Primary and Community Care: Improving Patient Outcomes

Lord Kakkar Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I join other noble Lords in thanking my noble friend Lord Patel for the very thoughtful way in which he introduced this important debate. In so doing, I remind noble Lords of my own interests. In particular, I am chairman of the King’s Fund and King’s Health Partners.

In opening this debate, my noble friend described—and many other noble Lords added to his description—the substantial challenges that the NHS faces in general and in particular in primary and community care. So far in the debate, there has been a consensus and recognition that failure to address those challenges will ultimately lead to the NHS, in general, becoming totally unsustainable. We see the manifestations of this every day in the crisis to ensure that patients in an acute situation can be delivered to hospital through the ambulance service; in the substantial waits and, quite frankly, clinically unsafe environment that now represents many accident and emergency departments; in the tremendous pressures demonstrated in the acute management of patients in medical, surgical and other disciplines in our hospitals; and, most importantly, in the failure to discharge patients from hospital back into the community. The result of all that is an NHS that is considered, regrettably, now to be failing in many aspects. That failure is attended by an increasing loss of confidence among our fellow citizens.

I strongly support my noble friend Lord Patel’s proposal to establish an ad hoc Select Committee of your Lordships’ House to examine in more detail the challenges and opportunities for reform in primary and community care. In proceeding along that line and in having identified the many challenges faced, the issue is to understand how we might address them. To do that, first, we must deal with a major problem, which is the discordant perception and expectation among some important groups, with regard to what should be delivered by primary and community care services in the NHS. The expectations are those of politicians, of the public, and of health and care professionals. Those expectations are starting to differ widely when we look at the reality of what can be provided through a model of primary and community care established at the birth of the NHS.

That model, having at its heart family doctors well versed with the needs of their patients in broadly small communities in small practice settings, was fine some 70 years ago, but the demographic changes in our country, and the nature of chronic diseases that now attend so many citizens, which have a profound impact on their quality of life and their need to avail themselves of health services, are quite different from 70 years ago.

In addition to that, advances in medical and clinical practice provide important opportunities to impact on many of these conditions, but those advances require changes in the way we deliver care, pathways of care and an important emerging recognition that the hospital cannot be the place where the majority of patients with chronic conditions are managed. They must be managed in the community. Indeed, many must be managed in their home. That requires a different approach to understanding how professionals in primary care and community care settings need to be trained and the skill sets required. It also requires a confidence in understanding that what clinicians might have done previously should be done by other professionals.

Therefore, a professional workforce must be developed, with a recognition that skill sets will have to be developed differentially and that those who might previously not have been involved in delivering direct care—more specialist nurses, community nurses and practitioners—will now need to be encouraged and developed to do so. It also requires the adoption of innovation and technology to ensure that this care can be delivered safely in the community. Patients and their relatives need to be confident that they can understand and have confidence in the digital and technological solutions provided in their own homes and in community hubs and community settings.

Regrettably, none of this seems to be being addressed cohesively, so we rightly welcomed the opportunity provided in the most recent Health and Care Bill for the development of more broadly integrated community care settings and integrated care partnerships and boards to supervise the delivery of that care and bring different elements of the healthcare system together. But we need to go far beyond that. The Minister will be aware that in the debates on that Bill, which he so ably took through your Lordships’ House, there were suggestions, which we have heard from other noble Lords, regarding ensuring that workforce planning, a better understanding of the methodology used in planning, and the parameters considered in terms of demographic change, emerging technologies, advances in our understanding of pathophysiology and the capacity to deliver care should be included in very sophisticated workforce planning that will help us understand not only the number of healthcare professionals required but their potential disposition by way of discipline and specialty, and the capacity, with emerging understanding, knowledge and technology, to train different groups of healthcare professionals so that, as we have heard, they can work more cohesively together as a team, delivering so much more of the care in the community and at home so that patients never need to come to the hospital.

Indeed, other European countries have been able to achieve these ambitions. They have much lower levels of bed occupancy in their acute hospitals. Therefore, they see no particular anxiety about times such as winter, when acute admissions will inevitably increase. We have failed to achieve that. This failure is now taking us to a place where the system will, as I said, become entirely unsustainable.

In closing, I urge Her Majesty’s Government to have the courage to start addressing the problems we face and to start establishing a narrative and communication to bring together professionals, politicians, the public and patients to help understand and develop a consensus around the very important, serious and far-reaching decisions that now need to be taken to ensure that we strengthen primary and community care with new models; to ensure that those models are properly co-ordinated with the changes that need to occur in secondary and tertiary care; and, attending all that, to ensure that we have appropriate workforce planning across those different environments and care settings, attended by a proper review of the regulatory framework in which those professionals will deliver care and a better understanding of how we will ensure proper adoption of innovation through funding innovation streams beyond the recurrent funding for day-to-day delivery of care.