Primary Care Service
7.1 When we seek health care or medical aid we look in the first place to services available in the community, and usually that is as far as we need to go. For this reason it is impossible to over-rate the importance of the quality of and easy access to services of this kind. At the same time it should be understood that the NHS is by no means the only provider of health care in [the community, its most noticeable allies being the local authorities who provide a wide range of complementary services. In this chapter we shall concentrate on some aspects of community care, namely, general medical practice, community nursing, health centres and the serious problem of providing health services to those who live in declining urban areas.
7.2 Historically, general practice has been an important element in publicly provided medicine. Even before the National Insurance Act 1911, which introduced the panel system, many general medical practitioners (GPs) treated Poor Law patients. In 1948 general practitioner services became part of the NHS. In nursing and midwifery too significant developments came in the second half of the 19th century, largely as a result of the public health movement. Before 1948 nursing services in the community were principally provided by voluntary associations. These services have grown rapidly since 1948 and at NHS reorganisation in 1974 health authorities took over the employment of local authority nursing staff.
7.3 The demands made on services in the community are already large and there is every reason to think that they will continue to increase. As we noted in Chapter 6, the proportion of elderly people in the population is growing and so is employment among women who would in the past have been available to care for dependent relatives. The trend in treatment of the mentally ill and handicapped is towards enabling them to live as far as possible in the community. Increased demand may well be generated by better health education and more screening of high risk groups, and the more interventionist approach of GPs and community nurses. Efforts towards shortening the length of stay in hospital benefit patients and stimulate the efficiency of the hospital service but necessarily throw an added burden on community services. Compared with most other countries we have an extremely well developed primary care system and we would be foolish to allow it to deteriorate.
7.4 A recent development of great significance has been the growth of teamwork in primary care. The grouping of practices and the spread of health centres have brought GPs into closer working contact with each other and with nursing and administrative colleagues; and in some cases, too, with dentists, pharmacists, clinical psychologists and social workers. Teamwork in primary care is at an early stage. It will have a major contribution to make to raising standards of service to patients in the community and this makes the development of joint training for the professions involved of considerable importance.
7.5 Choice of doctor by patient and of patient by doctor is an important freedom; and though its existence is largely theoretical for some people, it is highly valued. However, it makes rational planning of the delivery of primary care services more difficult. A general practice normally has no defined catchment area. The general practitioner and other members of the primary care team (unless they are employed directly by him) often do not serve the same geographical locality. The development of group practices and health centres, which provide a degree of choice for both patient and doctor, may encourage greater concentration of catchment areas and movement towards zoning or sectorisation. If that were to occur, it would provide a strong impetus towards the planning and delivery of co-ordinated patient care by hospital and community services for a given population in a given locality; and it would tend to blur the boundaries between these services. We support such developments.
7.6 In our work we have given much attention to NHS services in the community and although we have no doubt that the way in which the NHS provides health care in the community is good, and the general level of care is satisfactory, we are just as sure that there is room for improvement. The professions themselves have done much to assist changes in practice and attitudes to the benefit of patients. An example is the work of the Royal College of General Practitioners (RCGP) in raising professional standards to which we refer below. The criticisms which we make later in this chapter should be set against that background.
General medical practice
7.7 The following definition, quoted in evidence to us by the RCGP, commands general acceptance in the UK and Western Europe:
“The general practitioner is a licensed medical graduate, who gives personal, primary and continuing care to individuals, families and a practice population, irrespective of age, sex and illness. It is the synthesis of these functions which is unique. He will attend his patients in his consulting room and in their homes and sometimes in a clinic or hospital. His aim is to make early diagnoses. He will include and integrate physical, psychological and social factors in his consideration about health and illness. This will be expressed in the care of his patients. He will make an initial decision about every problem which is presented to him as a doctor. He will undertake the continuing management of his patients with chronic, recurrent or terminal illnesses. Prolonged contact means that he can use repeated opportunities to gather information at a pace appropriate to each patient and build up a relationship of trust which he can use professionally. He will practise in co-operation with other colleagues, medical and non-medical. He will know how and when to intervene through treatment, prevention and education to promote the health of his patients and their families. He will recognise that he also has a professional responsibility to the community.”
