Feature

Unsteadily into the future

Will the fast-changing nature of primary care work to the advantage of older people, or against them? Steve Iliffe assesses an uncertain future

If the gradual ageing of the population means that more people will experience disability and frailty, how will existing services respond to their needs? And if existing hospital services are hard pressed, with patients languishing on trolleys in casualty departments while the waiting lists for cataract and hip surgery remain stubbornly long, who will attempt to prevent disability developing in older people?

The NHS is believed to be poorly equipped to respond to this challenge, yet it has extensive resources in the community that could be put to use. British general practice is highly developed compared with other countries, and community nursing is an expert service, whatever its difficulties in recruitment and retention. Why then is there a pervasive sense of pessimism about the ability of primary care to meet the needs of older people with disabilities?

Part of the problem lies in the strengths of general practice. The general practitioner system is becoming more organised and taking on more medical tasks, but it is also slowly becoming less accessible, and offers diminishing continuity of care. These are long term trends which were visible 20 years ago, and have been reinforced by appointment systems, receptionists, specialisation among GPs, group practice, part-time working and the growing cohort of women doctors, and the creation of out-of-hours services. Nurses have gained a major role in primary care, initially in managing long-term problems like asthma or diabetes, and more recently in managing demand for immediate care.

At the same time, demand for medical attention has not diminished. The population is healthier, but also more health conscious, and more critical of professional knowledge and conduct, than in the past. Primary care is slowly re-configuring itself from the personalised ‘family doctor’ model towards a more industrialised, impersonal and scientific service driven by guidelines and protocols, not the idiosyncrasies of patients or professionals. The population, on the other hand, is becoming more diverse, with ethnicity, education, income and access to knowledge among the factors shaping responses to health, illness and loss of abilities.

How will an ageing population fare in this post-modern service environment? We can hypothesise that the more complex the medical problems of any individual, the more they need focussed and continuing attention, and that there will continue to be competition between people for limited services. Disablement is a complex process, involving the evolution of individual physiology and psychology in a particular social and physical environment. Unravelling this, and responding to gaps between environmental demand and personal capacity requires as much organisation and structure as planning chemotherapy or undertaking IVF. Such a systematic approach is not fostered by variable demand and the milieu of semi-continuous crisis found general practice, with its unpredictable changes in workload, and at present few would expect GPs or practice nurses to organise and deliver chemotherapy or IVF. But this does not mean that systematic organisation of assessment, treatment and rehabilitation, or a proactive approach to preventing or minimising disability in whole populations are not possible, for general practice has proved flexible enough to incorporate the management of long-term disease reasonably successfully.

Similarly, the present cohort of older people is not uncritical of medical care, but it is probably less articulate and assertive than its younger competitors. In the fight for attention, resources and agenda-setting positions of power it may not do well against younger and less deferential lobby groups and interests. Some evidence of this emerged during the fundholding era, when the savings achieved in fundholding were invested in counselling to provide psychological support for younger and middle-aged adults, and physiotherapy for treatment of acute musculoskeletal conditions, rather than in chiropody or benefits advice for older people. This imbalance in power is not in itself an obstacle to improving the quality or quantity of care, because the NHS has always had some capacity to redistribute resources towards those in greatest need. The question is how possible this redistribution will be given the new policy climate in the NHS, and how much the new structures can promote or offset the inequalities inherent in a demand-led service.

The most recent NHS reforms seem to offer a number of opportunities for service development, but also to create new hazards for professionals and the public alike. Primary care groups and trusts offer potentially powerful new structures that could re-configure local services to the advantage of older people, seem worth considering in more detail. We need to think about their negative and positive features if we are speculating about their ability to respond to demographic changes. This means accepting that they are unpopular with the majority of general practitioners and attractive only to a minority, and that they call for collaborative styles or working and strategic ways of thinking that are not core features of general practice. It seems unlikely that resource constraints on primary care will lift substantially, even with increased NHS funding, and hopes that hospitals can be commissioned into different patterns of service provision may fail because so many hospital trusts lack the spare capacity and organisational slack to change.

On the positive side, the public health perspective required in primary care groups or trusts is truly educational for those immersed in demand, especially given the proven ability of general practice to evolve in creative ways. If reconfiguration in response to demand happens reactively, why shouldn’t proactive reconfiguration in response to need be possible? The likely emergence of single structures bringing together medical and community nursing organisations, and possibly even social care services, may favour this type of proactive change. The appearance of salaried GPs might alter the working relationships between disciplines working in the community in positive ways, while specialists – from geriatric medicine and psychiatry, as well as physiotherapy and speech therapy – might have one less obstacle to negotiate in communicating with generalists once the dwindling but symbolic autonomy of GPs is replaced by accountability.

We can see a best-case scenario developing in which primary care trusts derived from the merger of community health trusts and primary care groups, and driven by public health agendas, are specially tuned into the needs of older people. They will produce the right mix of generalist and specialist expertise, and engineer skill transfer between disciplines – and between professionals and the public – while achieving economies of scale in the administration of single organisational structures. GPs in such a system may spend less time dealing with minor illnesses, which will be sorted out by nurse practitioners, and more time on complex case management with patients whose multiple pathologies need fine adjustment and regular review if they are to retain a good quality of life. Time and effort will be spent on health promotion with older people, recognising that their responsiveness to it and benefit from it is greater than that of the younger generations.

But the worst case is equally visible. New primary care trusts with limited resources may collectivise different, disgruntled professional interests, each of which seeks greater shares of those resources for itself, to deal with unrelenting demand and meet the targets emerging from the Department of Health. Competition for resources within the structure would match competition for care by the patients, with the weakest suffering most. In this dysfunctional system professionals will struggle to keep ahead of demands and wise citizens will make private arrangements for their care, if they can. The one-third of the retired population living on state pensions alone are unlikely to be the greatest beneficiaries of this type of health service.

It may take another decade before the real impact of the current reforms becomes obvious. It is likely to lie between these extremes, and may vary widely from place to place. If the needs of older people are met in very different ways in different places, the current ‘postcode lottery’ of care for cancer or infertility may extend yet further. Professionals who are seeking leverage in the present reforms on behalf of the older population, and voluntary organisations looking in from the outside, will need to be vigilant and should seize opportunities for change as they arise.

This article is based on discussion at a seminar held at Keele University in May 2000.