The Long-term Sustainability of the NHS and Adult Social Care

Viscount Bridgeman Excerpts

Thursday 26th April 2018 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I add my thanks to the noble Lord, Lord Patel, for the leadership he has given to produce this excellent committee report. It is a tribute to him and to the quality of the report that only a week ago, the date of this debate had to be changed, but he has still produced more than 50 contributors.

I shall confine my remarks to primary care and the role of general practice in England and, in particular, the primary medical services practices. I go back to 1998. In the revision of contracts at the time for GPs, they were offered two routes: the general medical service, which basically allowed them to continue as before, and the personal medical service. PMS doctors were paid a premium per patient for undertaking additional duties. This was a farsighted development instituted by the Conservative Government and put into action by the Labour Government, and it attracted a number of very forward-looking GPs. The arrangements worked well for 10 years. Patients benefited, and a significant contribution was made by many PMSs to reducing the workload of hospital A&E departments, of which I will speak further.

In 2014, NHS England reviewed the operation of PMSs, and concluded that the premium could not demonstrate value for money. As a result, it was to be withdrawn by the CCGs over four years and redistributed to all practices in the relevant health districts. Among the conditions handed down by NHS England were three significant ones to these other practices: to help reduce health inequalities; equality of opportunity to all GP practices; and support for fairer distribution of funding at a local level. Those are laudable intentions indeed, and I am sure that they will have the effect of bringing the standard of practices up, but I fear that that will be at the expense of the go-ahead PMS practices, which stand to lose a lot of money in resources.

Among the PMS practices, there is predicted an average fall in income in year four of 35%. How will those practices address this shortfall? Inevitably, it will involve a reduction of support staff, practice nurses, nurse practitioners, healthcare assistants and administrative staff. Perhaps some doctors will be unable to bring themselves to curtail some services, walk-in surgeries being an example. The shortfall will have to be made good out of partners’ profits.

One of the main points I want to make, and have made, is the effect that this is likely to have on A&E and emergency admissions. In one practice, in central London, with which I am familiar, the emergency admissions are down by 60% from the national average. A&E attendances are reduced by 35%, and ambulatory care conditions, which I think is outpatients, by 73%. The key figure, by which a GP practice is measured, is the 65% reduction of antibiotic prescribed per 1,000 patients against the average practice.

I am lucky enough to be a patient of a central London PMS practice that has walk-in surgeries for two hours five days a week in the mornings, and for four days a week in the afternoon. I am assured by the senior partner in the practice that this was made possible by PMS premium funding and would not be possible without it. Let me mention briefly the financial aspects of practices against hospital admissions. A few years back, a PMS surgery was paid an annual fee per patient for an unlimited number of attendances at the surgery. As it happens, this was broadly equivalent to the cost to the NHS of just one basic admission to A&E before adding the cost of extra services, such as radiology. That is a clear reminder of the savings to the health service that the more go-ahead PMS practices have up to now been able to offer. I suggest that this move by NHS England, admittedly four years ago, was certainly unintended and unforeseen, but it has been adverse for patients, for the viability of the practices and an additional workload for the hospitals’ A&E departments.

The British primary healthcare system has been described as the jewel in the crown of the NHS—I believe by Simon Stevens who is the head of NHS England. Both France and Germany, to take two examples, have fine healthcare structures, but I understand that primary care through general practice arrangements that we have in the United Kingdom are indeed the envy of both. The jewel in the crown the primary care sector may be, but it does not have the clout of the larger acute care trusts.

This debate coincides three days ago with my right honourable friend the Secretary of State’s letter to fellow Peers in which he outlined plans for health and now, newly under his jurisdiction, social care. This was to mark the 70th birthday of the NHS. Outlined in the letter are some quite radical plans for the reorganisation of the National Health Service, and I hope that he will bear in mind the fact that the PMS has been a huge success, contrary to the view of NHS England, and deserves further funding.