Extending Primary Care

Polyclinics, Resource Centres, Hospital-at-Home

Pat Gordon, Janet Hadley

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315346007
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

'Fundamental changes in the Health Service demand a radical shift in approaches to patient core. The NHS is becoming increasingly led by the primary care sector. This has a greater meaning than simply more involvement of GPs in secondary care purchasing. It means that we start from where the patient is, in their own home and community. We provide care for them there and only move them into secondary services if and when it is appropriate to do so. 'Extending Primary Care shows that it is possible to experiment beyond traditional boundaries in these areas. It will provide encouragement to people who work in some of these difficult settings by showing what can be done...This book could not be more timely as a resource to many managers who will need to extend their own understanding of primary care - in the fullest sense of the whole team of people in primary care and the associated community health services.' From the Foreword by Barbara Stocking

Primary health care – its characteristics and potential

1

Pat Gordon and Diane Plamping

Introduction

Every developed country is showing a renewed interest in primary care, either as a means of controlling rising health costs or because its neglect is causing concern among users of the service. From being a minority interest a few short years ago, primary care has shot to the top of the NHS policy agenda and is now the focus of considerable managerial activity, not least in efforts to extend it. There is a problem however in the lack of shared understanding of what is meant by the term primary care. It is an abstract notion (though no more so than the terms community care or secondary care) and few professionals agree on a definition. For the most part, primary care is much less visible than hospital care partly because it takes place ‘out there’, away from the offices and institutions where most managers work. And yet one of the major planks of NHS policy in the 1990s is the creation of ‘a primary care-led NHS’ and a shift of resources and services from hospitals towards primary care.¹ If we are to move in this direction, we will have to build a better understanding of the NHS as a whole system, rather than a loose collection of separate service sectors which have grown from different roots and traditions, and to this day remain remarkably unaltered, despite waves of reorganization. Stereotypes persist. Creating a shared understanding of the words we use and the meanings we give them is one way of addressing them. In this chapter we examine the characteristics of primary care in the UK, its historical development as a clue to how it might change in the future, and some faulty assumptions which hinder the search for common meaning.

Characteristics

Primary care is not something which is done in one place or by one group of professionals. It includes rather than excludes. It can be described as a network of community-based health services that covers prevention of ill-health, treatment of acute and chronic illness, rehabilitation, support at home for patients who are frail or disabled, management of long-term ill-health, and terminal care. This network is linked in turn to a much wider social care network and this is what makes it possible in the UK to deal with 90% of patient contacts outside hospitals, to limit patients’ length of stay in hospital and discharge them safely, and to maintain at home people who do not want to be institutionalized. In the NHS there are two main providers of primary care: general practice and community health services. Other providers are dentists, pharmacists and accident and emergency units, but the unique feature of our system is the combined potential of the two main providers. Recognizing their characteristics and what we value about them – as well as what we might want to change or to extend – becomes important. General practice brings one set of characteristics to primary care.

• It is delivered by highly trained generalists who can offer continuing and personal care for patients, described as ‘biographical’ care. This allows episodes of illness to be understood in the context of people’s daily lives and helps in making the frequent adjustments which are needed to cope with chronic illness.
• It involves teamwork in which a growing number of professionals share aspects of patient care. Some of these are community-based specialists.
• It offers first contact care and is the patient’s main point of entry to the health system (the other being the accident & emergency unit).
• It offers accessible care which includes geographical nearness, availability, language, culture, and old as well as new health problems. It is based on small organizations whose scale is critical to maintaining the non-institutional, personal care which many patients value.
• It offers comprehensive care which is not defined by sickness, age or gender. It includes disease prevention, health promotion, treatment of acute and chronic illness and rehabilitation. The availability of services 24 hours a day is essential to reduce inappropriate self-referral to other services.
• It offers co-ordinated care. The practitioner acts as advocate and information giver for her patient. This includes referral for specialist opinion and treatment.
• It has some responsibility for its population, ‘the list’.
• It is activated by patient choice.

The community health services are provided by larger organizations through a range of both generalist and specialist staff. They bring another set of characteristics to primary care.

• Support for general practice. In small practices this can mean employing the district nurse and health visitor. In larger practices it can mean service level agreements for staff such as the community midwife or community psychiatric nurse.
• Specialists in the community. These include consultant paediatricians, stoma nurses, clinical psychologists, Macmillan nurses. Not every practice wants to employ a physiotherapist, for example, but the patients on every practice list want access to one when needed.
• Services for people with continuing illness and disability. This often requires skilful networking and liaison with voluntary and local authority agencies.
• Services which support people discharged from hospital.
• Some community trusts are beginning to carve out a vigorous home care agenda and their ability to offer safe, high quality nursing at home will determine much of the shift in services from hospital to primary care.
• Services for well people. This includes school health, child health, family planning, HIV counselling, health promotion.
• Choice for people without a GP or those for whom family-based practice may be inappropriate, for example, young adults seeking advice on sexual health, homeless people, or refugees. Community trusts have the flexibility to respond quickly to changing priorities and the organizational capacity to sponsor service developments. They are not bound by bricks and mortar.
• Economies of scale. Home loans and equipment are the obvious example which can only be provided efficiently for a large population. Economies of scale also support study leave and in-service training which may extend, for example, to include practice nurses developing their family planning or diabetic skills.

