Primary and Community Care: Improving Patient Outcomes

Baroness McIntosh of Pickering Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

I add my congratulations to the noble Lord, Lord Patel, for calling such a timely debate. It is rather curious to hold a debate without any general practitioners being present to contribute. I understand that in your Lordships’ House there are no general practitioners. I declare my interest as advising the board of the Dispensing Doctors’ Association, which represents over 4,000 general practitioners in over 1,000 dispensing practices, accounting for 15% of all practitioners.

What lies at the heart of this debate and what I would like to focus on is how health services are delivered in rural areas. There are twin challenges which lie at the heart of this debate; there is a rural and urban aspect to health policies, which is often overlooked. We often have a metropolitan elite running the Civil Service at the highest possible level. There is also the challenge of the conflict between primary and secondary healthcare. It is a flawed approach to seek reform to primary care without looking at the bigger picture. I entirely endorse what the noble Lord, Lord Kakkar, said about needing a cohesive and holistic approach to any possible reform.

I put on record that there were 365 million GP consultations in 2021, which equate to about 6.5 consultations per patient. Excluding Covid vaccinations, that equates to over 311.5 million consultations—the same number delivered in 2019. There were 179 million face-to-face appointments in 2020-21, according to NHS Digital. It is also important to state that GP pay peaked in 2005-6 and has fallen every year to 2013-14. It is still not back to the pay between 2004-8, without taking inflation into account. The source for that, again, is NHS Digital.

My concern is the lack of joined-up government in delivering healthcare across the piece. Neither the Department of Health and Social Care nor NHS England rural-proof policy. That flouts the detailed proposals set out by the noble Lord, Lord Cameron of Dillington, in 2015, when our current Prime Minister was the Defra Secretary. Whenever rural-proofing is raised with officials, we are told it is a Defra issue. I hope that it is something my noble friend the Health Minister will take a personal interest in. Perhaps this could be addressed by a House of Lords committee, such as the one sought by the noble Lord, Lord Patel.

The expression “delivering at scale” fills me with alarm and anxiety. Policy which delivers at scale must recognise the challenges of delivering health policy in all its settings, particularly rural ones. For example, do officials understand the lead times to run a vaccination campaign and how this affects a GP workload? GP practices need to order vaccines in November and by January by the latest to run an autumn schedule. There has been much vacillation and incoherent messaging to contractors about the flu and Covid booster campaigns this year. I think that has added to uncertainty in GP practices and to their lack of preparation time.

The preference for large vaccination centres run directly by the NHS does not work in rural areas. Indeed, the National Audit Office reported:

“In terms of delivery costs, dedicated vaccination centres have been the most expensive method at £34 per dose compared with £24 for GPs and community pharmacies. GPs and community pharmacies were the most popular delivery model for all priority groups”.


There has clearly been wastage of valuable medicines in the big centres, which I see as an example of delivering at scale. I argue that it simply does not work in rural settings, where it is extremely difficult for patients living in a rural area to access such a big out- of-town urban centre.

Dispensing in rural areas is often the best choice for those with chronic conditions, and often rural practices dispense because there is no viable pharmacy. This dates back to Lloyd George and national insurance when it was first set up. Dispensing practices receive a disproportionate number of outstanding inspections from CQC, for some bizarre reason. They are often the last public service left in many communities and are highly valued by their patients.

I applaud the work done by successive Ministers for Health, not least my noble friend Lord Bethell, succeeded by my noble friend Lord Kamall, but the digitalisation of the health service in a health rural setting has not been a huge success. There are huge problems of rural connectivity. Poor broadband and mobile signals hamper delivery of the service and make remote consultations almost impossible. There is no electronic prescription service available for dispensing patients. Recruitment of GPs is difficult but, where they train in rural practices, they tend to stay and become partners.

I argue that the system of drug reimbursement needs to be overhauled to remove perverse incentives so that what is good for patients is also good for the NHS and contractors. I add that the closure of community hospitals in rural areas has put increasing pressure on acute hospitals and, indeed, community nurses. That has exacerbated the situation, as others have set out in this debate.

We need to assess the impact of Covid and the delays in diagnosis and treatment. We need to consider the impact on the morale of front-line medical and nursing staff. I applaud the fact that the Government are looking at the pension cap, which has been addressed by others today. We need to look at models such as that agreed by senior judges, which I think would be acceptable to all parties; that seems a good model to use.

In the briefing preparing for today, I noticed that one concern is that the need for regulatory reform has been extended at the moment only to regulating physicians and anaesthetists. When will that be extended and in what timeframe to, for example, general practitioners and all doctors generally? That goes to the heart of having a positive, cohesive approach.

I have a question for the Minister. Bearing in mind that some 15% of the population live in an area served by dispensing doctors—in rural, isolated, sparsely populated areas—how do the Government intend to deliver healthcare in those settings on the same basis as in urban settings?

I conclude with parity of esteem. My father was appointed as one of the first ever general practitioners in 1948. His brother eventually became a general consultant. He referred to my father rather affectionately as a panel doctor. Until then we end this contest and conflict between hospital consultants and senior GPs, I do not believe we will achieve the parity of esteem that best serves patients and the health service.