Health: Primary and Community Care

Lord Rea Excerpts

Thursday 24th June 2010 Lords Chamber

[Lord Rea]

My Lords, I thank the noble Lord, Lord Mawson, very much for raising this important topic, and particularly for his inspiring description of his Bromley by Bow project. It reminds me of the Peckham health centre from pre-war days, which was a concept ahead of its time. It is now, sadly, closed. There is much we can learn from the noble Lord’s project and his words this afternoon.

The noble Lord has worded his Motion constructively, concentrating on recent changes and the lessons to be learnt; basically, what has worked; what has not worked; and what might work better. If we were to start with a blank sheet, we would need first to look at the kind of health and social problems which the population presents—of course, the two are inseparable—both nationally and locally and then try to fit services best to tackle these problems. However, we have to build on what we have. As the noble Lord has described, this is far from ideal, but I am an optimist and I think that it is getting better. It is already a lot better than in many other countries.

Of course, we have an age pyramid typical of a western developed economy, getting top heavy with older people such as myself—there are more and more of them—and they are living longer and, sadly, becoming increasingly disabled, needing more care. Other than this demographic problem, the other main public health problem, which we share with the rest of the world, is the difference in health status between the best off and the worst: health inequality, in other words. This gradient applies throughout the social spectrum from top to bottom. We need to improve the health not only of the poorest but also of the middle of the range who have worse health than those on the next rung of the ladder and so on, as Professor Michael Marmot has recently re-emphasised. To restrict services such as Sure Start to the really poor and deprived does not tackle the relative health problems that exist, for example, between skilled and non-skilled manual and non-manual workers. There is work to be done right across the board.

Ideally there should be a gradation of health and social service funding taking into account the age and social structure of each community. To be fair, there has for many years been a serious attempt to do this, but the inverse care law still persists and it needs an even greater share of resources than we have so far allocated to it to reverse it. This might be politically difficult since if this was done on a tight budget, as now, and was in some years past, relatively well-off communities might have to accept a reduced budget. These communities know how to fight their corner, so it is a difficult situation. The health problems of ageing and inequality are deep-seated and have their root causes in the nutritional, physical and social environment of early childhood, which is largely outside the scope of the community health and social services. Even so, it is these services that have to cope with the lasting legacy: the social problems of young adults, including drink, drugs and crime and the chronic ill health of older adults.

Though those with chronic degenerative illness often need periodic admission to hospital, most of their care is appropriately and better done in the community. In a minority of cases “hospital at home”, including procedures such as intravenous drips, is sometimes possible, avoiding admission or enabling early discharge rather than treatment as an as an in-patient. However, the Royal College of Nursing is concerned that the development of specialist home nursing teams such as advanced nurse practitioners, community matrons, specialist nurses, and consultant nurses concerned with managing serious illness at home is having a knock-on effect in reducing the recruitment of community nurses and health visitors, who are still vital in overall community care, particularly for the disabled elderly at home, and in providing mother and child care and preventive services. The transfer of much hospital care to primary and social care at home has long been part of government policy but is not always cheaper. Patients may be discharged too early and need re-admission—a process perhaps encouraged by the payment by results scheme, which can result in a hospital being paid twice, once for each admission.

For many years, GPs have increasingly come to accept that they need to work in teams—not all, I agree, but the trend is there—including other health and social workers to give a really effective service. There are still a few Dr Finlays out there who prefer to work on their own. They are very different from my noble and professional friend on the Cross Benches. The primary care team is now the norm and is encouraged by the National Health Service. As the noble Lord said, my noble friend Lord Darzi proposed a network of polyclinics in which there were more services and links with hospitals than in most group practices, but this proved to be a bridge too far for many GPs and their professional organisations. However, the concept has become more acceptable, provided that the centres are GP-led and tailored to local needs and development. Many GPs are concerned, however, that the polyclinic concept will lead to primary care groups being taken over by private profit-making healthcare companies. This has occurred already in some PCT areas. The one that I know is in Camden PCT, where the contract for practice was awarded to United Health in preference to a local GP group which was offering a better and fuller service, but at a slightly higher price. The results have not, as far as I am aware, been fully evaluated, but the local feedback is unfavourable.

The new contract for general practitioners brought about major changes, as well as a rather generous package for most GPs. The BMA had a sharp negotiating team and the Government needed the GPs to be on board. The biggest change was to remove the obligation to provide 24/7 out-of-hours clinical cover for registered patients. PCTs had to take on this responsibility. They have not found it easy and have often farmed the work out to private companies. Patients are not always happy to be seen by a strange, often foreign, doctor who does not know the area; and of course there has been the occasional tragedy, as we all know. This is a far cry from the days when I was a general practitioner, when we were responsible for after-hours care. Our group made it tolerable by collaborating in a consortium or rota, with other local GPs. In fact, the BMA negotiating team was prepared to continue with the responsibility, if the money had been right. In the end, however, the cost to the PCTs of providing the service was much higher than estimated; in fact, according to my information, it was greater than the amount that the BMA had originally asked for.

The other important part of the new contract was the QOF—the rather grandly named “quality and outcomes framework”—whereby GPs receive a payment for each procedure in a list of measures which assist in monitoring, and thus improving, the health of their patients. They include weighing, taking blood pressure, keeping disease registers and so on. I and some of our colleagues were sad that GPs had to be paid for measures which many of us regarded as part and parcel of good practice, and should have been part of any contract. However, it is clear that this carrot has increased the capacity of general practice to anticipate serious illness. The standard of practice has improved and some lives may well have been saved through, for instance, control of blood pressure and weight reduction. However, I am sceptical about the accuracy of some of the numerical extrapolations that have been made about lives saved. It would be good to know whether, without the financial incentive, this exercise will result in permanently better practice by GPs.

An alternative or addition to the polyclinic model has been suggested by the Royal College of General Practitioners. It proposes primary care federations, which are associations of primary and community care teams, as a legally binding enterprise. I am sure that that concept is not unfamiliar to the noble Lord, Lord Mawson. The college cites three examples: the Croydon Federation, consisting of 16 practices; Lincolnshire General Practices, which has14 practices; and Epsom Downs Integrated Care Services, where 20 practices are collaborating. These hold considerable promise, but I should like to see more involvement of social services and mental health teams, as well as appropriate parts of the voluntary sector. This is very much in line with the proposals of the noble Lord, Lord Mawson. As it is, these projects provide better-integrated primary and community care as well as more emphasis and better facilities for preventive medicine and health education. They could also help to form, through their PCT, a nucleus for practice-based commissioning, which so far has had little impact on services provided by hospital trusts.

Local collaborations such as this, which very much fit the ideas of the noble Lord, Lord Mawson, including voices from all the caring professions, are more likely than top-down decisions to provide or commission good services for their communities.