Integration of Primary and Community Care (Committee Report)

Baroness McIntosh of Pickering Excerpts

Thursday 9th May 2024 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

My Lords, I congratulate the noble Baroness, Lady Pitkeathley, and the committee on their report and on securing this debate. I also welcome my noble friend Lord Jamieson and congratulate him on his excellent contribution today.

I declare my interest as an adviser to the Dispensing Doctors’ Association, and the fact that my late father and brother were both dispensing doctors. Dispensing doctors are general practitioners who provide primary healthcare to around 9.9 million rural patients. Almost 3.5 million of those patients live remotely from a community pharmacy and, at a patient’s request, dispensing doctors are allowed to dispense the medicines they prescribe for them. Only certain patients are eligible to receive dispensing services from a dispensing doctor. In total, around 7% of all prescription items are dispensed by such doctors.

The unique benefit of a dispensing doctor service is that it provides access to medicines and general healthcare under one roof. They provide a total network of 1,107 dispensing practices, spread across England, Scotland and Wales, and are a wonderful example of integration between prescribing and dispensing services that are collocated.

Turning to the conclusions of the report and the Government’s response, I think it is important to note that in Scotland health and social care partnerships have existed for a few years, yet funding arguments continue and, despite integration, there is still inadequate funding for social care, with a lack of care placements, delays in discharge from the acute sector and difficulties admitting patients in A&E, so integration has not yet met the needs of patients in Scotland. I ask my noble friend directly: does he agree that neither GPs nor their contracts currently prevent shared facilities? There used to be physios, district nurses, health visitors and others all collocated at a surgery, but it was these very organisations that removed themselves from the premises, not GPs.

I have some points to put directly to my noble friend the Minister. Remote consultations are simply not the answer. Complex patients and multiple conditions need more face-to-face time with GPs. Social care is means-tested; healthcare is needs-led. The difference between them must be addressed before integration can proceed further. Does he not agree that coterminous health and social care areas do not necessarily work for health, where patients may be given a choice, and it could actually destabilise current general practice if that were to happen? I also ask him to consider that it is not about who owns GP practices, which is perhaps a red herring. The Government must address the rules about occupation, then ownership itself becomes irrelevant. Will my noble friend and his department be mindful of the poor history of contracting, particularly GPs contracting out for out-of-hours service?

I ask my noble friend this directly, because this is something where NHS England, particularly in parts of Suffolk, has got the wrong end of the stick: why has EPS for dispensing doctors, and indeed hospitals, not been commissioned and the infrastructure put in place? The question of who is to pay for that infrastructure remains a vexed issue. I put to my noble friend the words of Dr West, who chairs the Dispensing Doctors’ Association; they strike a chord with those of many others, such as the noble Baroness, Lady Barker, and my noble friends who talked about data sharing, as well as the noble Baroness, Lady Pitkeathley. He asks why there is not one prescribing record per patient. Currently, there are different records for GPs and each hospital where that patient may be treated.

Will my noble friend urgently address the issue of GP training? The government response says:

“We will ensure that all foundation doctors can have at least one 4-month placement in general practice by 2030 to 2031”.


I am staggered, as I am sure others are, that this is not already the case. How can it be that, among doctors who are reaching the end of their training and are looking to have a placement, there are still about 100, as of this week, who do not yet have a placement to go to? That is unacceptable when they have reached the end of what is already a very long period of study and training.

To conclude, if integration is to proceed, which I would welcome, it has to be costed and well thought through. There is no one size fits all. What may well work in an urban area such as Pimlico, which was the example that was chosen, may not work in North Yorkshire or other very rural, sparsely populated areas. It has to be acceptable for the doctors and healthcare workers as well as the patients. Again, I note that integration in Scotland has not yet brought benefits to patients. I urge my noble friend the Minister to put GPs at the centre of patient care and ensure they have access to all patient needs, to ensure better care and fewer emergency admissions to hospital and a joined-up healthcare and social care service.