Edin lakasing and Zul Mirza call for greater commitment to the development of innovative primary care services
The latest reconfguration of the NHS, with the demise of primary care trusts and their replacement by clinical commissioning groups (CCGs), should in theory have the advantage of greater clinical engagement. Over a year since their implementation, however, the state of primary care is no better, and there must be concern about the power, priorities and strategic direction of CCGs.
A major concern within the NHS is the rising attendances at emergency departments, and the concept of a named GP for the over-75s, along with the implementation of care plans based on risk of acute admission, lies behind this. While these measures may improve continuity of care in stable situations, they are unlikely to prove effective when faced with the rapid deterioration in chronic conditions typical of such admissions. Such projects singularly fail to improve primary care and may foment the image of a limited, gatekeeper service.
The NHS lexicon is fush with populist rhetoric about choice, but this is often illusory. Take referrals as an example. Pragmatism and old loyalties mean that GPs overwhelmingly refer to the local provider, with only select metropolitan areas having more than one Trust in close proximity. NHS England – The Centre – remains powerful, and it is clear that CCGs have far less local clout than was promised, mirroring the trend in national politics for centralisation to Westminster. Like emergency departments, primary care has had to cope with an inexorable rise in workload in recent years while having its own percentage of the NHS budget eroded, and being denuded of vital services.
Proper investment into clinical services is the only way to meaningfully improve the patient experience and for primary care to fourish. This should happen at two levels.
Firstly, we should resurrect community services that have been progressively cut. With the ageing population, for instance, the reduction of district nurses is unwise. Consider end-of-life care, where around 75% of patients wish to die at home, yet fewer than 20% do so, testifying to the increasing “medicalisation” of death. Greater support of the dying and their families by district nurses could surely lead to more fulflling their wish, free of expensive interventions.
Similarly, health visitors have become more remote, reducing the support for mothers and children, with the result that feeding problems and minor illness often present to GPs or emergency departments less well geared to this. Disinvesting in the community is a false economy, ultimately leading patients to seek care in more expensive settings.
Secondly, GPs and consultants should exit their silos and work together at the primary-secondary interface. The forte of hospitals is expert, high-technology care, but as this grows they cannot continue without relinquishing some of the low and mid-tech areas. Properly funded and with technical expertise, much of this can be transferred to primary care, which has a respectable track record; the majority of hypertension and asthma and much of diabetes and COPD is, after all, managed here. For physiotherapy and counselling, there is surely no compelling argument for the bulk being conducted anywhere else. Some specialties like dermatology and psychiatry lend themselves well to outreach clinics in primary care, while echocardiography, upper gut endoscopy and elements of radiology are diagnostic services which could also be moved out selectively.
Ultimately, it is also in primary care’s interest for this to happen. The erosion of partnership opportunities in recent years is not a propitious development for a specialty supposedly at the forefront of strategic planning. The potential to be part of a dynamic, creative environment is more likely to attract enthusiastic and committed partners with a real stake in the profession, than a job of limited scope where all one hears is why something is not available or cannot be done. One hopes The Centre shares that view, and properly supports service development in primary care.