Primary and Community Care: Improving Patient Outcomes
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The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, before I begin the response to the noble Lord, Lord Patel, and other noble Lords, I am sure that all noble Lords will be concerned by the news from Buckingham Palace about concerns over the health of Her Majesty. I am sure that the thoughts of all noble Lords are with Her Majesty and her family at this time.
I begin by thanking once again the noble Lord, Lord Patel, not only for introducing this debate but for our many conversations and his advice. In fact, he has given me so much advice, I sometimes think about calling him “uncle”. It has all been part of my learning—understanding the processes and the whole range of our health service, as well as some of the challenges. That was very well demonstrated in the noble Lord’s opening remarks and in some of the issues he has raised with me over time.
What has been interesting in this debate is that lots of people have different views on answers. We agree that there are problems and that they have to be fixed, and we want to see better integration. Some say that we need a revolution; others say that it should not be a revolution but evolution; and others would criticise evolution as piecemeal. We have to be very careful about that. Some say GPs are central to primary care; others say that it should be not only GPs but a range of workers. In fact, a number of GPs complain that they spend far too much time on things that could be done by other professionals in their practice.
The noble Baroness, Lady Watkins, rightly said that we should be careful about a one-size-fits-all approach and trying to suggest or impose one model that would work everywhere. It has to be community led, in many ways. In answering, it is really important to address these issues. I suppose the final debate we had was of some saying that we need a clear distinction between primary and secondary care, and others saying that we do not, as the lines are blurry and what is important is that patients are able to access the health and care services they need. All of that is part of this whole debate, which I found fascinating.
The noble Baroness, Lady Pitkeathley, reminded us that we are now talking about an integrated health and social care system. It is absolutely right that we look to make sure that its social care aspect has parity with the rest of health. I pay tribute to the noble Baroness for consistently reminding me and the Government about that.
We all agree that primary and community care are essential services. As a Government, we recognise that they are under significant pressure, as do noble Lords. My noble friend Lord Eccles asked why this is. There are a number of reasons. At the moment, we have more doctors and nurses than ever before but, as many noble Lords reminded me, demand is outstripping supply. Think about our awareness. During the passage of the Health and Care Bill, we spoke about the importance of mental health and about it having parity. Think about how seriously we took mental health only 30 years ago: many syndromes—post-traumatic stress disorder, for example, and others—were not even recognised until the 1980s. Before then, people were just told to pull themselves together or have a stiff upper lip. Now we recognise how important it is to tackle people’s mental well-being.
Some noble Lords will remember a debate I took part in recently on neurological disorders. When I asked my team for a briefing, I asked them to list all the neurological disorders so that I could understand this. They said, “Minister, do you realise that there are 600 of them?” Imagine that awareness of 600 disorders and how many people are needed right across the country. That shows the challenge we face in demand outstripping supply. It also highlights one of the points behind the question from the noble Lord, Lord Patel: given that all this demand is outstripping supply, is it really appropriate to continue with a model from 70-odd years ago, as the noble Lord, Lord Kakkar, rightly said? The debate we are having is on whether it should be revolution or evolution, and how we ensure it is patient centred.
Another important point mentioned by a number of noble Lords was prevention. It should not be about waiting for people to get ill and then, hopefully, curing them; it should be about prevention in the first place. Individuals, bodies and organisations can all play a key role in that. As the noble Baroness, Lady Brinton, said, it is right that the voice of patients is heard. No one should ever say again to the noble Baroness—I would not dare to—that patients know too much. We want patients to have a partnership with their health and care professionals, so that they understand the issues and so the patient feels valued and understood—a number of noble Lords mentioned this when it comes to named GPs, for example.
It is critical that we look at prevention. That shows that it does not always have to be the GP. I am sure that if the noble Lord, Lord Mawson, had been here, he would have talked about the Bromley by Bow Centre and how there are a range of skills and individuals there. It is not about only the GP but about making sure people have healthier lifestyles. I think the website of the Bromley by Bow Centre and others is about creating health. In his book, Turning the World Upside Down, the noble Lord, Lord Crisp, says that we have to shift away from cures to prevention, not just curing people but creating health. We have seen a lot of progress in the thinking about how we get that into the system.
I will respond to some of the general points that a number of noble Lords made. To draw again on the noble Lord, Lord Crisp, he said that we should also look to other countries. We have this view—not just the United Kingdom but the whole western world— that the rest of the world can learn from us. However, as he said, if you go to some of these countries which have challenges such as resource challenges, they have some very innovative solutions. Some of them have defined completely new roles which would not be recognised here. These people are trained for shorter times and are more specialised, and although the doctors’ lobbies in those countries have railed against them, he said that it gives you effective outcomes. Perhaps we have to look at some of the traditional roles, such as doctors and nurses—we are seeing physicians’ assistants, for example, and specialists. I hope that the rest of the medical profession will be open to completely new hybrid roles, which are not the same as those of 70 years ago.
