Healthcare Services: Acute, Primary and Community

Baroness Gerada Excerpts

Thursday 25th June 2026 Lords Chamber

[Baroness Gerada (CB)]

My Lords, I am grateful to the noble Baroness, Lady Janke, for securing this debate and to the noble Baroness, Lady Walmsley, for saying many of the things around primary care and general practice that I want to say. I always feel that I am here defending my own profession.

The NHS was founded on a vision of care delivered close to home—in communities, general practices and by district nurses. Yet, over recent decades, a profound imbalance has appeared in resource allocation. Hospital-based care has grown in workforce, infrastructure and funding, while services that form most of the patient’s first point of contact have been left to wither, as we have heard. When I started general practice, on 17 February 1991, I had time with my patients and time to do what my patients—many noble Lords in this room—wanted.

The mantra of moving care into the community has not been associated with a simultaneous move of resources, people, infrastructure support or estate. I now do more than any other GP in any other comparable health services. General practice in this country does more and to a greater degree of complexity than in any other. I do everything except open heart surgery in my consulting room—I confirm, for Hansard, that I do not do that.

The consequences of this non-shift are evidenced across the full breadth of primary care. Millions of patients cannot register with an NHS dentist. Many resort to emergency departments for toothache—or, worse, leave decay untreated until it becomes a serious health problem. Optometrists, who are often the first to detect conditions such as glaucoma, diabetes and hypertension, are increasingly unable to sustain NHS-funded services. Continuity of care with a GP, which I will say a little bit about later, is becoming a rarity, while community nursing is stretched to breaking point.

These crises, which include physiotherapists and all the other community specialists that we have heard about, are not separate. They are symptoms of the same structural neglect: a system that has consistently prioritised acute, visible hospital care over the quieter but equally essential work happening in surgeries 360 million times per year, in consulting rooms and in communities. General practice alone receives less than 8% of the NHS budget—the lowest proportion for decades. This risks replacing continuity of care—the bedrock of my profession—with brief transactional encounters, despite clear evidence that continuity delivers better, safer and more effective care. Without continuity, the NHS becomes a maze where patients get lost.

On workforce, no system succeeds without the people to staff it: practice nurses, health visitors and district nurses. The quiet architecture of community health has been hollowed out over decades. Over the same period, the consultant workforce has increased by 120%, while the number of GP partners has fallen. Even with that fallen number, around one in five GPs cannot find full employment because we do not have the funding to employ these doctors.

When community care buckles, the consequences flow downstream. The result is a system paying premium prices for intensive care to manage problems that should never have reached that threshold. This is not simply an administrative question but a moral one. What kind of health service do we want: one that catches people only when they fall, or one that walks alongside them and, where possible, prevents the fall altogether?

What does “fair distribution” mean? It means teams without walls. It means multidisciplinary teams built around the patient rather than the disease or body part. It means shared records that follow the person rather than sitting in silos. It means social prescribing that connects people to their communities before loneliness becomes a clinical problem. We need step-down facilities that bridge the acute ward with a patient’s home.

I had all those resources 20 years ago. Noble Lords will remember the Tomlinson review in the early 1990s: integrated, step-down, community-based, multidisciplinary hospitals. Please let us stop reinventing the wheel. When community care buckles, the consequences flow directly downstream. As I said, redistribution is not simply an administrative question but a moral one. What is required is not another review or reorganisation but sustained political will, clear frailty pathways, a realistic workforce plan, training that ensures that all doctors—I mean all—spend meaningful time in community settings, and a rightful place for community practitioners on integrated care boards. When will we finally redress the balance and stop the imbalance of more and more resources going into hospitals rather than where patients receive most of their care?