Although general medical practice exists in other countries, it differs from ours in one important respect; in this country patients do not normally have direct access to the hospital consultant and the GP is usually the first point of contact. The different approaches found in other countries are more likely to reflect their different history, geography and social organisation than a systematic attempt to provide the best system of doctoring. Those who gave evidence to us both in this country and abroad valued the concept of general practice, but services often fall below the ideal standard described in the quotation. We deal with the role of the GP in Chapter 14.
7.8 GPs are not employees of the NHS but contract with Family Practitioner Committees (FPCs) in England and Wales and health authorities in Scotland and Northern Ireland to provide all necessary and appropriate services within the scope of general practice to patients registered with them. There are variations within this contract; for example, not all GPs provide maternity services but receive extra remuneration if they do. GPs have considerable freedom to choose their own premises, methods of work and the extent to which they are personally available to deal with patients. It is open to them to practise privately, or to hold part-time hospital or other appointments within the NHS, to work in industry or for an insurance company, although the evidence suggests that most GPs undertake little work outside general practice. It is also open to a GP to arrange for a locum tenens or deputy to stand in for him when he is sick, on holiday or chooses not to be available, but the responsibility for his patients remains with him, except where a deputy is on the same FPC or health authority list. This is not true in Scotland and we recommend that the position there should be brought into line with the position elsewhere in the UK.
7.9 Most GPs contract to provide a 24 hour service, although it will be rare for a GP to be personally available all the time. In a well organised group practice GPs cover for each other and may be on call only one or two nights during the week. However, the use of commercially organised deputising services to undertake this responsibility has grown rapidly over the last ten years and about one third of all GPs now make some use of them. In large cities the proportion is much higher. Deputising services are seen by some as a sensible arrangement which enables GPs to get proper rest and relaxation, but by others as striking at the root of general practice. In recent years public concern about the quality and use of commercially provided deputising services by GPs has grown. Complaints most often made in evidence were that the deputy lacked personal knowledge of the patient and access to his medical records that contacting the service could be difficult, that deputies were slow in responding to emergencies and that the standard of some deputies was unsatisfactory. But there are advantages in having a deputising service available, especially for GPs who work single-handed. They can provide an element of flexibility and relieve the burden of night visits and weekend duties.
7.10 In our view, it is in the patient’s interest that GPs should normally ensure continuity of care by providing their own out-of-hours cover. At present FPCs and health authorities have the power to control the use of deputising services by individual GPs and to withdraw approval to use services which are unsatisfactory. They are advised on the use of these powers by representatives of local GPs. We recommend that health authorities should keep under review the operation of deputising services in their areas and, if they are unsatisfactory, improve or replace them. We look forward to the end of unsupervised deputising services.
7.11 The use of appointment systems in general practice has increased substantially during the last 15 years. One recent study suggests that the GPs of three-quarters of all patients surveyed used them, but, in spite of this, surgery waiting times have not declined substantially. Our published study of access to primary care suggests that the introduction of more flexible systems, including sessions with appointments and others where appointments are not necessary, is helpful to patients.
7.12 We received complaints about GPs’ receptionists from patients and from a number of community health councils (CHCs). The main difficulty seems to be that some receptionists appear to patients to make it hard for them to see their doctor. These receptionists may be over-protective of the GP and inclined to take too much on themselves. A receptionist’s life is not always an easy one and the pressures exerted on her by patients may sometimes be considerable. Adequate training for this demanding work is essential. We recommend that, where this does not happen already, the full costs of attendance of GPs’ receptionists at training courses should be met by the FPC or health authority concerned. We hope that education and health authorities will make more courses available for training receptionists, and welcome the health departments’ intention to give guidance on the content of training courses.