My noble friends Lady Hodgson and Lord Eccles talked about the right to see a named GP. We understand that, but not every patient will want a named GP. We have to get the balance, because the technology gives us a better service but it is not just about that; it is about people’s first interface. They want to speak to someone who understands their condition. Clearly, however, in other cases it will be important to see a named GP. At the moment, all practices are required to assign their registered patients to an accountable GP but, as my noble friend Lady Hodgson reminded us when we debated the Health and Care Act, that does not mean that the individual always responds. In theory, they should be responding, so one thing we want to look at in more detail is why that is not happening in many places.
A number of noble Lords, including the noble Baroness, Lady Finlay, talked about how we are growing the GP workforce. There are concerns. One of the things I promised in previous debates—I have not had the answer yet; I hope I get it before I leave office, whether that is this week or whenever—is on this cap on training numbers. Yes, we are training more GPs, but at the same time we are losing an awful number of them. Programmes on retention are in place, and the issue of pensions is clearly important. Sadly, I am not able to update the noble Baroness, Lady Meacher, on this; I have asked the question but, let us put it this way: discussions are taking place with another government department. When I worked in other areas of commerce and elsewhere, quite often people reminded me that the price of acquisition is often more expensive than the cost of retention., so we should be investing in the retention of people who still want to work. However, we do not want any of these artificial retirement dates; people are all living healthier lives. We are increasing the number of trainees but we also have to look at morale and retention. A number of proposals are there, but how do we make sure that they get out?
The GP business model is changing—it should not be one size fits all. I talked about the Bromley by Bow Centre; I speak to some GPs who are concerned that their practice is seen as too small. They say, “I am under pressure to go into a practice, but I give a personalised service and I worry about the service we are getting.” At the other end, you get these large health centres that are taking on some functions which were previously secondary care. I understand that challenge, therefore we agree that the primary care entry point should be about multidisciplinary teams. It should be making use of the best capacity we have and looking at alternative sources of expertise, such as dieticians, a physiotherapist or social prescribing, which a number of noble Lords mentioned during the passage of the Health and Care Act.
We made an announcement in July about reforms to dentistry. These are not the complete reforms; there are still conversations around the UDA, for example, and what is felt to be fair remuneration, but we have at least made some progress in those conversations and now have a collaborative discussion. For some people, that is not enough and we have to speed up; I completely understand that, but at least we are making some progress. Up to now they have just been at loggerheads, and we have had others saying, “You’ve got to look at the UDA, which is the source of all these problems.” We are now looking at that, and I pay tribute to the BDA and others for those collaborative conversations.
My noble friend Lady McIntosh of Pickering always raises the issue of rural practices—and rightly so; it is critical that we are reminded of it. We recognise that there are issues with retention in certain areas, and one thing we have been doing with the new medical schools is understanding that people are more likely to stay where, or close to where, they are trained. That is why we have been looking to open some schools in those areas. That will not solve everything. My noble friend also talked about rural connectivity. That issue is widely recognised at the top of the NHS, which is looking at connectivity to be managed locally and the availability of networks. I had a meeting earlier this week with a number of different suppliers on telecare. The meeting was about the switch from analogue to digital, but an issue that came up was the poor provision in many rural communities. One conversation we must have is with the broadband suppliers. Fortunately, technology will fill in a lot of this—we are seeing the cost of satellite coverage dropping and more support for fill-in systems—so I hope we will be able to improve on that. We want to recruit more people in rural areas.
Let me just make sure that I have tackled all the points raised. The noble Baroness, Lady Masham, talked about the steps to discharge patients. It is the Government’s priority to make sure that people are safely discharged. The moment the previous Secretary of State came into office just before the summer, he got together the heads of the various parts of the NHS and spoke to particular trusts and said, “What can we do to clear the pipeline to make sure that people can leave quickly to the community, and what challenges are there?” I know that my new boss, my right honourable friend the Secretary of State for Health, will look at that.
