The draft overall Welsh Government 2015-16 Health & Social Services budget will increase by 3.6% compared to an overall WG departmental increase of less than 1%. In making this allocation the Welsh Government “.. recognise(s) the importance of taking a prudent approach to healthcare to ensure we secure greater value for patients. Prudent healthcare is underlined by a commitment to rebalance the healthcare system by strengthening primary and community-based care to support the establishment of a more equal relationship between patients and professionals and changing the relationship between health care services and the public characterised by a shared responsibility for securing improved health outcomes.”.
Two recent publications, A Prescription for a Healthy Future ( General Practitioners Committee – BMA Cymru) and “10 Steps towards Future NHS Wales ( SHA Wales / Cymru), and an earlier paper, The Next Steps, (Royal College of General Practitioners Wales) offer well informed views on how this can be achieved. While these documents cover a lot of common territory and have shared views on the way forward, they also have a number of points of difference which merit consideration and debate.
Over 90% of NHS contacts take place in the community. Patients in Wales see their GP approximately 6 times per year and the practice nurse 4 times. Following the new GP Contract, the overwhelming bulk of continuing care for conditions such as diabetes, asthma and heart disease covering a quarter of the population is also undertaken in a community setting, close to people’s homes.
As the over-whelming majority of NHS contacts are in general practice it provides an important gatekeeping role in our health care system. It also plays an important gateway role. In an increasingly specialist and complex health care system, general practitioners identify potentially serious illnesses and work with patients to choose the most appropriate care pathway for them to pursue at either hospital or primary care level.
Both these gatekeeper and gateway roles make a major contribution to the cost effectiveness of the NHS as socialised health care. This places general practice and wider primary care at the heart of a “prudent health care” system. But despite this crucial role NHS spending on general practice services has declined over the last half decade.
According to the Health Minister, Mark Drakeford, NHS spending for general practice care was 7.87% in 2012-2013 – down from a high of 10.27% in 2005-2006 and 8.15% in 2003-2004. As well the per capita spend on general medical services has seen a recent decline. Between 2008 and 2012 hospital consultant numbers have increased by 15% compared to a 4% increase in GPs.
Since 2008 the numbers of patients per GP has reduced by just 2%. The health boards with the biggest lists are in Cwm Taf and AMBU, areas which have some of the highest morbidity levels in Wales. Of equal concern is the increasing age of the profession with a growing number of GPs over 55 years increasing from 330 to 469 (23% of total GPs) in the decade to 2013.
If “prudent health care” is to have a real meaning, these trends will have to be reversed. But how is this to be achieved? There can be little doubt that primary health care services will become increasingly unsustainable if these trends continue. Greater priority must be given to the sector.
When the final residues of the internal market in Wales were abolished and new Local Health Boards established in the 2009 few tears were shed. The structures became more streamlined and a whole tier of complexity was removed from the system. But from the point of view of primary care something was clearly lost.
Compared to their predecessor local health boards, the new local health boards had a dramatically reduced community make-up. They have the appearance of and operate like a hospital trust board. Much of the new senior managerial LHB leadership came from a trust background as well. These factors, as well as the imperatives created by hospital reconfiguration across Wales, made it difficult for primary care to be heard.
In the post-2009 world the purchaser – provider split was replaced by a planning process. This is correct in principle but it neglected primary care both in terms of its operational needs but also in terms of its potential to inform the planning process.
The “NHS Wales Planning Framework” (2013) which sets out how the new planning system should operate highlights this. There is no expectation that clinicians at any level will have a significant input into either the needs assessment or the local scrutiny of planning process. Indeed the document itself states that “ there are currently no formal requirements for other partners to scrutinise and approve an NHS organisation’s Integrated Medium Term Plan ” though it does concede that there is an expectation that it will “ have been through” undefined local collaborative mechanisms. Patient involvement is also only mentioned in passing though engagement with local third sector partners and Community Health Councils.
