Primary And Community Care And The Myth Of The Demographic Time-Bomb

Primary Care SHA policy

This is a discussion document not agreed policy.

The SHA is concerned that general practice under the Tories may go the way of dentistry and optometry. The SHA aims to eliminate the private sector except in exceptional and transient circumstances.

The SHA wants to see improved access to primary care for both acute and chronic care. We are keen to maintain continuing personal care. This will require significant increased funding for clinicians in primary care. The government’s proposals are too little, too late. They have resulted in immense frustration with GPs threatening industrial action for the first time. The SHA recommends reassessing many aspects of the current arrangements for general practice to reassure and energise primary care. This should include boosting numbers of clinicians and making the most of opportunities afforded by information technology.

The SHA does not support GPs being responsible for planning although they must be centrally involved, alongside other key stakeholders, in local planning decisions.

Independent Contractor status:

There are advantages and disadvantages to the independent contractor status. The SHA would recommend a trial of a mixed economy, where in some areas, primary care is salaried and in others as it is now, the benefits and risks to be evaluated. One option should include one of the current New Models of Care (NMC), that under which hospitals run some general practices. It is unclear whether this will lead to improvements or more problems and such a move needs evaluation before any decision about permanence.

In some areas where there are difficulties in sustaining general practice, we may need a directly operated model, employed by the NHS. The franchising arrangements for primary care must always include clear national standards.

Planning Primary Care

The SHA sees that primary care must be planned and managed rather than just administering it which is the present predominant model.. One of the outcomes should be a more consistent quality of primary care. How to best manage primary care must be discussed with primary care, but as with the rest of the NHS, we would expect national standards with local delivery.

The SHA recommends primary care workforce planning and joint multi-disciplinary training where appropriate.

We should have a large-scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care, for a single County or City. This should include social care free at the point of use. This could include GP practices collocated with other services, including hospital services; a strong focus on intervening in the social determinants of health. All to be under national standards.

Clinical developments

Care plans for all patients, jointly written and jointly carried out.

The SHA notes the connection between psychological problems in children and young adults and mental ill-health in later life, and supports investment in

  1. community-based programmes to identify and support children and young adults with depression, anxiety and other psychological disorders, and
  2. research efforts to identify the best approaches to reducing psychological distress in this age group.

The SHA understands the difficulties of changing the health of the population and so encourages Labour to commit to a long-term plan for health promotion, preferably coordinated by a national arm’s length health promotion agency. This needs to include ways of engaging ‘hard to hear” groups and approaches to healthy community development.

We would like to see Labour commit to:

  • promoting specialist medical and nursing care closer to home.
  • prioritising innovative ways of running ‘Hospitals without Walls’, where specialists and generalists work alongside each other in community settings to improve outcomes for patients, enhance generalists’ skills and contribute to specialist training.
  • prioritising the development of 24/7 ‘Hospital at Home’ services for admission avoidance, early discharge and rehabilitation, in parallel with all acute Trust hospitals.
  • investing in the expansion of community nursing services and other community-based specialist services to create stable ‘Hospital at Home’ services. Also investing in social services’ input to ‘Hospital at Home’. Decisions about clinical responsibility for ‘Hospital at Home’ services to be made at local level, but a budget to be provided for an expansion in the numbers of community geriatricians

The SHA notes the underdeveloped and underperforming state of falls prevention services in hospitals as well as in the community, and recommends investment in community-based programmes to identify people at risk of falling and encourage them to take up preventive services (like exercise promotion classes).Community care

The SHA wishes to see community care in both the health and social care sectors adequately funded and skilled.

The SHA does not recommend wholesale focus on community care as a means to avoid acute hospital admission. The evidence is weak. In the current climate of austerity, it becomes a way of cutting hospital beds even further. However, there may be a case in those areas where particular pathways make it particularly appropriate to shift hospital work into primary care.

We want to see resilient out-of-hospital solutions for the care of older people, including increased recruitment of GPs, District Nurses and Health Visitors. One example that needs evaluation are Older People’s Assessment Units and extended primary care.


The SHA rejects the concept that an ageing population results in unacceptably high costs. On the contrary, we are proud that we have an increasing number of older people whom we value.

Older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years. Increased life expectancy means more years lived in good health.

Older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

It is not age but nearness to death that accounts for health expenditure. Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

It is those dying between the ages of 50 and 60 who cost the most.

Old age dependency has fallen substantially in the UK and elsewhere, when measured using remaining life expectancy. It is likely to stabilise in the UK close to its current level.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ If the cost of death declines with age then an ageing society could lead to lower health care costs.

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’