A number of noble Lords raised the issue of seeing a GP in person, and technology. One challenge we have had is that sometimes there is too much technology. We want the NHS app to be the gateway. The noble Lord, Lord Patel, referred to the recent report by Policy Exchange, and I thank Policy Exchange and the other experts who sent us all notes to help us with this debate. When you go on the NHS app, you can, in theory, book an appointment—but you cannot. Then I go to my GP’s website, which says, “You can book an appointment”, but when I go to book one, it says, “You can’t book that appointment; you have to phone us up.” Then we get back to the problem of 8 o’clock in the morning—and not just Monday, but all the way through the week.
One very sensible question is why you have to phone that day for the appointment. Can we look at a way to ensure that you can book today for up to, say, seven days in advance? We have gone backwards. When I was ill as a child, my mother could pick up the phone, phone the local GP and if they could not see you that day, if it was not that urgent, they would say, “How about next Tuesday?” How do we get back to that situation? We are still trying to understand those challenges and why that cannot be done. It says on the website that you can book an appointment, but when you press it, you cannot do so.
We are trying to make the NHS app the gateway. If I get an appointment at my local hospital, I think, “Oh great, I will just look at the appointment on my NHS app.” It does not appear there. I then get a text from that hospital that says, “Please go on to our portal.” So I have the NHS app, my GP website and my hospital website. This is the challenge. They have all said, “Yes, we want technology”, but it is about the processes behind that. On top of that, we all have to know how to make sure it works and to plug the gaps. I was asked to go to have an ECG at a primary care centre. I thought, “That’s very clever. Good, that works much better”, and was told that the consultant would phone me a week later for a conversation. I am quite relaxed about having a phone consultation, but when the consultant phoned me a week later and started talking, I asked, “Sorry, did you see my ECG from last week?” He said, “What ECG?” Then I said, “I tell you what, I can tell you the exact time and date, you can get it and then we can have the conversation.” He said, “Oh, don’t worry about that, I will make a new appointment for you.” We can have all the technology in place, but how do we ensure that the people processes are in place too?
This shows that we all have a role to play in this. The noble Baroness, Lady Merron, often brings up, rightly, the amendment on workforce planning. We talked about this during the debate. There is local-level workforce planning in the ICS. Individual practices and centres have their workforce planning. Many noble Lords will know that regarding the long-term, the department commissioned Health Education England to look at and report on those drivers. We have also commissioned NHS England to develop the long-term workforce plan for the next 15 years, including long-term supply projections. Also, under the Health and Care Act 2022, the Secretary of State has a duty to report every five years at minimum describing the NHS workforce planning and supply system. A lot is being done on workforce planning. One reason we did not accept the amendment at the time was the timeframes, and whether they would change between one report and another. We wanted to look at it in the long term, and for it to come from the NHS and to be from the bottom up.
I have gone on for far too long, but I really hope that this debate has shown everyone not only that all political parties are committed to reform but that at the same time, we must ask ourselves some very big questions. In some ways, it is a valid criticism that we are tinkering with a system that was designed 70 years ago. We must evolve a system rather than tinker with a system. We must tackle the supply of workforce, and we must look at the roles as defined today and whether there are newer roles. Can we learn from overseas, from some of the new roles that are defined elsewhere? Is everyone ready for change? Sometimes, I am not entirely convinced that every player in this system is ready for change. I have had GPs say, “I can take on more patients in my area, but the problem is that the system does not incentivise me to take on a patient elsewhere. They must deregister then re-register with me.” I hope that some of the primary care network initiatives we have will help that, but we all must accept that the current system has just been tinkered with for the last 70 years.
I am not necessarily concerned about the distinction between primary and secondary. It is important that the patient speaks to the right person when they need to, whether in person or remotely, and that they get the right follow-up care. I have had conversations about the model with the noble Lord, Lord Patel. As it is, if you can see a GP, you get five to 10 minutes. Noble Lords rightly expressed the pressures of that. You then hope for a referral. There must be a better way. Some patients are voting with their feet and getting direct referrals to consultants, and others are not. We do not want that two-tier service. We want everyone to have the same access.
The Government must do more. We clearly understand that. Maybe we are not doing it quickly enough, but we must look at the whole system and the roles as defined, while ensuring that it is not “one size fits all”. What is appropriate for one area and one population is not the same as what is appropriate for others. One of the really interesting things that the noble Lord, Lord Crisp, said, when talking about community workers, was that these are people who know about 120 people in their location. They know the families, they are trusted, they go out and knock on the doors of families to ensure that they are all right and help them with their diets and lifestyle. That is being tried in a couple of wards in London. We look forward to the results, but it might be revolutionary in terms of prevention.
I thank the noble Lord, Lord Patel, and all noble Lords. There were more specific questions that I did not answer. I will read the Official Report and write to noble Lords in response to those questions that I have been unable to answer today.