Call For Radical Refocusing Of Health And Care System To Put Primary And Community Services At Its Core

15th February 2024

A Kings fund report published on 13 February 2024. Although the focus is on England there are many similar issues for Scotland's Health Services.

Call for radical refocusing of health and care system to put primary and community services at its core

‘Answer to over-crowded hospitals is not more hospitals.'
30 years of policy and implementation failure in moving ‘care closer to home'

Need for clear vision, with funding, staff and political energy directed at general practice, pharmacy, community services and social care.
The health and care system in England must be radically refocused to put primary and community care at its core if it is to be effective and sustainable, according to a major new report published by The King's Fund.

The report authors argue that the failure to grow and invest in primary and community health and care services, despite successive governments stating a commitment to this agenda, is one of the most significant and long-running policy failures of the past 30 years.

The vast majority of interactions with the NHS are through primary and community services - such as general practice (GPs), community pharmacy and district nursing. On average there are more than 876,164 GP appointments in the NHS every day, an increase of 34,219 appointments a day since 2018/19.

Despite this rise in demand, and despite repeated pledges to boost out-of-hospital care, the proportion of Department of Health and Social Care (DHSC) spending on primary care has actually fallen (8.9% in 2015/16 to 8.1% in 2021/22).1 In 2021/22 the largest proportion of DHSC spending, £83.1 billion, went to acute hospitals, compared to £14.9 billion spent on primary care.

The NHS has received additional funding in recent years, but while acute hospital trusts saw 27% funding growth since 2016/17, community trusts saw just half that level of growth, at 14%.2

Trends in staffing reveal a similar pattern, with the number of NHS consultants growing by 18% between 2016/17 and 2021/22, but just a 4% increase in the number of GPs over the same period.3 There has also been a significant jump in social care staff vacancies rising from 110,000 vacant posts in 2020/21 to 152,000 in 2022/23.4

The authors outline how patients struggling to get appointments with their GP, are at risk of their condition deteriorating and having to seek urgent help from already over-stretched acute hospitals.

In their assessment of the key reasons for this longstanding policy failure, the researchers found that progress has been hampered by an incorrect belief that moving care into the community will result in short-term cash savings. Other factors include a lack of data about primary and community services leading to a ‘cycle of invisibility', funding flows that prioritise hospitals, and urgent challenges such as A&E waiting times and planned care backlogs becoming the priority for politicians tempted by quick fixes instead of fundamental improvement.

The King's Fund cautions that bolstering primary and community care should not mean closing hospitals, noting that England already has fewer hospital beds per capita than other nations.

Instead, the authors call for future funding to be directed into a comprehensive plan to refocus the health and care system towards primary and community care. They warn that a piecemeal approach of cherry-picking policies ‘will not miraculously unlock change'.

The report proposes several steps to begin the shift.

Vision: A clear vision for bolstering primary and community services, with all policies aligned to achieving that vision, and the political will to stick to the vision over the long term.
Funding: Future growth in health and care funding needs to be targeted at primary and community services
Workforce: Incentivise more staff to work in primary and community services through pay, status, career progression, and by considering mandatory primary and community training placements for clinicians and leaders.
Estate: Prioritise investment in primary and community care buildings and equipment, and cut red tape so organisations can better pool the space they have.
Flexibility and accountability: Give local health and care leaders more flexibility to meet local needs and hold them to account for improving overall patient care, rather than waiting lists.
Social care: Without reform of the ailing social care system, the ambition of ‘care closer to home' cannot be fully realised.
Sarah Woolnough, Chief Executive of The King's Fund, said:
‘The answer to over-crowded hospitals is not more hospitals. Despite this being well understood for many years, there is now a higher proportion of the NHS budget and staff going into hospital services. At the same time, there has been a slow erosion of capacity and confidence in primary and community care.

‘Many people across the country will have personal experience of struggling to get a GP appointment, trying to contact other services, and when all avenues have been exhausted, reluctantly going to A&E. It feels like all roads lead to the hospital, but our hospitals are already full.

‘To achieve an effective and sustainable health and care system, politicians and national leaders need to embark on a radical and wholesale refocusing of the health and care system towards primary and community services. Doing so will free up hospitals to treat the patients they are best placed to treat, thanks to many more people being diagnosed and cared for in the community.'

Beccy Baird, Senior Fellow at The King’s Fund and lead author of the report, said, ‘Like other countries, England needs to bend the curve on the predicted rise in demand for high-cost, reactive and hospital-based care. That means supporting people to take care of their health and wellbeing, intervening early and keeping people healthy at home for as long as possible, which can only be achieved by bolstering primary and community services.

