Still here, still trying, still healing

Dr Michael Dixon, chairman of the NHS Alliance, reflects on the 60 th anniversary of the NHS

The NHS, in its 60 th year, has much to be proud of. Witness our ranking last year in the Commonwealth Fund Report as best overall health service when compared to the health services of several other developed countries. First, too, when it comes to specific areas such as equity or cost effectiveness. British primary care can take a disproportionate share of the glory for these results. Especially, because research shows that the quality and quantity of primary care is the main factor when it comes to issues such as the level and equity of health in the population and cost effectiveness of its health service.

Primary care’s success lies in the registered GP list, which in principle, offers everyone the potential of a GP practice and practitioners directly responsible for their health and care. Satisfaction rates are notoriously high-between 80% and 90%. Meanwhile, extended primary care teams and community services are able to offer more than ever before.

That is the good news! Beneath the surface, aspirations for a 21 st century health service are being held back by disengagement, division and the dead hand of inertia.

Disengagement is all too rife in the current debacle between the government and BMA on GP opening hours. Clinicians are insufficiently signed up to current aspirations for reform and public/patient involvement in recent years has been a disaster. Division – especially between primary and secondary care and between health and social services - is a long running sore with patients perpetually falling into the ‘gaps’ between services and facing delays and poorly coordinated treatment. Finally, there appears to be an intrinsic inertia within the NHS which ensures that good policies such as practice based commissioning and increased out of hospital services proceed only at a snail’s pace.

“In Health and Sickness – integrated services in a primary care led NHS” published at the beginning of March is NHS Alliance’s contribution to getting the show on the road again. 2008 is Alliance’s tenth anniversary and having produced three vision documents – “Restoring the Vision,” “Implementing the Vision” and “Vision in Practice” – NHS Alliance’s latest work is less vision and more a practical look at how we can establish rapid improvement in primary care. It is Alliance’s wisdom for the forthcoming Darzi strategy but also, uniquely, it represents the combined voice of all frontline professionals as well as primary care managers and non-execs.

So how do we engage primary care and especially its clinicians? Alliance recognises that the NHS needs another set of instructions falling from the sky like a hole in the head. This piece of work is designed to inspire, emancipate and enable everyone in primary care to delivery better health and care for their communities. Practice based commissioning is the key to enabling frontline professionals and their patients to achieve their hopes. NHS Alliance’s report says it is time for PBC to ‘shift gear’ and has a number of suggestions on how this can be achieved. Included within these are recommendations that PCTs and practice based commissioners should see themselves as partners and as mutual customers with an element of contestability, when they are providing insufficient support for each other. Alliance’s report also advocates the creation of an innovation fund in each PCT with a given percentage specifically for health initiatives. It also recommends that practices as practice based commissioners should take back 24 hour responsibility for patient care thus ensuring that integrated in and out of hours care – albeit by different providers. Overcoming divisions between primary and secondary care can be achieved by two complementary directions of change. The first is to develop integrated health services in local communities, which bring together GP practices (often as PBC collectives), community providers or voluntary providers, social services, specialists and others. This ‘coming together’ of services, possibly encouraged by an ‘integrated service alliance’ will lead to a number of organisational models and Alliance believes that pilot sites for integrated care organisations should be established to provide lessons and a glimpse of the future. Meanwhile, better working between a smaller secondary care sector and expanding primary care can be encouraged by mutual incentives on both sides to improve patient care and cost efficiency with the possibility of a combined budget covering primary and secondary care in some disease areas and mutual incentives in primary and secondary care to make best use of it.

The report believes that a second type of specialist/consultant of equal status to the hospital consultant called a ‘community consultant’ will need to be established with its own system for training and qualification. The report also suggests that the NHS still has far to go in terms of encouraging and supporting clinical leadership and the establishment of a national clinical leadership academy would go a long way to establishing an education and career pathway as well as raising the profile and voice of clinical leaders.

Patient involvement is another major theme of the work. The development of the NHS market will empower the patient as consumer but patients will also have a future role as partners within the health service. They will become an intrinsic part of GP practice provision and practice based commissioning with Alliance encouraging the development of patient groups in every practice and PBC collective. This role for local patients in developing local health services and initiatives will be reflected in increasing support for personal health and self help. The report suggests that there should be a health lead in each PBC consortium but that all frontline professionals (and for that matter their patients) should see health as part of their job. One specific recommendation is that patient self assessment through “LifeCheck” could be supported by a GP practice health check or MOT paid for through the quality framework of the GP contract.

Primary care access and access to general practice, in particular, are major NHS themes at present. The report suggests that improving GP access should be a local issue between a practice, its patients and the PCT. Quality of general practice nationally should be standardised through practice accreditation, which would licence a practice to provide a service within the NHS. Short term contracts might be offered to market newcomers initially as a means of holding to account those, whose ability to provide high quality care was, as yet, unproven. The report also emphasises the need for a level playing field between large companies bidding to run inner city GP practices through APMS, who can loss lead as part of market entry and have resources for high quality tendering applications and small neighbouring GP practices that are often unable to do either. Again, the local population voice should have a greater say on outcome.

The NHS Alliance report heralds the Darzi primary care strategy expected in May this year. NHS Alliance clearly hopes there will be a synchronicity between the two. Late spring and early summer will provide opportunities for renewal in every sense. The conflict over GP opening hours, which has masked so many other priorities, will hopefully be over. Then we can get on with achieving all the things that have so far evaded all attempts during the first 60 years of the NHS. These include the universal registration for every patient with a good quality general practice, being able to access personal care and continuity when desired, an easily accessible service integrated around the patient and, perhaps most important of all, a service that takes personal and population health seriously and delivers it more effectively. All that, while maintaining enthusiasm and dedication that are part of a unique NHS ethos. An NHS of which we are all members. One where, in the byline of a previous NHS document, ‘health is the incentive.’