It is 15 years since I published the following piece in the GP newspaper Pulse. This afternoon it caught my eye as I restructured my website, and it seems to me it is as relevant in 2017 as it was in 2002. Perhaps more so - because the inevitably necessary change in political thinking concerning the NHS has yet to take place.
So here it is again: It is controversial and will at first strike many readers as daft. But give it a chance. Unless we shift our emphasis concerning health care policy in this country, we never will have a service which serves everyone equally according to their relative clinical need. And I believe that is what the vast majority of us want.
"Pause and daydream for a moment. Imagine it is your task to set up a health care system from scratch, in a country where none exists already. One that is available to everyone, treats everyone the same, covers all conditions, and yet has to be provided from a fixed, central budget. Importantly, you are charged with making the best use of the money available to you to improve the health of the population.
Would you start by
a) setting up a network of community, primary care centres to which everyone has access, or
b) using the available money on an inevitably much smaller number of intensive care units, holding perhaps 6-8 people each?
I will assume your answer.
Now consider the NHS, established with the same principles but where the central priority for investment has for years, perhaps always, very definitely been upon hospital care.
A few months ago [2002/3] the Audit Commission noted that general practice accounts for eight out of ten patient contacts within the NHS, but only 1/5 of NHS spending. It went on to report that “growth in spending on general practice has risen by 20% in real terms over the last ten years, compared with over 60% on hospitals over the same period.”
Yet GPs are the key playmakers of the NHS; they are its rugby fly halves or its American football quarterbacks. GPs’ decisions directly or indirectly determine the use of a very considerable percentage of all NHS clinical resources. More than any other clinical group, GPs determine the workload of hospitals. Their pivotal role should be valued and nurtured. Common sense as well as research evidence suggests that investing in high quality general practice will produce benefits not only there, but also in secondary care.
The opposite is not true. In a remarkable paper in the British Journal of General Practice in April 2001 Professor Barbara Starfield cites international research evidence that supports these claims. Countries with strong primary care systems have lower health care costs than those with weaker primary care structures. Greater primary care availability produces a greater effect in disadvantaged areas, so it reduces inequity. And she reports evidence to show that hospitalisation rates for certain conditions are improved by a higher ratio of primary care physicians to the population, but not by a higher ratio of specialists.
Finally, and intriguingly, patients in the USA with a primary care physician, rather than a specialist as their personal physician, not only have lower costs of care overall but also live longer. On a recent visit to the Kaiser Permanente Health Maintenance Organisation in Southern California [in 2001] I saw the benefits of investing properly in primary health care.
If the UK government wants to make a real change in the public's perception of the NHS, and if it wants to improve health care quickly and cost effectively, it should invest in general practice. And do it now. We need an acceptance that GPs and practice nurses should only do tasks requiring their particular skills, with all other work delegated to an expanded workforce of administrative personnel. Nurses should be recruited and trained as fast as possible ~ the ratio of nurses to physicians in Kaiser Permanente is three times that of British general practice.
We need better information systems, integrated throughout the PCT [now CCG} and local hospitals, and we need protected time set aside each week for personal as well as PCT - based continuing education.
Of course such things cost money, but investment in general practice will bring greater dividends throughout the whole NHS than continuing to prioritise the insatiable, costly appetite of hospital services.
That’s not a daydream. It’s evidence - backed common sense."
Let me be clear. I was not, and am not, advocating depriving hospitals of the resources they need to function. They do a fantatic job and obviously require the funds necessary to continue doing their work.
What I am saying is that - at the same time - primary and community services require more. Only then can they provide better services for patients and at the same time take some pressure off hospitals. Everyone wins.