‘While these changes may not unlock the quick-fix savings many mistakenly expect, the alternative is to build more expensive hospitals to manage acute needs that could have been prevented or better managed in the community.’

Read the full report HERE

For a quirky column on NHS matters See Roy Lilley at https://ihm.org.uk/nhsm/
Here is today's news from him
If you’re a member of the eclectic, curious and cantankerous group of friends who are regular readers... you will know.

If you are new to this happy band of realists and revolutionaries, let me take a moment to back-fill some detail.

Three things.
I was born before the NHS and harbour a haunting suspicion I might die after it has gone.
I'm a passionate supporter of family practice.
I'm a realist, which, in the NHS is like walking-the-walk with shoes that pinch.

I know the value of family practice. I’ve written, repeatedly; as a young child, the kindness and skill of our family GP diagnosed my symptoms, drove me and Dad to hospital, in the dead of night. Without that, I’d’ve been a goner.

Now we have industrialised primary care with care-guides and Zumba classes...

... because the suffocating burden of being a GP is overwhelming. The inflation infested running costs of family practice are unaffordable.

The unwelcome truth: doctors once wanted a job for life; today, youngsters want a job and a life. The up-sum, this is no job for the sane.

The reasons are multifactorial.

Successive government’s, long-running policy failures, they've been mesmerised by hospitals and failed to invest in primary care.

The misconception that somehow the NHS and in particular, primary care, can stop people getting sick.

It cannot...
... that’s all about housing, the environment, jobs, education, diet, security and a list of things, too long for this page. The NHS is the dustcart that sweeps up the horse’s doo-doo, after the Lord Mayor’s Show of life.

All this is true and obvious... at least to me and probably you.

Which brings me to the King’s Fund’s latest report;
Making care closer to home a reality: Refocusing the system to
primary and community care.

It is an elegant production. The colours are nice and it is very clear to read, I couldn't see any obvious spelling mistakes… that’s about it.

It describes our reality well enough but don't we look to the great brains of the King’s Fund for, ideas, solutions and practical fixes. Alas, missing.

The Kings ignore the direction of travel, the reality, the nitty-gritty of why primary care is collapsing and their best idea is to prop it up.

‘Transfer services’, ‘rebalance funding’ the usual; tropes. ‘Focus on active, meaningful engagement’… ‘holding ICBs to account for their achievements in growing primary… care services’.

Flam-flam, it ain’t gonna happen. Frankly, I think I’ve read the same stuff ten times in ten years.

Their bullet-in-the-foot moment comes at the end of the report;
‘…There will be many other changes needed and areas to explore further, but our work is clear that a total change in focus is needed to finally realise the vision.’

… and, no doubt the health management fairy will come in the night and sprinkle magic-dust on us all.

This is my shoe pinching moment;

Primary care, as a momma-poppa shop, partnership business, is heading for the rocks
Shifting care into it’s baileywick, is to move it into an estate that is too old, too small, with no money to expand it, no staff to do it, with kit that’s too expensive for a small business to get a return.
Pulling money out of Trusts damages the internal cross-subsidies in their system that keeps them viable.
Shifting care can only be justified if a higher value is placed on patient convenience than on operating costs… and for the foreseeable, money wins that argument... coz there isn't any... and won't be after the election.
Polyclinics, Darzi centres, Vanguard care hubs, the London Boro’s health centres of the 1930’s all fabulous in their intent but gone… too expensive, services and kit duplicated in secondary care.

The King’s report is ethereal and dainty. If it were a tea cup, it would be Royal Doulton... at a time when we need a mug of builder’s.

The reality is; the best opportunities have passed us by. Now, we must circle the wagons. Make the best of what we have. Sweat the assets and consolidate.

Vertical integration of primary care with Trusts. It's turning out to be a life saver for practices and for patients who might otherwise see their local surgeries close.

Let Trusts shoulder the back-and-middle office overhead costs. Interoperable, digital first services and fast-lane access to testing and diagnostics.

Free-up GPs to be GPs.

The Kings Fund are clinging to the wreckage when the should be looking for a lifeboat.

I know, it’s not pretty. I know people will hold-on for grim death and I don’t want this any more than you do but…

… alas, I fear primary care is turning into the Body-Shop of the NHS.

Much loved, fond memories, admired… but eclipsed.

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