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The future of the NHS must be in primary care

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This post was first published by PCC.

Well, the NHS has a new CEO in Amanda Pritchard to replace Simon Stevens whose legacy not only gave us a strong management of the covid crisis for the NHS, but – more visionary and hopefully long-lasting – instigated Primary Care Networks (PCNs) and Integrated Care Systems (ICS).  A much overdue initiative to bring together the health service, the care services and the public health service to focus on prevention, cure, care and the health of the population with an emphasis on primary care.

I have long feared a post Stevens regression to a traditional ‘top down’ compartmentalised mindset which will negate the broader vision and with the usual undue focus on the hospital sector. Pritchard is an outstanding hospital manager, and has for the last two years been the Chief Operating Officer (COO) of NHS England, and is described by the prime minister and others to be the continuity candidate.

Her predecessor and two chief competitors for the post have a wider experience of care systems but her role as COO embeds her firmly in the integrated vision. The question is how will the aforementioned ‘traditionals’ react and will the old culture rear its head again? Given the weaknesses of the NHS which have been hugely emphasised by the pandemic, continuity is not enough. And our entire health and care similarly. It is of concern that the Commons committee of the Health and Care Bill has scant mention of primary care

Of huge import is the assessment of the Commonwealth Fund, a highly rated US organisation, whose mission is to promote a high-performing healthcare system. The Fund carries out its mandate by supporting independent research on health care issues and one of their many intellectually vigorous publication series is the appropriately named Mirror, Mirror – comparing the performance of health care systems of 11 high-income countries.

The reports are readable and well worth the read, the indicators used cover five domains – access to care, care process, administrative efficiency, equity and healthcare outcomes.

The latest in the series recently published once again places the USA overall significantly last but has salutary messages for us in the UK. In 2017 the overall top ranked healthcare systems were UK, the Netherlands and Australia; now it’s the latter two joined by Norway. In fairness, with New Zealand and Germany, we are second ranked though persistently over the years we perform poorly on health outcomes and brilliantly on affordability for our public.

Is this an early warning sign to us of slippage given all the countries are bedevilled by covid-19?

To me the most important overarching feature is the Fund’s consisted message over their several Mirror, Mirror reports is the comparison of the feature of top-performing countries and poorer-performing countries. The Fund postulates that top-performing countries rely on four features to attain better and more equitable health outcomes:

  1. They provide for universal coverage and remove cost barriers so people can get care when they need it and in a manner that works for them.
  2. They invest in primary care systems to ensure that high-value services are equitably available locally in all communities to all people, reducing the risk of discrimination and unequal treatment.
  3. They reduce the administrative burdens on patients and clinicians that cost them time and effort and can discourage access to care, especially for marginalised groups.
  4. They invest in social services that increase equitable access to nutrition, education, childcare, community safety, housing, transportation, and workers benefits that lead to a healthier population and fewer avoidable demands on health care.

Prioritising maternal health is critical for reducing maternal mortality. Top-performing countries have had success in preventing maternal deaths through the removal of cost sharing for maternal care. They invest in primary care models that ensure continuity of care from conception through the postpartum period, including midwife-led models. They offer social support benefits, including parental leave. And separately and significantly, several additional causes of avoidable mortality are linked to mental health.

It is clear that primary care is of paramount value in a successful health system, but also clear is that – even in the UK – primary care centrality is not assured unless we consistently lead from within it. Primary care is a dispersed service requiring a dispersed leadership that is nevertheless highly coherent and connected. The essential mantra  being small and local and concomitantly strategically big and influence.

The principles and achievements of the Primary Care Homes, the voluntary ‘bottom up’ precursor of Primary Care Networks demonstrate those attributes par excellence. Now it is incumbent on all of us to make sure those self- same attributes prevail throughout primary care. A social movement of dispersed yet connected leadership led predominantly by Primary Care Networks but also general practices, ‘super practices’ and hopefully well beyond general practice and by an engaged public.