7.13 Continuity of care is widely regarded as one of the benefits of general practice. However, patients sometimes find it difficult to see the doctor of their choice for successive consultations and continuity is broken. Very brief consultations, particularly for patients with psycho-social problems, are unsatisfactory and may encourage over-prescribing of psychotropic drugs. Admission to and discharge from hospital without the proper exchange of information between health workers impairs continuity of care. Adequate warning of discharge is required to enable community services to be mobilised. It is not going too far to say that continuity of care may simply not exist in many large The OPCS study on access to primary health care suggests that in one year 15% of people had occasion to use (or take their children to) the accident and emergency departments of large hospitals rather than consult their GP. Fifty per cent of them said that their reason for using the hospital was because it was better equipped to provide the service they required.
7.14 The BMA, in their proposals for a revision of the GP contract, record that:
“In the course of his practice the family doctor recognises his ethical obligation to his patient to provide continuing care. In our view the community is fortunate that GPs’ sense of ethical responsibility for the continuous care of their patients still features so strongly in their attitude to their work, despite the current pressure of demand.”
7.15 We share the view that continuity of care is an important objective for NHS services in the community, particularly for those groups like children and the elderly, who make most use of these services. We now examine whether there is a significant shortage of personnel which might adversely affect the prospects for continuity of care, and more generally the quality of service provided to patients.
7.16 Table 7.1 shows an increase in the number of GPs in the last ten years, and average list sizes have been falling as have the number of home The BMA in its new charter proposals has suggested that average list size should be brought down from its present level – about 2,300 – to about 1,700 patients. Because GPs are free to select and reject patients they can, for the most part, adjust the size of their lists to suit themselves. There is considerable variation in list size, but little is known which would help determine an optimum range of sizes. Consultation time could be extended either by increasing the numbers of GPs, and thus reducing average list size, or by increasing the numbers of other professions who work with GPs and delegating more of the GP’s work to them. We recommend that before a maximum or minimum list size is adopted, considerable research on this important question should be undertaken.
7.17 List size is affected, particularly in areas which are regarded as over-or under-doctored, by the willingness of the Medical Practices Committees (MPCs) to approve the appointment of GP principals. Some GPs restrict their lists, either because they are elderly or not in good health, or because they have other commitments, but the MPC is powerless to introduce new practitioners if an area is numerically over-doctored. Another problem is that list sizes may be inflated in areas where the population is highly mobile. These problems are particularly marked in London. We recommend a review of the present controls exercised by the MFCs to see whether they should be strengthened.
7.18 There are two other measures which we think should be considered. Many GPs over the normal retirement age provide an excellent service, but there seems to us no reason in principle why retirement arrangements for GPs should differ from those for hospital consultants. We recommend that the health departments should consider offering an assisted voluntary retirement scheme to GPs with small lists who have reached 65 years of age. We also recommend that the health departments should discuss with the medical profession the feasibility of introducing a compulsory retirement age for GPs. We are conscious that both these measures may present practical difficulties, notably in relation to pension arrangements, but we would expect that these could be overcome.
Nursing in the community
7.19 We quote below the description of the roles of nurses in primary health care services from a recent circular from the Chief Nursing Officer at the DHSS:
“The Health Visitor is a family visitor and an expert in child health care. She is trained to understand relationships within the family and the effects upon these relationships of the normal processes of growth and ageing and events such as marriages, births and deaths. She is concerned with the promotion of health and the prevention of ill health through giving education, advice and support, and by referring to the general practitioner or to other NHS or statutory or voluntary services where special help is needed. The Health Visitor is a professional in her own right, and she initiates action on behalf of her clients and refers to other agencies as she considers appropriate. She makes a very special contribution by visiting families who may have no other regular contact with health services, or who may be visited by no other voluntary or statutory worker, so that she alone may be in a position to identify physical, mental or social illness or family breakdown, and to alert others as appropriate. She is the leader of a team which may include SRNs, SENs and nursing auxiliaries working in schools or clinics. The scope for the employment of supporting staff, and the nature of the tasks which the Health Visitor delegates to them, will vary according to the needs of the population she serves.
