Primary and Community Care: Improving Patient Outcomes

Baroness Watkins of Tavistock Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Baroness. I congratulate my noble friend Lord Patel on securing time for this important debate and support his proposal for a special committee. I declare my interests as a registered nurse and as president of the Florence Nightingale Foundation.

Other noble Lords have spoken about the medical workforce—in particular, general practitioners—and the need to invest in dentistry services. I will focus on the multidisciplinary teamwork in general practice and community care, with a particular emphasis on nurses, midwives and health visitors. In England, the primary care networks have enabled some community nurses and GP practices to work closely together at a local place level. This is building on a successful neighbourhood model that has been in existence for many decades. However, as briefing from the Queen’s Nursing Institute reminds us, a one-size-fits-all model does not apply because of the variety of geographical neighbourhoods—including rural and urban communities —and the different needs within those communities.

The Fuller stocktake report referred to by other noble Lords gives good examples of where services work closely together, successfully emphasising that the focus in both community and primary care should be on good outcomes for patients, not a one-size-fits-all approach for the sake of administrative uniformity. It is for that reason that the local integrated care boards should ensure that local practitioners, in partnership with the people they serve, are closely involved in determining the shape of local community services. It is widely recognised in government that there is a significant workforce shortage in the NHS, including in primary and community care. Yet everything points to the need for more care to be delivered in patients’ homes and in community settings, and this must be considered in workforce planning.

It is particularly vital that we educate more qualified specialist district nurses to lead and manage teams in the community. This in turn links to patient safety and quality outcomes. Similar investments are necessary in the mental health and learning disability community nursing services. Our extremely esteemed colleague my noble friend Lord Kakkar, who is a surgeon, defined this very accurately in his speech, so it is a pleasure to agree with him. There is significant untapped potential in the nursing workforce and many other healthcare professions including, for example, physiotherapy and occupational therapy. All healthcare professionals should be encouraged to use the skills and knowledge they have to the highest level of practice for which they have been educated. Instead, many feel frustrated that they are not enabled to work to their maximum potential. We need to be clear about career development for healthcare professionals working in community settings. This would aid retention and develop more independent and professional practice, meaning that many patients with long-term conditions would need to be seen by GPs only when their healthcare status changed significantly.

It is argued that the first 1,001 days from pregnancy to the age of two are a period of unique rapid development which lays the foundations for a child’s lifelong mental and physical health. Midwives, who lead interventions, including support with breastfeeding, smoking cessation and parental emotional well-being, have a positive and far-reaching impact on a child’s subsequent health development and life chances. The reverse is also true, and it is often during pregnancy that families get locked into the intergenerational cycles of inequality. For example, babies born to families on lower incomes are significantly more likely to be born underweight, have higher risks of mortality and experience of developmental problems.

The latest NHS workforce figures for England show that there were 541 fewer midwives in June 2022 compared with 12 months earlier. The drop in numbers was particularly pronounced in the north of England—evidence of the need to level up. The most recent Office for National Statistics figures show that 11,000 more babies were born in 2021 than in the previous year, so we have fewer midwives yet more births. The Institute of Health Visiting estimates that there is a shortfall of 5,000 full-time equivalents in England—a loss of over a third since 2015. It is worth noting that there were 536 child serious harm events in 2020-21 including, sadly, some child deaths. This was an increase of nearly 20% on 2019-20.

The health visitor performance matrices from August 2022 show that the lowest-performing local authorities had 4.2% of new birth visits within 14 days and 5% of two to two-and-a-half-year reviews, against the highest-performing local authorities, where the figures were 99.3% and 100% respectively. This means that, in some parts of the country, almost all children receive a two to two-and-a-half-year review whereas, in others, fewer than one in 10 children is assessed by health visitors for what are deemed to be mandated contacts. This kind of postcode lottery should be of significant concern to us all. Health visitors make a difference through improved identification of children with developmental delay and vulnerabilities by supporting families through early intervention and thus improving outcomes.

Does the Minister agree that it would be helpful to harness the skills and experience of all clinicians in the delivery of public health and to locate health and care services in easily accessible and prominent community facilities? This would enable healthcare teams to work closely together and make preventive care easily accessible to all. Early intervention is not only crucial to the health and well-being of families and children but good for community cohesion and economic productivity, as well as leading to savings in the cost of unemployment, crime and mental illness.

Finally, I turn to information from the Royal College of Nursing. In June this year, it reported that over half of nurse respondents in primary care said that there were insufficient nursing staff to safely meet the needs of their patients, and two-thirds said that the skill mix was not appropriate to meet the needs and dependencies of the service users and patients effectively. With advanced skills, registered nurses in primary and community care should be able to lead care for patients who have received accurate diagnosis and treatment plans from GPs and/or hospital consultants. Safely delivering high-quality care improves patients’ outcome and reduces readmission to hospital.

Key to patient outcomes are the structure and processes of health and social care services—and, I would add, housing. Investment is urgently needed to improve the digitalisation of patient records and test results in primary care. Patients want effective healthcare delivered by compassionate, professional, trained staff and to understand their treatment, which assists them in adhering to their own personal care plans. The latest idea in general practice is to be told, “You’ve had this blood taken, but if you don’t hear from us then everything is fine.” None of us trusts it, to be honest.

Local integrated care boards should be involved in planning the most appropriate structures and processes of services to meet their local need, but must also be mindful of ensuring uniformity of access to NHS-funded services in England; I recognise that not all services have to be delivered directly by the NHS. Access to community-based physical and mental health services is as important as the right to an operation or emergency care following an accident. Can the Minister assure the House that this aim will be supported by the Government to improve patient outcomes and reduce the disparity of access to primary and community services in England?