Dr Jonathan Shapiro on the whats, whys and hows of increasing capacity
Recent NHS reforms have all included an emphasis on the expansion of primary care, and the two case studies in this edition reflect the diversity of what primary care can deal with – from sleep apnoea (How we diagnose sleep apnoea in primary care) to the classic heart-sink presentation of patients with ‘funny turns' (A symptoms-based approach to ‘funny turns').
The expert panel (Primary care in a different capacity) explores the issues of what deciding to ‘make' instead of ‘buy' throws up. In this introduction, I thought it would be worth giving a overview of moves to expand primary care, under the headings of ‘what', ‘why', and ‘how'.
In many ways, defining the ‘what' may be the hardest task, as primary care has traditionally been defined by its role and not the specifics of the conditions being treated. According to Starfield,1 good primary care has several important properties:
- first point of contact
- contextualised care (covering the social and psychological aspects of illness as well as the physical ones)
- continuity of care
- the co-ordination of wider services.
In Starfield's definition, the specifics of care are not mentioned – the term is generic, and could be applied to any illness. In the current discussions, the changes being mooted are less about the nature of primary care, and more about the ‘movement of care closer to home' – a policy that seems to be based on the obverse of Starfield's definitions. It is all about the location and content of the care, and little about its nature.
We need to be aware of this dissonance. The various roles of primary care underpin its success and if we forget that, we will merely recreate secondary care in the community – an entirely different kind of entity.
The second question is why expand primary care? Starfield went on to analyse primary care-based systems internationally, and concluded that they offer several advantages:2
- greater access to necessary services
- better quality of care
- greater focus on prevention
- early management of health problems
- the accumulation of the main primary care delivery characteristics
- reducing unnecessary and potentially harmful specialist care.
It is worth noting that Starfield didn't mention costs here, given that one of the main drivers for expanding primary care in England seems to be that of cost reduction.
The current assumption is that moving activity out of institutional settings into community ones is bound to save money. But this is likely to be true only if the shifted activity requires marginal change to staff and facilities – in other words, the system doesn't need to erect new buildings or employ new staff – and if the primary care model of care doesn't merely replicate the hospital model (which is where we came in…).
Finally, there is the issue of how to expand primary care, and it is here that the real philosophy underpinning 20 years of reforms matters most.
If those who work in primary care are allowed to extend their ownership of services and the supporting resources, then an opportunity genuinely exists to change the paradigm of care once and for all: allowing each unit – whether doctor, practice or clinical commissioning groups – to decide what to make and what to buy, and to carry the appropriate accountability for their decisions. That should encourage responsible inventiveness in a way that a centralised bureaucratic public service will never permit.
The risk is that building up the earned autonomy required to allow the units their independence will be so bureaucratic and cumbersome that any creativity will be stifled, and indeed it seems that the minutiae of public-sector ‘grey suitedness' is already demotivating those who might be at the vanguard of change.
The final message is therefore about encouraging the system to tolerate a modicum of risk, enough to let the embryonic responsible inventors realise their potential, without destroying the system that they are there to develop.
Dr Jonathan Shapiro is senior lecturer in health services research at the University of Birmingham and a former GP
References
1 Starfield B. Primary care: balancing health needs, services and technology. Oxford University Press, 1998
2 Department of Health. Implementing care closer to home: convenient quality care for patients. 2006