The School Nurse is involved in the health surveillance of school children and in the health education of school children of all ages. The present trend is away from regular medical inspections and towards a more selective system by which school doctors see children brought to their attention by parents, teachers and school nurses. Certain regular screening tests, e.g. for vision and hearing, remain important. Infestation remains a problem in some areas, and must be looked for and treated by school nurses. In some areas school nurses work direct to Health Visitors. There is much benefit to be derived from the closer integration of the school nurse into the primary health care team.
The District Nurse is a SRN who has received post basic training in order to enable her to give skilled nursing care to all persons living in the community including in residential homes. She is the leader of the district nursing team within the primary health care services. Working with her may be SRNs, SENs and nursing auxiliaries. It is the District Nurse who is professionally accountable for assessing and re-assessing the needs of the patient and family, and for monitoring the quality of care. It is her responsibility to ensure that help, including financial and social, is made available as appropriate. The District Nurse delegates tasks as appropriate to SENs, who can thus have their own caseload. The District Nurse is accountable for the work undertaken by nursing auxiliaries who carry out such tasks as bathing, dressing frail ambulant patients, and helping other members of the team with patient care.
Treatment room nurses are employed by some AHAs. These nurses undertake a wide variety of treatments in health centres or general practice premises. In other AHAs the district nursing team undertake these tasks as well as their domiciliary work.
Midwives are, in most areas, working within Midwifery Divisions, but there is an important role for them as a member of one or more primary health care teams in the provision of ante and post-natal care, and health education. They attend confinements of those mothers delivered in their own homes, and may deliver mothers in hospital. Those mothers discharged early from hospital come under their care until responsibility is transferred to the Health Visitor. Midwives in primary health care are professionally accountable for their own work. Midwives are becoming increasingly involved in family planning and genetic counselling.
Practice nurses. Some general practitioners employ nurses on nursing and/or reception duties, and these are known as practice nurses. They may work alongside AHA employed nurses who are attached to the practice, but seldom undertake work outside the surgery premises. They may be included in training programmes organised by the AHA.”
7.20 Although these roles are distinct, they can on occasions be combined. Some nurses in rural areas undertake all three. Nurses in most of these categories are employed by health Authorities and form an integral part of an authority’s nursing resources. A health visitor, for example, may be attached to work with a particular group practice but she remains accountable to the nursing management of the authority. Many GPs also directly employ practice nurses who work under their supervision.
7.21 As Table 7.1 shows, the numbers of health visitors and district nurses have increased in recent years but the number of community midwives has decreased with the falling numbers of home confinements. There has been a marked increase in visits and treatments carried out by district nurses although numbers of staff are well below target level. Cases attended by district nurses in Great Britain have risen from 39.6 per 1,000 population in 1972 to 57.6 in The rate of increase in the number of health visitors has not been as great as that for hospital nursing staff and this at a time when there has been an increasing emphasis on care in the community. The Royal College of Nursing drew attention to the shortage of community nurses in their evidence to us and to the strain which this places on nurses working in the primary care services. It also reduces the effectiveness of other members of the primary care team.
TABLE 7.1
Numbers of General Medical Practitioners, Health Visitors, District Nurses and Community Midwives: Great Britain 1967-1977
whole time equivalents
| 1967 | 1972 | 1977 | |
| General Medical Practitioners (number) | 24,005 | 25,183 | 26,810 |
| Health Visitors | 6,403 | 7,608 | 10,248 |
| District Nurses | 9,369 | 11,359 | 14,929 |
| Midwives | 5,685 | 4,654 | 3,399 |
Source: compiled from health departments’ statistics.
