Access dispute masks challenge to deliver better primary care
Chris Hanvey
Tuesday, October 15, 2013
The goverment wants to get general practice on board to tackle overused hospitals.
The rubber chicken circuit is over for another year.
For those who attended the three major party conferences, there will be a greater knowledge of how the Clyde has been transformed as a site of boat building to (for the Lib Dems) one of vote-building: an opportunity, alongside Ed Milliband, to dip a toe into the waters of Brighton and frozen utility prices and, in an uncharacteristically dry Manchester, to hear more about additional funds for some GP surgeries. It is on the last of these that I would like to concentrate.
David Cameron's response to the growing problem of crowded accident and emergency departments and a real or perceived belief that general practice could do more is the same as that of senior politicians since Aneurin Bevan and the establishment of the NHS. To get through his bill, Bevan "stuffed their mouths with gold".
Today, Cameron's proposal is additional funding for a number of practices, in exchange for longer opening hours. It's a response which in the short term appears expedient, since it delivers immediate extra capacity into the system and gives the appearance of action. But does it do much good?
Those who follow emerging health statistics will know that the growth in attendance within A&E departments has grown exponentially in the last couple of years. At one level, the introduction of triage several years ago, by which patients were seen for an initial consultation, usually with a nurse, helped to massage the figures. While you might have been initially seen in the first 15 minutes, you then joined the walking wounded for several hours hunkered down in a crowded waiting room.
Now, with winter fast approaching and a general election looming, no government would wish to see more headlines about failing A&E departments. After all, if the NHS is the UK's religion, it will not play well in the ballot box. Hence, too, the announcement earlier in the summer that extra money would also be given to prop up A&E departments during the winter.
Seeking the cause of this problem, Health Secretary Jeremy Hunt has not dampened speculation that a large part of this is the fault of general practice. Still smarting from pay settlements years ago, it is the apocryphal belief that GPs received large salary increases to do less work.
So the press has been full of stories of nine-to-five practices, where appointments for treatment have to be made days in advance. In reality, few practices work these hours and, as the incoming leader of the GPs has said, there are more than one million interactions in general practice every day and they, too, have seen a considerable increase in public demand.
This manufactured conflict between A&E departments and general practice partly masks the real problem. Neither a one-off payment to prop up A&E departments or an experiment to get GPs to work longer will solve the challenge of how primary health care is delivered. It is a problem of two kinds: co-ordination; and 21st century delivery of key health services.
In relation to co-ordination, you only need to look at the sad deaths of Daniel Pelka and Keanu Williams to see the familiar pattern of health and social care agencies not talking to each other and each contact with a statutory agency seen as a discrete interaction. And this leads to the second point about the delivery of 21st century services.
While business has long ago woken up to the massive implications of new technology, health services remain reluctant to paddle in the shallows of electronic communication. So, instead of being an effective first port of call for worried parents, the 111 telephone line, for example, is inefficient and badly resourced by those not always skilled in medical practice. At the same time, IT systems fail to link up, there is little coordination between, say, A&E visits and general practice, and still we're unable to find effective ways of sharing information safely online.
But more basic than this is the lack of real creative thinking about how preventive services can help or the possibility of delivering services in new and imaginative ways. More thought, for example, needs to be given to the essential role played by pharmacists to family health.
For many families with small children, they will often be the first port of call before making appointments at busy GP surgeries. Similarly, much greater use could be made of paediatric nurses in GP practices and we need a fresh debate about the location of primary care in communities, rather than in expensive hospitals. It's people, not hospital buildings that make people better.
Cameron indicated his £50m injection into general practice will explore flexible access, such as a greater use of email, Skype and phone consultations, and the possibility that patients will be able to visit a number of GP surgeries in their home area. With the right kind of safeguards, it is this kind of creative thinking that could transform primary care services for families.
The pity is that these issues were not at the heart of the Health and Social Care Act, still dominating discussion. Instead, we face a winter of strained services and a mutual blame game between A&E departments and general practice.
Dr Chris Hanvey is chief executive of the Royal College of Paediatrics and Child Health