Primary care

Future NHS funding: kneejerk populism ≠ enduring strategy

This is an expanded version of a comment written in reply to an article in the Guardian of 19 June 2018 (http://tinyurl.com/yd5wcnp5).

Polly Toynbee is precisely right; not enough extra money, with dubious provenance, applied in a populist manner without any careful planning, will result in little change.

In system terms, the whole supply chain needs to be reviewed, and the incentives carefully applied to ensure any impact at all. There are four main stages in this supply chain, and they all need to be considered:

1. Demand is rising because of our increasing healthcare needs as we age and have to manage increasing numbers of co-morbidities (think of someone with diabetes, high blood pressure and chronic leukaemia who is (perhaps not surprisingly) also depressed, for instance), but there are also rising ‘wants’ as our expectations keep rising, often because of irresponsible political promises of ‘more and better’ services. These haven’t ever been addressed, with the result that health services are seen as a ‘free good’ used as we might use our cold water tap. As one might expect from politicians who depend on re-election to continue in office, there have rarely been any serious attempts to manage (for which read ‘contain’) demand, and the new rhetoric is no different, continuing to use the same language as before.

Screen Shot 2018-06-19 at 08.56.342. Primary care, in the shape of general practice, is the Unique Selling Point (USP) of the NHS, managing the vast proportion of most people’s diseases (and dis-ease), but perhaps more importantly, choreographing patients’ journeys through the intricacies of institutional care to ensure that their care is appropriate in human as well as clinical terms, and preventing duplication of investigation and intervention. GPs, who are seeing little recognition of, or encouragement to treat people (and not just physical symptoms), are currently leaving practice in their droves, and recruitment is becoming ever more difficult, as their sense of overwork and under-appreciation grows. Yet general practice is barely mentioned in the rhetoric about ‘increased performance’ and ‘reduced waiting lists’.

3. Acute hospitals continue to do what acute hospitals do, which is to treat diseases, not people. Their perspective on real life, and their ability NOT to intervene are both conspicuous by their absence; surgeons measure themselves by their operations, physicians’ fingers itch to treat, and the current markers of success generally drive activity ever-upwards, rather than measuring patient outcomes and (rarely sought on an individual basis) genuine user satisfaction. Giving new money to the acute sector will merely produce more of the same, yet that is precisely what seems to be intended…. and don’t get me started on the way that mental illness is considered as an entirely separate part of the NHS…

4. As patients become medically fit for discharge from hospital, many will continue to need some sort of social support, whether in the form of occasional visits from carers, or intensive support of their long term conditions (see co-morbidities, above), and not everyone can afford to pay for it themselves. Yet funding for social care has dramatically dropped over recent years, and the drive to balance the public expenditure books as quickly as possible means that these services are rapidly disappearing, without any apparent, viable alternatives appearing. The new initiative overtly turns a blind eye to this, expecting the health system to improve without any reference to this end of the supply chain.

Only if all these factors are taken into account can we have any chance of improving the health service, but we are not seeing any evidence whatsoever of a strategic approach to public spending in general, and health services in particular. Sure, more money is required, but more thought too, and an analysis driven by logic, empathy and long term thinking, rather than tomorrow’s headline in the Daily Mail.

Primary care: gatekeeping or weaving?

warp_and_weftThis is a slightly revised version of an article submitted to the BMJ on 5 October 2016.

There is an interesting article in the BMJ this week[1] by Greenfield et al on ‘Rethinking primary care’s gatekeeping role’ that covers only one element of primary care, and in excluding other, more important, aspects of the role risks these others being left out of the debate entirely.

Greenfield’s premise is based on a model of health care that is currently fashionable, but which is simplistic and linear in its philosophy: ‘I’ve been diagnosed with prostate cancer, it needs treating, I need to see the right specialist as quickly as possible’. Such a symptomatic approach to medicine is clearly important, but assumes an entirely straightforward, physical spectrum of disease.

The reality of modern health care is that it is being overwhelmed by complex illness that combines multiple physical diagnoses, often chronic in nature, with social and psychological overlays. Treating my prostate without considering my diabetes, my hypertension, the impact of my illness on my job, income, and mental wellbeing is reductive and sub-optimal, not only in clinical terms, but also in terms of cost-effectiveness.

Whilst the role of general practice clearly includes gatekeeping, that function needs to be put into the context of care co-ordination and the management of complexity. In the multilayered fabric of the NHS, the warp of clearly defined clinical pathways being organised in efficient straight lines needs to be held together by the weft of primary care, weaving the intricate patterns that make up genuinely effective care. Just as the conductor of an orchestra balances the dynamics of the different sections of the orchestra to produce an harmonious melody rather than a cacophonous row, so effective primary care juggles the different (and often conflicting) drivers that influence us all, to produce coherent and effective care.

When this is done well, the whole system benefits, and researchers such as Barbara Starfield[2] have pointed out that the cost-effectiveness of health services is proportional to their degree of primary care orientation, not because of gatekeeping per se, but because of effective and appropriate holistic case management.

The risk is that an article like Greenfield’s (which doesn’t mention anything outside the linear referral model) is that it reinforces our increasingly symptomatic approach to medicine, where we treat diseases rather than people, with the inevitable result that demands and costs rise, duplication and inefficiency ensue, and everyone suffers from care that is completely at odds with the human condition.

What is required is a model that is more co-ordinated professionally and organizationally, that aligns incentives appropriately, and that carries public opinion with it. As long as the public continues to expect the linear simplicity described by Greenfield and colleagues, that is what will be provided; only when there is a better understanding of the subtlety and complexity of health care will we have any chance of rebalancing the system. Articles such as this risk moving the debate in precisely the wrong direction.

[1] BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4803 (Published 23 September 2016)

[2] Starfield B: The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998 Health Services Research Volume 38, Issue 3, pages 831–865, June 2003 DOI: 10.1111/1475-6773.00149

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