Primary careThe changing face of primary care in EnglandDr Richard Lewis from The King's Fund discusses the Government's current focus in its reform of healthcare delivery. ABSTRACT Primary care in England is now at the centre of the Government's healthcare-reform agenda. The impending white paper is likely to introduce proposals to increase accessibility, patient choice and competition between service providers. As a consequence, we can expect to see much greater diversity in the number and type of primary care providers. In particular, the broadening of primary care teams to include a range of specialists is likely as primary care increasingly takes on work that has previously been carried out in hospitals. However, these changes will present primary care with the important challenge of maintaining continuity of care, as services are potentially fragmented. Br J Healthcare Comput Info Manage 2006; 23(1): 15–17.
An impending white paper promises radical change in the provision of primary care and the Government has already made a commitment to secure the participation of all general medical practices in practice-based commissioning (a scheme whereby practices face incentives to manage the financial consequences of their referrals to other clinical services). While the detail of the forthcoming white paper is not known at the time of writing, it is likely that primary care will face challenges similar to those directed at NHS hospitals; in particular, the Government has already made clear that primary care services must become more accessible to patients, should offer more choice and experience competitive pressures from alternative providers and should work more closely with other parts of the healthcare and socialcare system.(1) Widening patients access to primary healthcare General practice is among the most popular parts of the NHS, achieving consistently high satisfaction ratings among patients.(2) Relatively poor access to services (for example long waits for routine appointments) have, however, proved the Achilles heel of an otherwise successful sector. The Governments initial response to set targets for maximum waits with associated financial rewards has achieved some progress. But setting maximum waits for consultations has also had unintended consequences: some practices have chosen to meet the target by simply refusing longer-term appointments. This rigidity has proved unpopular with patients, as evidenced by the intense debate during the last general election campaign. A complementary strategy has been to broaden access to primary care through the provision of alternatives such as NHS Direct and walk-in centres. These look set to continue. Already, more than 15m people in 2004/5 accessed healthcare advice online or via the telephone through NHS Direct and more than 2m patients annually visit a walk-in centre.(3) The Government's commitment to open-access care is strengthening, and new contracts have recently been let with private healthcare providers to run NHS clinics for commuters close to major stations. Choice for patientsProviding alternatives to mainstream primary care, however, is unlikely ever to offer a sustainable solution to the deeper problems of access. Instead, the Government is urgently seeking ways in which to generate greater responsiveness to patients among existing service providers. Here a number of strategies have been mooted, perhaps the most eye-catching has been the suggestion that patients be allowed to register simultaneously with more than one practice. This would breach the long-held principle that a single primary care team should be responsible for the coordination of all care for an individual patient. If such an idea is pursued, it is hoped that patients will enjoy more flexibility over when and where they are able to receive care. The underpinning strategy for easing the difficulties of access may well be that of an increased use of market forces to ensure that practices are more mindful of the demands of their patients. This has dominated Government thinking on its reform of hospital care and looks set (barring political difficulties) to provide a major focus in primary care reform. Certainly, this is the view of the Prime Ministers healthcare advisor.(4) Of course, in theory, a patient has always enjoyed the right to select his/her GP. In some parts of the country, though, this right is difficult to put into effect, as practice lists are closed to new patients.(5) Competition between service providersAs it seems likely that the Government will introduce opportunities for greater competition, the more difficult question is how far they will go in this regard. At the very least, one might expect opportunities for new entrants to the market from the corporate sector when primary care trusts exercise their powers to contract with non-traditional providers (through what is known as alternative-provider medical services contracts). Such competition might extend to an open market where any willing provider is able to register patients, particularly in areas where access is currently a problem. Such a market-oriented approach to primary care relies on patient choice to drive the responsiveness of providers. There are reasons to doubt, though, whether patients, who are traditionally very loyal to GPs and their teams, will move in sufficient numbers to generate an adequate force for change. An alternative approach might be to give powers to primary care trusts to regularly market-test their current providers. As things currently stand, general medical services contractors essentially have a preferential right to provide services so long as they are not professionally incompetent. This would not be accepted in other industries and is unlikely to endure in primary healthcare for much longer. Contestability is also to be extended to community healthcare services. The Government has signalled that PCTs may become exclusively commissioning organisations (although the Government has backed down on the timescale for such a change and has apparently made this transformation voluntary).(6,7) This suggests that a range of new forms of community healthcare provider is likely to emerge within the NHS. Voluntary and private-sector providers will be encouraged and may find a market in providing services to specific population groups or to those with certain medical conditions, in particular chronic diseases such as diabetes and chronic obstructive pulmonary disease. While the organisational characteristics of primary care providers are likely to change, will the job that they do undergo a similar revolution? It is likely that the role of the primary care team as care co-ordinator will continue. Indeed, Government initiatives such as Choose and Book rely on primary care teams to enhance their navigator role. Although the core role of primary care will remain, new roles will be added and the range of skills within the multidisciplinary team will expand even further than it has already.(8) In particular, primary care will be expected to provide significant specialist services that have hitherto been provided by hospitals. The Government has estimated that, in the future, up to 15m outpatient appointments across a wide range of specialties will be provided in community settings. This will of course require a significant investment in new facilities.(1) In part, this expansion in role will be driven by the financial incentives within practice-based commissioning. As general practice teams increasingly take responsibility for the financial resources allocated to healthcare, they will face a decision as to whether to refer a patient to an external provider such as a hospital or whether to treat that patient within the practice team. Some practices will decide to extend their activities, expanding their teams correspondingly. The primary care team of the future may well feature community care specialists as well as medical generalists. These commissioning-provider organisations could become sizeable (indeed, experience in the United States suggests that they could become very large corporations). One way in which such a scale could be achieved would be through the voluntary merger of existing independent practices. Early experience of practice-based commissioning suggests that already a number of commissioning clusters are beginning to take shape, which could act as precursors to a more formal union in due course. A growth in practice-based commissioning also implies a growth in the intelligent use of information about patient needs and desires. In particular, practice commissioners will need to monitor carefully activity at the level of the individual patient if they are to resist any slide towards supplier-induced demand (under the new NHS payment system providers will face strong incentives to increase activity levels). There will also be incentives for primary care commissioners to avoid hospital admissions where possible through proactive care management and the provision of a wider range of community based services. The future of primary care depends ultimately upon how the Government seeks to balance competing priorities.(9) If it decides that greater responsiveness is its most important objective (compared, for example, with addressing healthcare inequalities) then more competition, organisational fluidity and patient choice are likely to dominate the landscape. This means that patients may come to be served by a far wider array of providers and to enjoy more rights to selecting a package that is right for them. It also suggests that primary care providers will face a significant challenge in constructing and maintaining a wide coalition of primary and community service providers. Whether the objectives of access, choice, continuity and equity can be welded together in the future is the key question that remains to be answered. Dr Richard Lewis, Senior Fellow, King's Fund. References
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This year will see primary
care come to the very
forefront of the NHS-reform
agenda in England. After years
apparently languishing in the
relative backwaters of healthcare
policy, primary care has now
captured the imagination of
government. Indeed, a reformed
primary care sector is now seen
as a crucial component of wider
reform of the NHS.