Primary and Community Care: Improving Patient Outcomes

Lord Bethell Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Bethell (Con)]

My Lords, I thank the noble Lord, Lord Patel, for bringing about this important debate. As ever, he has a canny nose for the timing of these things and he is absolutely spot on. I know from my time in office that the pressures on primary and community care are intense and I agree that we need an urgent rethink. That is why I will put my name to any forthcoming proposal from the noble Lord to the Liaison Committee for a Select Committee on primary and community care.

The NHS has experienced long waits in hospital care before, which are extremely distressing, but it has never faced such a grave challenge in general practice—and as we know, general practice is the bedrock of the NHS. This is the right moment for noble Lords to distil complex recommendations for primary and community care into succinct, wise counsel for the Government to consider. I will share a few thoughts on how that might work. First, primary and community care is the first point of contact with the care system for the public. When we consider the remit of this Select Committee, we must remember that for many people this is not a GP. It is likely a website, an app, a school nurse, a community hospital or a pharmacist.

Secondly, there is definitely a workforce crisis—briefings from the Royal College of GPs, the Royal College of Nurses, the King’s Fund and others make that very clear, and I am grateful for their persuasive statistics—but the crisis in primary and community care is not just a workforce crisis that can be answered through solving recruitment, retention, workload and the GP contract, although those are extremely important challenges. Anyone who listened to the Minister’s answer yesterday to the OPQ about GP training will be clear that there is no massive new wave of GPs set to save the day. As the noble Lord rightly pointed out, only one in four GPs are currently working full-time, and training numbers are going sideways, so we should assume that there will be fewer GPs rather than relying on imaginary regiments of doctors riding to the rescue. Rather than deluding ourselves, we should make our plans accordingly.

Thirdly, we should not over-romanticise relational-based care when the role of the GP is evolving as quickly as that of the bank manager or the priest, and when many patients never ever visit the practice. We got through much of the pandemic with most practices shut, after all. People have extraordinarily diverse needs, from the long-term sick who certainly need regular clinical, face-to-face care to those at the other end of the scale, the occasionally sick or injured who might need a more transactional relationship. We must avoid lazy generalities, and we need a modern service that is flexible enough to meet different needs. That is why I would like any Select Committee studying primary and social care to look at four issues in particular.

The first is the importance of prevention. Too much traditional thinking around primary and community care assumes that patients turn up with symptoms and are guided by the GP on to some care pathway. These days, though, by the time patients have symptoms, it is often too late for the best treatment. This system-wide focus on late-stage acute medicine is costing the country a fortune in hard expenses and opportunity costs: expensive procedures, long recovery times, falling longevity, falling workforce productivity, and hefty social care and welfare bills. It is a huge price to pay. Primary and social care should play a much more proactive role in achieving “domain one” of the NHS outcomes frame- work, which is preventing people dying prematurely.

Secondly, technologies to “transform” healthcare are at our fingertips. I saw the power of digital transformation in primary care from my experience during the pandemic, with virtual wards, testing, the vaccine rollout, surveillance through the REACT survey, the prompt delivery of antivirals, and so on. We should study how primary and community care put digital first and become the foundational layer for scaling digital healthcare through the NHS. This approach is outlined in the persuasive policy paper from Policy Exchange that the noble Lord, Lord Patel, mentioned, At Your Service, by Dr Sean Phillips, Robert Ede, and Dr David Landau. They rightly argue that there is much to do to enhance the existing infrastructure and clarify the legal regulation of data. That is why I am interested in their recommendation for a digital health and care Bill, and in a “smart” first contact navigation programme—an “NHS Gateway”—that can deliver a more personalised “front door” to the NHS. We also need to address the use and sharing of data in primary care for management, clinical and research uses, with suitable resources allocated for this absolutely invaluable work.

Thirdly, I support the recommendation by Dr Rebecca Rosen at the Nuffield Trust for embedding more non-medical clinicians—such as pharmacists and dieticians—into primary care, an approach that worked well for us in the pandemic. There are lots of great examples already in primary care of working differently, from community health worker models in Westminster to the Healthier Fleetwood approach. The question that arises from these experiments is: how do we make innovation in primary care the norm rather than the exception?

Lastly, I will say a word about diagnostics. The pandemic demonstrated the value of consumer diagnostics, attached to digital reporting and used at home or on the high street. These tools engage people with their own healthcare, improve personal responsibility and relieve the pressure on overburdened healthcare systems. It makes no financial or clinical sense that people book a hospital or GP appointment for often extremely simple procedures such as swabs, serology, and faecal and blood pressure tests. During the pandemic, the Lighthouse Lab processed 150 million PCR non-NHS test samples, lateral flow tests were shipped at up to 4 million a day at their peak, and over 2 million blood samples were taken at home by finger prick and posted to labs to maintain the ONS infection study. I give a loud cheer to our new diagnostic hubs, but I fear that on diagnostics we are going back to the old-fashioned, cottage-industry-based pathology mindset rather than embracing the opportunity presented by the consumer diagnostic revolution.

Let us not fight the last war or try to recreate Dr Finlay. This Select Committee must examine the opportunities presented by this crisis for moving away from cumbersome paternalistic models towards a data and diagnostic-empowered citizen patient. That is what a Beveridge 2.0 could look like. That is the way to grow the economy and protect our people.