A huge ask but visionary aims are built on small beginnings underpinned by a continuing visionary energetic leadership to deliver what I call the ‘primary care triple aim’:-

  • To level up quality and increase the range and scope of primary and community service provision.
  • To significantly contribute to reshaping hospital services which acute providers and commissioners have failed to do,
  • To have a central role in health and wellbeing beyond healthcare by developing a public health for primary care.

Primary care is the only NHS service that can contribute and hugely to all of the triple aim, and with leadership described ensure our continuing necessary centrality.

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Radix is the radical centre think tank. We welcome all contributions which promote system change, challenge established notions and re-imagine our societies. The views expressed here are those of the individual contributor and not necessarily shared by Radix.

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Get email notifications</p></li><li id="field_2_1" class="gfield gfield_contains_required field_sublabel_hidden_label field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_1'> <span id='input_2_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_2_1_3' value='' tabindex='70' aria-required='true' placeholder='First Name*' /> <label for='input_2_1_3' class='hidden_sub_label screen-reader-text'>First</label> </span> <span id='input_2_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_2_1_6' value='' tabindex='72' aria-required='true' placeholder='Last Name*' /> <label for='input_2_1_6' class='hidden_sub_label screen-reader-text'>Last</label> </span> </div></li><li id="field_2_2" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label' for='input_2_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_2_2' type='email' value='' class='large' tabindex='74' placeholder='Email*' aria-required="true" aria-invalid="false" /> </div></li><li id="field_2_4" class="gfield gf-conf-check gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Confirmation<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_4'><li class='gchoice gchoice_2_4_1'> <input class='gfield-choice-input' name='input_4.1' type='checkbox' value='Please keep me updated on new website content and Radix news. (We will process your data in accordance with our <span class="pp"><a href="https://radixuk.org/privacy-policy/">Privacy Policy</a></span>. You may withdraw this consent at any time by &lt;a href=&quot;"mailto:hello@radixuk.org"&quot;&gt;emailing us&lt;/a&gt; or clicking “unsubscribe” at the bottom of our emails).' id='choice_2_4_1' tabindex='75' /> <label for='choice_2_4_1' id='label_2_4_1'>Please keep me updated on new website content and Radix news. (We will process your data in accordance with our <span class="pp"><a href="https://radixuk.org/privacy-policy/">Privacy Policy</a></span>. You may withdraw this consent at any time by <a href="mailto:hello@radixuk.org">emailing us</a> or clicking “unsubscribe” at the bottom of our emails).</label> </li></ul></div></li><li id="field_2_6" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_2_6' >Name</label><div class='ginput_container'><input name='input_6' id='input_2_6' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_2_6'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='SUBSCRIBE' tabindex='76' onclick='if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} jQuery("#gform_2").trigger("submit",[true]); }' /> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=69' /> <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='2' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjg1ZGYwZWM3YzAyMDRmYTcyZDYxNmIwMWJiNmFhYzVhIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <p style="display: none !important;"><label>&#916;<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js" name="ak_js" value="237"/><script>document.getElementById( "ak_js" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form> </div> <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'></iframe> <script type="text/javascript"> gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https://radixuk.org/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https://radixuk.org/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_2').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}, 50);}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [2, current_page]);} );} ); </script>
[gravityform id=5 title=false description=false ajax=true tabindex=64]
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_5' ><div id='gf_5' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_5' id='gform_5' action='/opinion/the-future-of-the-nhs-must-be-in-primary-care/#gf_5' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id="field_5_5" class="gfield gravity_head gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" ><h3>Get emails</h3></li><li id="field_5_1" class="gfield gfield_contains_required field_sublabel_hidden_label field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_5_1'> <span id='input_5_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_5_1_3' value='' tabindex='65' aria-required='true' placeholder='First Name*' /> <label for='input_5_1_3' class='hidden_sub_label screen-reader-text'>First</label> </span> <span id='input_5_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_5_1_6' value='' tabindex='67' aria-required='true' placeholder='Last