Community health services in the UK are as internationally unique, if less well known, as the family doctor services.² Their history is of professional and organizational development quite separate from general practice but, together, they form the building blocks which allow us to even contemplate the notion of a primary care-led health service. Between them they have the potential to deliver the NHS policy agenda of earlier, safer discharge from hospital, more frail people supported in their homes, better co-ordinated and more flexible community care, and more efficient and effective use of hospital resources.³

The new health agencies charged with implementing this agenda come into full legislative power in 1996. The functions of district health authorities (DHAs) and family health services authorities (FHSAs) have been merged and it seems likely that the new agencies will want to invest more in primary care, but not necessarily in ‘more of the same’. In order to help put current events in context, the following section gives a brief analysis of how the UK model of primary care developed, and therefore how it might change in the future.

General practice development

The roots of general practice are distinct from those of both physicians and surgeons and can be traced back to the apothecaries of the 19th century (and earlier) who diagnosed conditions and recommended treatments, as well as preparing and dispensing medically prescribed therapies. In order to protect the public from ‘quackery’ in the rapidly changing world of Victorian Britain, the 1858 Medical Requisition Act was passed to help guarantee basic standards of medical qualification and practice. It also helped fuse three previously conflicting groups into one medical profession – the British Medical Association (BMA). Thereafter ‘demarcation disputes between general practitioners and the more specialized physicians and surgeons were metamorphosed into medical etiquette’.²

In the early days of the NHS the emphasis was on access to health care for all. Two of the fundamental principles of the NHS were:

• to divorce health care from personal means, in other words to make access to medical services (and therefore it was hoped to preventive action) free
• to ensure that medical services were available to everyone, in other words comprehensiveness.⁴

This meant a new right to be included on a GP’s list, but for many people this represented little more than an extension of ‘the panel’, though, importantly, it was an unstigmatized extension. Within a short space of time it was possible for almost the whole population to register with GPs. The really big change brought by the NHS, however, was access to specialist care in hospitals. The agreement reached between the Government and the British Medical Association left GPs as independent practitioners who continued on their pre-NHS path separated from the mainstream of NHS policy and finance which, in turn, paid little attention to the place of primary care in the health system.

Most managers probably know little about the first charter in the NHS, the Doctors’ Charter but without understanding its significance and legacy, it is difficult to understand how our system of general practice has evolved.

During, the 1950s and 1960s an extraordinary movement developed within general practice. A remarkable cohort of GP leaders developed a theoretical basis for family medicine and a vision of how the role of a clinical generalist might develop within a national health service.^5,6,7 They created a Royal College of General Practitioners and a professional culture of audit and vocational training far ahead of the hospital sector. They challenged the notion of the GP as ‘the poor relation’ of the hospital specialist. Most remarkably they ‘kept the faith’ when most health care systems were turning away from the generalist to an increasing reliance on specialists. This is their gift to the current system which allows us to even contemplate a primary care-led future.⁸ Other countries which lost their generalists, most notably the USA, face a 20-year development cycle to rebuild an adequate supply.⁹

By the mid-1960s there was growing awareness within the health service of the importance of the gatekeeping role of general practitioners and this combined with their professional leadership to produce the charter for general practice. This was a recognition of the need for public spending on general practice buildings, and for access to revenue for staff and equipment, and marked a significant shift in policy. General practice underwent a renaissance. The best undergraduates began to choose it as a career option. Departments of general practice sprang up in medical schools and further strengthened the theoretical and research base of the profession. Over the next twenty years the range and quality of services blossomed in many places. The new mechanisms were used to create models of care which are recognized as probably the best in the world.

However, it has to be remembered that this was a system built on professional development which insisted that independent practitioner status was necessary to safeguard clinical freedom; and which built up its collective strength and identity within a dispersed professional group by perpetuating a myth that all GPs are equal. In fact the developments were uneven and during this time the gap between the best and the worst probably widened. The good GPs took advantage of the terms of the charter but those who did no...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Series introduction
• List of contributors
• Foreword
• Acknowledgements
• Introduction
• 1 Primary health care – its characteristics and potential
• 2 Boundaries in primary health care
• 3 Primary care resource centres – a means of supporting general practice?
• 4 Polyclinics – an alternative to practice-based care?
• 5 Hospital care at home
• References
• Index