and these are among the challenges, what help is there on the bookshelf? Five volumes have come to hand — of the several now around — and they each bring something different to the debate.

The slimmest is from the national primary care research and development centre, based at Manchester University. This is a multidisciplinary enterprise, funded by the Department of Health to conduct and disseminate primary care research and promote service development with a sound evidence base. What is the future for a primary care led NHS? is a collection of brief papers by staff of the centre. Topics covered include user involvement, the view from the hospitals, the development of general practice teams, implications for mental health services, and the interface between primary health and social care. There is a useful policy overview by Martin Rowland and David Wilkin. The basic conclusion is that the primary care led NHS initiative is sound but needs cool and reflective management and evaluation. The book is light on passion, but it would give the lie to its message if it were otherwise.

The second volume, nearly as slim but much more tightly packed, is Making sense of a primary care led NHS, edited by Peter Littlejohns and Christina Victor. What is distinctive about this collection of papers is that all are written by public health doctors or GPs — those, the editors claim, who have to make it happen on a day to day basis. Taken together the papers carry a good deal of useful material, perhaps with a cautious overall tone.

Then there is A primary care led NHS: putting it into practice, edited by Geoff Meads — who describes it, accurately enough, as a pragmatic guide for managers of different kinds at different levels (who may also have to make it happen). There is something about everything here, an excellent starting point when the next half-foreseen difficult bit presents itself. The book has an outstanding contribution from June Huntington who takes a high level look at the kind of primary care organisation that will care for the professional carers and support their continuing commitment. Ros Eve’s chapter on the promotion of evidence-based practice in the GP surgery is excellent. So are several of the other twenty-one, and there are few disappointments.

The fourth and fifth books are about more specific things. Total purchasing: a model for locality commissioning, edited by Rod Smith, Fran Butler and Mike Powell, is a collection of not very clearly connected perspectives on total purchasing. Some are better than others. Chris Ham’s foreword delivers the basic message that total purchasing, by drawing practices together in common cause, attacks the isolation that GPs may experience, unlocks the power of alliance and foreshadows new models of organisation. The book was published too far in front of the white papers to reflect them, which is a pity.

Extending primary care, edited by Pat Gordon and Janet Hadley, is a well organised collection of essays on polyclinics, primary care resource centres and hospital-at-home schemes. The best contribution is by Pat Gordon and Diane Pampling, a useful historical perspective on the development of general practice. History, as ever, is a good teacher for those who need to understand the present and move things on.

Do these books help? On the whole, yes. Between them they capture a large slice of the development agenda and set out a wide range of insights and solutions. In their breadth they faithfully reflect the pervasive nature of the initiative and the challenges to the creativity and energy of local managers and clinicians. Thankfully they steer clear of over-defining a primary care led NHS and, in the process, diminishing it.