The RCGP paper states that as NHS organisations grow more remote, the need for democracy is ever greater. The SHA states that you cannot plan what you do not own or lead. The BMA makes a similar point in highlighting that the new arrangements fail to build on the commissioning experience of primary care clinicians which was acquired during the internal market period. Rather than assimilating it into the planning process it has been ignored and abandoned. This major omission which will need to be rectified if the NHS is to be re-balanced in line with “prudent healthcare” principles. Patients and clinicians must be at the very core of the planning process.
All three papers see a continuation of general practitioners’ independent contractor status as being part of the future of the NHS in Wales. However there are major differences as to the significance it will play. They all correctly emphasize the key values of general practice as being continuing, personal generalist health care in a community setting. However both the RCGP and BMA argue that retaining the best of these values is only possible with general practitioners continuing as small business people.
The new GP contract in 2004 succeeded in getting general practice to take on board the management of the bulk of chronic conditions such as asthma, diabetes, high blood pressure and heart disease. Though the care is often a mechanical, tick box exercise to earn Quality & Outcome Framework points ( and points mean money !!) it is a big step forward on what preceded it.
However in the process patients have found it more difficult to see “their” GP, much of care is fragmented across the practice team and accessing services can be difficult both within and out of hours. There are still high levels of patients satisfaction with GP services and continuous, personal generalist GP care remains greatly valued. But the system is rapidly fraying at the edges with the key assets of British general practice under serious threat.
The RCGP argues that the continuation of the independent contractor status is being undermined by the rise of salaried general practice and the dearth of GP practice partnerships. These developments “.. risk eroding the nature of traditional general practice”. However other than making nostalgic appeals, the RCGP struggles to come up with a realistic strategy which will preserve the key assets of general practice.
The rise of salaried general practice and the dearth of practice partnerships are linked. Many doctors who now wish to follow a career in general practice are not attracted by the “partnership model”.
New doctors are often not in a position to take on additional debt to buy into a partnership. As well partnership involves a degree of permanence that new young doctors do not find attractive particularly early in their careers. And in areas with high workload and the greatest health care need property values are declining and an investment in practice premises does not make financial sense. In addition domestic and family commitments mean that many GPs are not able to take up a full-time position which could make partnership purchase more affordable.
In these circumstances it is not surprising that many new general practitioners will chose a salaried option. Figures from 2010 show that about 8% of doctors working in Welsh general practice are salaried. This is considerably less that the 21% UK average but the key forces that have led to this relatively high UK figure operate in Wales as well.
These developments mean that the traditional, partnership based, independent contractor status of general practice is becoming more and more unsustainable. Change in the “old model” is needed and with the aging of the general practice workforce this change is needed sooner rather than later. In seeking change there are clear choices to be made in either going down a market or a public service route.
Over the years the independent contractor status has proved resilient but the pressures on it are growing ever greater. If fewer doctors wish to become partners in general practice it creates an opportunity for the corporate private sector to move in to take over. This has happened to a large extent in community primary care services such as dentistry, optometry and retail pharmacy. And with a fair political wind there is no reason why the corporate private sector should not move into general medical practice as well. Indeed in England this has already happened in a number of areas.
The SHA document “ 10 steps toward future NHS Wales” offers a different vision in which general practice evolves in line with the aspirations and practice of a new generation of doctors but remains firmly with a public service model.
The core values of continuing, personal generalist care are at its heart but in the context of the 21st century and the specific challenges we now face.
This vision calls for more community based salaried health and care practitioners (doctors, nurses, health visitors, social workers, physiotherapists, occupational therapists, care assistants etc) working with a defined population of patients. These community based services need to be linked more organically with hospital based services thus narrowing the growing chasm between increasing sub-specialism in hospitals and community based holistic care. This integration will involve single systems for unscheduled emergency care and for continuing long-term care underpinned by agreed clinically led care pathways and a modern technological infrastructure.
A number of local health boards have had experience with running salaried general practices. Sadly some undertook the task under sufferance with an end-game view of returning it to the independent contractor model. But others were much more innovative and used salaried GPs both to support existing struggling practices or to develop new exciting new ways of working in primary care. “ 10 steps towards future NHS Wales” provides a clear vision and rationale for this more optimistic scenario. It does represent a radical challenge but it must be at the heart of any sustainable, “prudent” health care service in Wales.