The Nuffield Trust’s new interactive timeline illustrates well the durability of many of the ‘wicked problems’ afflicting the NHS and the range of managerial doctrines deployed against them since the health service was created: hierarchy; consensus management; general management; the internal market, and more recently collaboration, competition and patient choice.
One of the issues successive governments have returned to over the past seven decades is the question of general practice and its links with the broader system of community-based care.
Whether it is concern about improving the relationship between doctors and health visitors (subject of the 1956 Jameson report) or balancing GPs’ ownership of primary care with the need to boost action on prevention (several White Papers and contracts) most health ministers, to borrow an analogy from noted primary care expert Geoff Meads, have tried at some point to mix the oil and water that is general practice and public health.
This is not surprising. Research into primary healthcare in the international context has revealed a clear link between the strength of a country’s primary healthcare system, the degree of cost-effectiveness of the overall health system, and the level of health outcomes achieved for the population.
General practice also theoretically provides a rational geographical basis for local service planning and the development of new primary and intermediate services and facilities.
In other words, ministers (and this applies internationally) cannot ignore the gains to be had from situating a strong primary care sector within a thoughtfully designed system of community services.
The reverse of this natural, if perhaps sometimes one-sided attraction, is a tendency for governments to appropriate GP-led organisations for their own ends. For example, primary care groups in the English NHS in 1999 sounded the end of GP multi-funds and total purchasing schemes.
One reading of this phenomenon is that when GP-led organisations get too powerful and independent, publicly-funded health systems struggle to engage with and control them.
Another is that it represents the oil and water of general practice and public health, with very different cultures of training, perspective, values and service delivery appearing to be irreconcilable.
The challenge facing CCGs needs to be understood against that backdrop – they will essentially be population-based statutory organisations depending on the enthusiasm and engagement of the general practice mainstream. How far these new organisations will feel owned by GPs will be critical to their success.
Dr Judith Smith is head of policy at the Nuffield Trust