The future of primary and community care in England
Authors: C. Ham
Journal: BMJ (2008)

Starting with the bold statement that “primary and community care services are regarded with pride at home and admiration abroad,”1 Lord Darzi’s plans for the future extend the process of permanent NHS revolution into the heart of general practice.

The government’s strategy for primary and community care in England acknowledges that many improvements have occurred in the past decade. Despite these achievements, the standard of primary care varies widely and needs to adapt to rising public expectations, changes in risk factors, and an ageing population. Accordingly, the strategy outlines proposals for reform in three areas.

Firstly, it argues that there is a need to promote healthy lives through a greater emphasis on prevention. The main initiative in this area is a vascular risk assessment programme for people aged 40 to 74 to be delivered by general practitioners, pharmacies, and other services, as foreshadowed in the prime minister’s first major speech on the NHS.

Secondly, the strategy sets out proposals for continuously improving the quality of care. This is to be done through refining the quality and outcomes framework to focus more on health outcomes rather than process measures, and by collecting and publishing data on service quality, including outcomes reported by patients. The Department of Health will also work with the Royal College of General Practitioners to develop an accreditation scheme for general practices.

Thirdly, and most radically, the strategy includes plans to increase choice and give patients a greater role in shaping services. These plans include the continuing development of health centres led by general practitioners and offering walk-in services and bookable appointments, the use of care plans for anyone with a chronic disease who wants them, and the piloting of individual budgets. Individual budgets presage the introduction of patient based commissioning, giving service users direct control over resources.

Absent from the government’s plans is any mention of polyclinics. Although the idea of patients having access to a wider range of services in the community is commended in the strategy, it places the emphasis on providing these services in different settings rather than in a single building. Whether this amounts to a change of heart or a change of presentation is unclear.

Underpinning the government’s policy proposals is a series of ideas on how they can be implemented. As in the main report on the NHS Next Stage Review,2 the emphasis is on change being driven locally and by clinicians. To this end, the strategy makes a bold commitment to “redefine and reinvigorate practice based commissioning” in the process acknowledging, if only implicitly, that practice based commissioning has so far failed to deliver.

In seeking to reinvigorate practice based commissioning, it proposes incentives for a broader range of clinicians, including hospital based specialists, to become involved. This is intended to support the development of more integrated care for patients. In an ambitious and welcome extension of this principle, the strategy includes a commitment to test and evaluate how primary and community clinicians can improve health outcomes through a pilot programme of integrated care organisations.

The theme of integration recurs in the discussion of the relationship between health and social care, although in this context it seems to be more of an afterthought than a well considered policy. Lacking specific proposals, the document expresses a commitment to support organisations that wish to go further in integrating health and social care services, effectively kicking this idea into the long grass by announcing the setting up of a group, chaired by the health minister, to work with stakeholders to decide how this should be done.

The strategy throws down the gauntlet to community health services by signalling the intention to focus on ways of improving productivity and quality in these services. This includes developing measures of performance that can be used by commissioners and providers to secure better value for money. Community health services could undergo substantial organisational change as primary care trusts divest themselves of their responsibilities to provide services in a rerun of Nigel Crisp’s ill fated plans from 2005.3

In general practice, patient choice and competition between providers will be driven by a fairer system of funding in which money will follow patients’ choices. This sounds the death knell for the guarantee of a minimum income for practices and the protection it has offered some practices since the introduction of the new contract. The impact of this commitment will depend on how and over what period it is implemented, and the willingness of the BMA to treat with health ministers, with whom they have not enjoyed the best of relations.

There is much common ground between the strategy and the government’s previous vision for community services, Our Health, Our Care, Our Say, published in 2006.4 The need to reiterate earlier policy commitments suggests that the biggest challenge in taking forward the vision rests in the means of implementation and whether thesewill be fit for purpose.5

Lord Darzi believes that an appeal to professionalism is the best way to advance consumerism and implementation of the proposals in his strategy. This may be what the profession wants to hear,6 but sits uneasily alongside the claims of Ben Bradshaw, his fellow health minister, that GPs operate cartels that hinder patient choice. With Darzi cast as the good cop and Bradshaw the bad cop, there is a risk of mixed messages from the government.

Whether the strategy will help to consolidate domestic pride in and international admiration of primary care, or whether it will undermine the fragile flower that is British general practice, remains to be seen. The strategy is good in parts, and in many areas there is the prospect that it will strengthen a system that is already functioning well. Much now hinges on how it is taken forward and the skill with which health ministers and the medical profession navigate the treacherous waters that lie ahead.