Review

State of the nations

Primary Care in the UK
Stephen Peckham and Mark Exworthy
Palgrave Macmillan, 2003. £17.99

This is a scholarly and comprehensive assessment of the state of primary care in terms of policy, organisation and management. Since Labour came to power in 1997 there has been a shift in health policy away from secondary care towards primary care, putting it at the centre of developing and commissioning services and public health.

The authors chart the rapid development of primary care policy in 1990s, and show how primary care organisations are increasingly constrained by a nationally imposed agenda closely monitored through national service frameworks, the National Institute for Clinical Excellence, the Commission for Health Improvement and so on.

Even local partnerships between health and social care agencies are being driven centrally. Government has tighter control than ever before, despite its stated ambition of bringing services closer to communities.

The book traces the increasing professional acceptance of the wisdom and economic sense of involving patients in decisions about their own care, yet it predicts conflicts ahead. The medical model of service delivery still dominates and some professionals are reluctant to give up their power. It also foresees difficulties securing effective interagency working.

Patient participation is slowly being formalised, however, and the shaping of future services by service users is government policy. The authors see in this the potential for a more democratic model of NHS governance. But they are sceptical of the government’s desire for primary care trusts to play a major role in addressing health equalities and cite research showing that primary care will have difficulties addressing this vital issue.

The authors consider the different approaches to delivering primary care in each of the four countries of the UK (although British readers outside England are likely to be disappointed at its limited coverage and analysis), and asks if political devolution will test the robustness of a national health service.

The findings suggest that it is easier to show where primary care has come from than where it is heading. The authors see a continued blurring of the boundaries between organisations and professionals and wonder if primary care as a separate entity might cease to exist in 20 years – an exciting and stimulating prospect.

As a non-academic I found this a difficult read: the dry style and attention to detailed research are taxing. But it is worth the effort to learn more about an issue of fundamental importance to the nation’s health. And if you need more, there are the 600 references to pursue at your leisure.