Name*' /> <label for='input_5_1_6' class='hidden_sub_label screen-reader-text'>Last</label> </span> </div></li><li id="field_5_2" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label' for='input_5_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_5_2' type='email' value='' class='large' tabindex='69' placeholder='Email*' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_4" class="gfield gf-conf-check gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Confirmation<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_4'><li class='gchoice gchoice_5_4_1'> <input class='gfield-choice-input' name='input_4.1' type='checkbox' value='Consent' id='choice_5_4_1' tabindex='70' /> <label for='choice_5_4_1' id='label_5_4_1'>Please keep me updated on new website content and Radix news. (We will process your data in accordance with our <span class="pp"><a href="https://radixuk.org/privacy-policy/">Privacy Policy</a></span>. You may withdraw this consent at any time by <a href="mailto:hello@radixuk.org">emailing us</a> or clicking “unsubscribe” at the bottom of our emails).</label> </li></ul></div></li><li id="field_5_6" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_5_6' >Email</label><div class='ginput_container'><input name='input_6' id='input_5_6' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_5_6'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='SUBSCRIBE' tabindex='71' onclick='if(window["gf_submitting_5"]){return false;} if( !jQuery("#gform_5")[0].checkValidity || jQuery("#gform_5")[0].checkValidity()){window["gf_submitting_5"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_5"]){return false;} if( !jQuery("#gform_5")[0].checkValidity || jQuery("#gform_5")[0].checkValidity()){window["gf_submitting_5"]=true;} jQuery("#gform_5").trigger("submit",[true]); }' /> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=&amp;description=&amp;tabindex=64' /> <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='5' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_5' value='WyJbXSIsIjg1ZGYwZWM3YzAyMDRmYTcyZDYxNmIwMWJiNmFhYzVhIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <p style="display: none !important;"><label>&#916;<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js" name="ak_js" value="168"/><script>document.getElementById( "ak_js" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form> </div> <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_5' id='gform_ajax_frame_5' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'></iframe> <script type="text/javascript"> gform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https://radixuk.org/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_5').val();gformInitSpinner( 5, 'https://radixuk.org/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [5, current_page]);window['gf_submitting_5'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_5').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_5').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}, 50);}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [5, current_page]);} );} ); </script>
[gravityform id=6 title=false description=false ajax=true tabindex=999]
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_6' id='gform_6' action='/opinion/the-future-of-the-nhs-must-be-in-primary-care/#gf_6' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id="field_6_5" class="gfield gravity_head gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" ><h3>Before you go!</h3> <p>Stay up to date with what's happening at Radix. Get email notifications</p></li><li id="field_6_1" class="gfield gfield_contains_required field_sublabel_hidden_label field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' tabindex='1000' aria-required='true' placeholder='First Name*' /> <label for='input_6_1_3' class='hidden_sub_label screen-reader-text'>First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' tabindex='1002' aria-required='true' placeholder='Last Name*' /> <label for='input_6_1_6' class='hidden_sub_label screen-reader-text'>Last</label> </span> </div></li><li id="field_6_2" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label' for='input_6_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='email' value='' class='large' tabindex='1004' placeholder='Email*' aria-required="true" aria-invalid="false" /> </div></li><li id="field_6_4" class="gfield gf-conf-check gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" ><label class='gfield_label gfield_label_before_complex' >Confirmation<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_4'><li class='gchoice gchoice_6_4_1'> <input class='gfield-choice-input' name='input_4.1' type='checkbox' value='Please keep me updated on new website content and Radix news. (We will process your data in accordance with our <span class="pp"><a href="https://radixuk.org/privacy-policy/">Privacy Policy</a></span>. You may withdraw this consent at any time by &lt;a href=&quot;"mailto:hello@radixuk.org"&quot;&gt;emailing us&lt;/a&gt; or clicking “unsubscribe” at the bottom of our emails).' id='choice_6_4_1' tabindex='1005' /> <label for='choice_6_4_1' id='label_6_4_1'>Please keep me updated on new website content and Radix news. (We will process your data in accordance with our <span class="pp"><a href="https://radixuk.org/privacy-policy/">Privacy Policy</a></span>. 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