A manifesto for primary care

The season of manifestos and mellow thoughtfulness is upon us.

We are not party political but we care about primary care and the policies which shape it.  Here is what the evidence is telling us:

1.  Stick to the principles of the NHS, universal, comprehensive and free at the point of use, because they work.  The NHS is far from perfect but it happens to be judged overall the best health system in the world.  The fully capitation funded model, with no fee for service, is gaining ground as other countries see the benefits.

2.  Primary care is the bedrock of the NHS and embodies its principles in simple yet powerful ways.  The registration of nearly 100% of the population makes it universal, and a very large proportion of patient encounters (90%) mean that comprehensive care is delivered largely in primary care.  Around 95% of consultations with a GP resolve the patient’s problem, demonstrating their efficiency.  Consider, when under 5% of consultations result in a referral to secondary care, and attendances at A&E are only 6% of those at GP practices, strengthening primary care is likely to produce the greatest benefit for the whole NHS.

To reduce inequalities investment must be targetted where the demand is greatest.  Our evidence shows that the slope of demand vs deprivation is much higher than allowed for in the current funding formula.  The investment is needed both to equalise access for all, and to make GP careers just as attractive in every locality.

3.  The purpose of NHS primary care is to help patients resolve or manage their medical problems.  Understanding and improving its function comes before debating its form.

4.  Primary care should be accessible, local and relational.  It should be led by GPs, as the most qualified clinicians.  Matters of clinical quality, safety and effectiveness are the domain of others and are taken as read in this document.

5.  What matters to patients?  Rapid access to a GP, and a choice of GP when it matters (around half the time).  The level of trust in GPs is high, but the problems are around access and continuity, “I can’t get to see MY doctor”.

6.  The service needs to be designed around patient demand, enabling rapid response from the most appropriate clinician (usually a GP), better clinical quality, higher morale and lower costs.  These are not alternatives to be traded off, they can and must be pursued together.

7.  Relational continuity is at the heart of primary care, ie the relationship between patient and doctor.  All the evidence points to the benefits for patients, GPs, quality and lower costs in secondary care.  Policies need deliberately to enhance continuity, and ensure it is properly measured.

8.  The form of primary care is secondary, but that does not make it neutral or unimportant.  We do not propose one ideal form, but rather ask the question, what forms best support the above?  The evidence points to some conclusions.  Single hander practices can give good access and continuity, but may be limited in offering the services of a full primay care team.  Very large primary care organisations can suffer from diseconomies of scale, loss of continuity, increased travel time and an impersonal feel which sits badly with a sense of local community care.  Between the extremes a broad band of unit sizes may be similarly effective.

9.  The business model must support the above principles and measures.  We do not propose one ideal form, but note that the independent contractor model has served the NHS extremely well.  Partnerships are currently feeling neglected and indeed unloved, but the model is not broken.  They have suffered relative to other parts of the NHS from a high 2005 – 2007, to the point where there is a danger to large parts system.  Rather than leap to different business models for which evidence is lacking. political leaders should strengthen the existing well proven system unless and until evidence clearly points in a different direction.

10.  Particular strengths of partnerships are…

11.  Current and proposed policies we oppose are… because…

 

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