Continuing the continuum of care?
At the base of all healthcare is treatment in the home, whether by self
or on the advice of a practitioner. This has been an enduring pattern — long
before the appearance of hospitals, which were often regarded as dangerous
places or places of last resort. As Jane Austen might have said, it is a
truth universally acknowledged that primary care and being cared for in the
community is part of a very long tradition.
That being the case, it is perhaps understandable that, at its inception,
the National Health Service regarded primary care as a totally separate
entity from the hospital service: executive councils looked after general
practitioners (and pharmacists and opticians), local authorities were
responsible for public health. And the division was made stronger by the
view prevalent in big hospitals that general practice was where a doctor
went if he could not make the grade in one or other branch of hospital
medicine.
The 1974 reorganisation of healthcare began, in a half-hearted way, to
recognise that primary care and hospital care were in some way
interdependent, but it took until the late 1980s for the organisational
arrangements finally to pull the various parts of the Service together. That
process had in many ways been preceded by the realisation amongst those
actually delivering care that there was indeed a continuum between their
various spheres of work. At the same time, the balance between the various
spheres was shifting — a shift stimulated in many ways by advances in
medical thought that, in turn, led to changing methods of care and a
reassessment of the role of secondary care. In some ways, therefore, as so
often, the wheel has turned full circle. Care in the home or the community
has resumed the importance that it had in previous ages.
That is the background against which to look at current developments in
primary and community care. The NHS Plan laid, amongst other things,
enormous stress on patient choice, on the continuum of care that patients
might be entitled to expect as they moved about the country, or between
various healthcare deliverers. As the Journal has consistently observed,
these are benefits achievable only with massive computing assistance.
The ground for regret is not that the aims of the Plan are faulty, but that
the Government has never had an overall approach as to how they might be
achieved. Healthcare, of course, is not alone in this respect. In his recent
memoirs, Sir Christopher Meyer, a recent Ambassador to Washington,
emphasises that the Prime Minister is long on vision and very short on how
to achieve it. The consequence, in healthcare at least, is that changes have
been implemented piecemeal and often subsequently reversed.
Take, for example, the disappearance of regional health authorities (14)
and the appearance of strategic health authorities (28) with remarkably
similar functions. Even more bizarre is the case of primary care trusts
(302) — the building block upon which the new Service, and eventually its
funding, is proposed to rest: though they have only been in existence for
some two years, a consultation has recently finished on drastically reducing
their number. This continuing organisational flux cannot possibly induce the
stability that any dramatic advance in healthcare demands, and it is
scarcely helpful in the introduction of the computing systems that those
advances demand.
Articles in this month’s issue illustrate some of the challenges ahead
and current difficulties in maintaining a continuum of care in the wake of
radical policy shifts.
In his look at the changing landscape in healthcare, Dr Richard Lewis from
The King’s Fund focuses on the very likely introduction of new proposals to
increase accessibility, patient choice and also competition between service
providers in primary care. He foresees a significantly difficult time ahead
in constructing and maintaining a wide coalition of primary and community
service providers.
Two articles in this issue offer evidence of difficulties being
encountered at the front line in keeping information flowing in the
turbulence of present changes. Brian Derry, ASSIST’s Vice Chairman, not only
points out that what healthcare information systems will have to achieve in
order to enable clinicians to meet the 18-week target from GP referral to
hospital treatment by 2008 is “hardly feasible”, but also asks why
healthcare policy makers consistently fail to assess the informatics
requirements of new policies. And, by kind permission of the British Medical
Journal, we reproduce an account by an anonymous hospital consultant of the
breakdowns experienced when the departmental secretary’s keyboard was
changed for one to allow exchanges on the Choose and Book system.
Delivery of the ICT system at the heart of England’s Choose and Book
Service, which suffered delay from policy change midway in its construction,
shows, however, that progress is being made. And, in their article, Dr
Richard Gibbs and Dr Sebastian Alexander bring us up to date on the features
of the new service for patients and its national rollout.
There can be no doubt that primary care and community care will develop
an even greater role in healthcare in the years ahead. The point that must
concern us all, however, is whether that crucial role will be properly
supported; that there will be a time of stability for PCTs (or whatever
their successors may be called) really to grow into their expanding role;
and that their will be sufficient resources — financial, administrative, and
computing — to enable them to do so. Given the Government’s propensity to
change something in the Health Service nearly every week, one can only say
‘watch this space’.
Michael Fairey Buy
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