Primary and Community Care: Improving Patient Outcomes

Baroness Brinton Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Brinton (LD)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Watkins, and to hear the voice of the nurse talking about their important role within primary and community care. I also congratulate the noble Lord, Lord Patel, on securing this vital debate: I cannot think of a better champion to talk about reform of medical services—I will not use the word “NHS” because I think “medical services” is what we are discussing here today. I thank all the organisations that have sent us briefings.

Like the noble Baroness, Lady McIntosh, I want to go back to 1947-48. My husband’s grandfather was a general surgeon at Huddersfield Royal Infirmary, as well as being a GP and a qualified pharmacist. He had to make the choice in 1948 and he chose the hospital. It was right for him. An amusing side note is that after his death, when we were clearing his house, his entire pharmacy was in the attic, in those glorious 19th century-type glass bottles. He took his joint role very seriously. One thing that has happened to general practice over the last 10 to 15 years has been the beginning of general practice specialisation, which is almost inevitable because of the specialisations of hospital doctors as well. I think that, although I have not heard much discussion of it, we should focus on that as well.

Primary care is the bedrock the NHS but, Cinderella-like, is often out of the limelight while providing that first point of essential contact for a patient, be it with their GP, the practice nurse or the healthcare assistant. But what is primary care? Always, the public will tell you that it is the GP, but we have heard in this debate today that it is so much more. It is community nurses; it is physiotherapists; it is occupational therapists; dentists; end-of-life care practitioners; health visitors; school nurses; and those who provide support to people with long-term conditions. And, of course, it is the invisible support staff who back them all up.

But primary care is broken and too many of those working in it are at breaking point too. The noble Baroness, Lady Finlay, helpfully laid out the real problems in her contribution. The noble Baroness, Lady Hodgson referred to some research. Unfortunately, research by GP Online, published in January this year, showed that GPs were completing 46 patient contacts a day, and the corresponding admin work that goes with it, which is 84% more than the 25 daily contacts recommended as a safe limit. Ministers have complained frequently, including during the recent leadership campaign, about too many part-time GPs, but that research also showed that, because of the 30% increase in paperwork over the last five years, most GPs are working 12 to 14 hours a day: that is one to three hours extra at the end of the day on admin alone, as routine, as well as being on call. One GP, responding to a publication of this survey, said, “It’s awful, it’s unbearable, there is too much to do to get it all done safely and if you try to be efficient, patients complain. I’m shattered and there is just no stopping the demand.” The noble Baroness, Lady Meacher, spoke movingly about the increasing number of GPs leaving. This is why.

I come back to the more general strategic issue, outlined so well by the noble Lord, Lord Kakkar, who gave us an overview of the crisis facing us. The service has changed; the funding has changed. Twenty years ago, when Governments of all colours started to reduce the number of hospital beds on the grounds that people did not need to stay so long in hospital, which is absolutely right—although demography needs to be taken into account, and they have gone beyond that point—what failed to happen was an understanding that recovery time and support is needed in the community, and there was no corresponding increase in support, finance and reframing of primary care services. That is one reason we have the problem that we do.

The noble Baroness, Lady Masham, raised the issue of sick notes, and perhaps reforms are needed there. I make the point that that is one of those admin jobs that has increased and grown. It may be that we have to review how sick notes are dealt with.

The noble Viscount, Lord Eccles, talked about his experience of community care and said he was given no explanation of why it happened. I have to say, from a recent discussion with a person awaiting an assessment of care adaptations that would be needed to their home as their long-term condition was worsening, that no explanation was given other than that they would have this appointment. That individual was terrified that their house was going to be changed out of all recognition for things they did not want to happen. When they actually had the assessment, their life was transformed, but the difficulty was that for the three weeks between being told that someone was going to come and make changes to their home to the point at which that happened, the communication was not good enough. But I suspect that that is because the pressure on the service as a whole means that in a five-minute appointment, you cannot explain.

The noble Baroness, Lady Pitkeathley, was absolutely right to focus on carers, whether paid or familial. Yet again, communication to patients is vital. I agree too that social care is not fixed: it may be that the money coming in is now being paid from a different source, but where is it going to go? How are we going to improve the workforce in social care and the support? Familial carers are currently having to pick up extra burdens, such as the increase in virtual wards at home that we were discussing in an Oral Question just a day or two ago. In all the discussions, there has been no mention either of the extra support for familial carers of virtual wards or of primary care support, which must inevitably grow. So I ask the Minister: will there be support for primary care with the increase in virtual wards?

The noble Lord, Lord Farmer, spoke of family hubs and the inverse care law: I think that was very powerful. I hope—as the noble Baroness, Lady Pitkeathley, said—the “not invented here” syndrome and not learning from excellent practice elsewhere will change within the NHS.

The problems in dentistry absolutely speak to the issues that GPs are beginning to face. Net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. Over 40 million NHS dental appointments have been lost since the start of the pandemic, and 91% of NHS dental practices were not able to accept new adult patients, mainly because of the problems with the contract. That is a real issue because—as with primary care, particularly rural primary care—when there are inequalities, it is much harder to access those services.

The noble Baroness, Lady Hodgson, spoke of the effective triage systems that are needed, and also how it can happen very poorly. She spoke powerfully about the need for patients to know their GPs. I absolutely agree with that, which is why I am concerned. The noble Lord, Lord Bethell, said it: we do not need a certain number of GPs; what we need if we are reframing services is the right number of GPs to be able to support the population. It is all about the needs of patients and what we are expecting GPs to do, while accepting that technology is going to play a part and that support staff and other healthcare professionals will have an increasing role. If we start the discussion about reforms by saying we can manage with fewer GPs, we are deluding ourselves.

I do not think I have heard anyone mention the role of expert patients. I am lucky to be such an expert patient. I have a long-term condition; I have done the course—tick. I have to say that that has transformed my relationship with my GP and other staff. Hospitals often do not understand it: I was told once by a consultant when I had a temperature and had gone in that I knew too much about my disease. My specialist soon put him right, I have to say. But my GP surgery completely understood.

So we do need reform. We need to start afresh. Let us accept new technology and other roles, but the key issue must be that primary care remains free at the point of access, available as needed, with signposting and education for the public. The post-pandemic period is a good time for this, because the public have accepted changes. But we must have real investment in doctor training, campaigns to encourage GPs to come forward and, above all, we must get to grips with the current crisis so that we do not lose more of our really valuable primary care staff.