Still the envy of the world?

The ‘primary care tsar’ paints a rosy picture of the service in his progess report. But it’s not quite that simple, argues GP Ron Singer

The aim of any health and social care system should be to prevent illness where possible and treat early where necessary. But UK health policy has always put hospital treatment before investment in primary care or measures to improve health, inside and outside the NHS.

Has this finally been reversed with the advent of a ‘primary care-led NHS’ in 1993, new primary care organisations (PCOs) in 2001 and a new GP contract this year? And is David Colin-Thome, the government’s ‘primary care tsar’, right to present an optimistic picture in his latest report?¹ Is his claim that ‘NHS care is admired throughout the world’ still tenable?

David Colin-Thome emerged as a GP innovator in the 1990s when he broke ranks as a former Labour councillor and became a GP fundholder, thereby seeming to support the Conservatives’ ‘internal market’ healthcare policies. History shows that the fundholding model could bring new services to a practice, but at increased cost. It was mostly taken up in affluent areas and became another example of the inverse care law.

Fundholding did, however, spur radical practices to develop an alternative model – GP commissioning – where groups of GPs influenced secondary care, crucially for whole, local populations rather than single practices.²

Both laid the way for primary care trusts, but neither tackled the restructuring of primary care or general practice.

Prime minister Tony Blair has increased investment in the NHS and the various GP contracts have channelled more money into general practice. But because the NHS had been starved of adequate investment – £257bn in the past 25 years according to the 2002 Wanless report – the new money has often funded deficits rather than innovations.

The government has made pleas for services rather than funding them directly. For example, a sexual health strategy was published in 2002 that suggested GPs should take on all first-contact sexual health work. No extra money was provided for this new work, yet Colin-Thome still recommends that GPs provide basic sexual health services, with the mantra that GPs are ‘best placed’ to treat the chlamydia epidemic.

If this was the plan then sexual health should have been funded through the GP contract and the sexual health strategy could have been a national service framework, with PCOs monitored for measurable improvements.

Recently, the government has ‘discovered’ that chronic diseases absorb up to 60 per cent of NHS spending. Partly as a result of this, there is investment in the quality and outcomes framework of the new GP contract. The aim is to reward practices for work done to a measurable standard.

Policy makers are also trying to develop integrated pathways for chronic care, with selected PCOs working with US health providers such as Kaiser Permanente to learn how to reduce bed stays and develop mechanisms for integrating primary and secondary care.

The revelation about chronic care should remind policy makers that primary care is more than GPs, that teams need to be built across the primary-secondary care divide, and that general practice and community care infrastructures need significant development as more care is delivered in the community.

One of the more important innovations in the NHS is the use of IT. General practice clinical systems are well ahead of anything in the community or secondary care, yet the whole NHS financial system is about to become dependent on sophisticated technology. Payment by result, where hospitals are paid on a case-by-case basis by primary care organisations, means that clinical coding for each event will become mandatory. Payment to practices for the new quality and outcomes framework will depend entirely on correct recording and coding of clinical processes.

At last there is the prospect of quantifying morbidity and the processes of the NHS, and facilitating service planning at local and national levels. Whether the NHS has enough money for both the IT and the resulting improvement in quality remains to be seen.

As part of the government machine, David Colin-Thome is bound to be optimistic. As an innovator he is right to see the possibilities that the NHS Plan offers. But he also needs to acknowledge that funding is still a real problem. There is a lack of management and clinical capacity in general practice and community nursing, particularly in inner-city areas. There are also contradictions in policy – the emphasis on secondary rather than primary care, and the potential fragmentation of multiple providers versus the integration offered by PCOs – are still obstacles to patient pathways and to making a difference that all can celebrate.

Is primary care ‘better’? Perhaps, marginally, but there is potential for improvement as new care workers such as graduate mental health workers and first response assistants come on stream. There is likely to be a separating out of: ‘acute primary care’ – coughs, cold and minor injuries – dealt with in walk-in centres and practices – with chronic disease care handled mainly in practices and primary care centres, and specialist care taking place in hospitals and, increasingly, in the community.

The government sees the private sector as the solution to improving the NHS including, now, primary care. But this will increasingly become a problem: the private sector will be more expensive and, if the lack of accountability in residential homes is repeated in primary care, the ‘patient journey’ could become a patient nightmare.

Is the NHS still the envy of the world? Not at present – its outcomes are average. But there is the opportunity for data to become the engine of change and for services to be re-engineered. Whether outcomes will improve with adequate funding remains an open question.