I always welcome converts.
“More and more demands are being placed upon GPs who are expected to deliver an ever-wider range of services and to integrate care for more and more complex patients. Despite rising productivity, an expanding role, and evident capacity constraints, the relative share of NHS expenditure towards primary care fell by a quarter in just over a decade, continuing a downward trajectory from their peak in 2004. With primary care doing more work for a lesser share of the NHS budget when the hospital workforce appears to have expanded to the amongst the highest levels in the world. The overall result is that since the 2006 commitment to shift care towards the community, the share of NHS spending on hospitals increased. This means that the NHS has implemented the inverse of its stated strategy.’’
Well would you believe it? A fulsome praise of general practice though with little mention of other primary care services. My playful subtitle relates to the initial Darzi Report of 2008 for which I led on the primary care strategy section, but with scant mention when published. At least it spurred me to originate the Primary Care Home in 2011. The current Report is a comprehensive statement on the mess the NHS is in but is an investigation only, not a policy statement. Four areas piqued me: funding, long-term conditions, staff and patient engagement.
“Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need not ability to pay. With the prominent exception of the United States, every advanced country has universal health coverage—and the rest of the world are striving towards it. But other health system models—those where user charges, social or private insurance play a bigger role—are more expensive, even if their funding tends to be more stable.’’
I disagree, universal coverage with stable funding would be hugely desirable, and our European neighbours with their better outcomes (referenced in the Report) would claim a cost effectiveness rather than expensive.
‘’Substantial rise in the prevalence of some long-term conditions, more significantly, more people now have multiple long-term conditions. As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace. GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure and authority that this requires’’.
So where has NHS policy leadership been when the evidence is so clear? The UK has a much lauded universal, population-based GP system yet only Israel in 1995 and now Ireland has delivered a primary care led healthcare system. I quote Ireland “The imperative to address an aging population, the burden of chronic diseases (as they describe), and the lessons from recent global health crises have spurred Ireland to usher in a new era of healthcare, placing community care at its heart. These ambitious reforms go positively beyond the recent reforms in England. To wit, The Enhanced Community Care Programme’s objective is to deliver increased levels of healthcare with service delivery reoriented towards general practice, primary care, and community-based services. The focus is on implementing end-to-end care pathways that will care for people at home and over time, prevent referrals and admissions to acute hospitals where it is safe and appropriate to do so, enabling a “home first” approach. Fundamentally the ambition for this programme is to bring care closer to home.’’ What is particularly commendable to me is the population focus throughout their reformed system,
‘’Too many staff are disengaged.’’ This to me is an endemic problem and reversing it should be the absolute essence of NHS reform but sadly has never been so. People thrive if they have an internal locus of control. The underlying philosophy behind the primary care home for instance was about creating energy and fulfilment to facilitate service advances. Change must be organic and vitalising whereas NHS reform has traditionally been functional, top down, structural, inheriting status quo leaders and frequently disabling. Reform can only be deemed successful if internal control for NHS staff can be sustained. The implicit ‘deal’ for NHS workers is transparent accountability to lead to transparent autonomy for more local ownership and even some budgetary responsibility. Subsidiarity is a reform principle.
‘‘Patient engagement. The patient voice is not loud enough.’’ The NHS struggles to see the public as both citizen and customer. Engagement is such a weasel word if it means paying lip service to patient/public involvement. I am part of the development of community oriented integrated practice. Early days for an involvement of the public as partners with community based staff. Modelled in Ealing by a Dr Paul Thomas, it offers a radical shift providing a ‘vision for society where people of different backgrounds integrate their ways of working to bring things together at local level. Depending on the context this can result in collaboration for initiatives that improve the health of individuals, specific groups, or whole populations.’ Not engagement, participation. And supported by another convert, a former NHS chief executive.