7.22 Community nursing services are highly important to the improvement of services in the community. They have not yet been fully developed, and we recommend that the health departments continue their current plans for their expansion. Community nursing services are an essential element in the support of patients and their families, giving care in their own homes, and we have been impressed by the satisfaction which most community nurses find in their work. But there is a need for more research into the way nursing services are provided. As the Royal College of Nursing said in its evidence to us:
“The provision of primary care has grown up in the rough and tumble of empiricism and little research has been done into the changed needs for primary care in the community. There are a number of questions that need to be asked about the traditional roles of the various members of the team and the training they receive to fit them for those roles.”
7.23 There has been a growing trend towards the attachment of district nurses to general practices. Attachment can mean that a nurse works exclusively with one general practice or with a number of them. A survey in England carried out in 1974 found that 68% of practices had attached nurses. Well equipped and designed health centres encourage attachment of district nurses to general medical practices, but the development of a team approach to primary care requires an understanding of and respect for the professional roles of its various members. Attached district nurses may be torn between the heavy demands of maintaining patients in their own homes and treatment work in GPs’ surgeries. In addition patients on a GP’s list may be widely dispersed and this may mean additional travelling for district nurses. Many see home nursing as their primary function. We welcome the introduction of a new syllabus and mandatory training for district nurses.
7.24 Increasing numbers of health visitors are attached to general practices, but here the working relationship is more complex and they retain a geographical responsibility in addition. Florence Nightingale was the first to comment on the distinctive features of nursing the sick and what she called “nursing the well”. Health visitors are unique in the health team because of their contact with the “well population”. They visit families on their own initiative in the absence of crisis and hence are often the first point of contact with the NHS. The health visitor is a key worker in the primary health care team and makes a major contribution to its role in prevention and health Her training equips her to assess the social aspects of health and disease and gives her a knowledge of epidemiology. The health visitor’s work may be aided by access to the age/sex register of the GP’s list, but she also needs an identifiable geographical area for case-finding. Her work relates to that of the community physician and the GP and she needs to have a working relationship with both. We welcome the advances which have been made in the education and training of health visitors which should help them to achieve their full potential.
7.25 Nurses working in the community, who are employed by health authorities and attached to work in a health centre or group practice, sometimes experience a conflict of loyalties between the team with which the nurse works and her superiors in nursing management. The problem is not unique to the community nurse – the hospital nurse has also a dual loyalty to the clinical team, of which she is a member, and to nursing management in the health authorities. The difference is that the community nurse works in relative professional isolation. Community nurses certainly need access to professional advice and support, and it is important for nursing management to ensure that community nurses keep up-to-date with professional developments and to prevent unnecessary distortions in their workload, but these matters need to be handled sensitively.
7.26 We think that there is considerable scope for expanding the role and responsibilities of health visitors and district nurses. As Dr Jillian MacGuire pointed out in a review of the current literature on nursing roles which she prepared for us:
“the involvement of nurses in screening both the very young and the elderly is already well accepted … It is not yet routine in all practice settings for nurses to be the main contact for elderly patients … In many cases the nurses are effectively making first contact decisions anyway though this may not always be recognised for what it is.”
We consider that there are increasingly important roles for community nurses, not just in the treatment room but in health surveillance for vulnerable groups and in screening procedures, health education and preventive programmes, and as a point of first contact, particularly for the young and the elderly.
7.27 We recommend that the health departments promote research intonursing in the community. Some of the issues which need investigation are:
- the workload of district nursing and the respective demands of domiciliary care and treatment room work
- the respective roles of district nurse, treatment room nurse and practice
- nurse vis-a-vis the GP;
- their training and lines of responsibility;
- the use of aides in community nursing; and
- standards of care.
Quality of care
7.28 In Chapter 3 we pointed to the difficulties of measuring the performance of the NHS. We deal generally with quality control questions for the health professions in Chapter 12, and standards of nursing care in Chapter 13, but there are particular difficulties in general practice and good reason to think that standards of competence are not always as high as they might be. The RCGP told us:
“our picture of the assets of good general practice must be balanced by the frank recognition that care by some doctors is mediocre, and by a minority is of an unacceptably low standard.”
7.29 We agree with this admirably candid view and we think there are three main reasons for this state of affairs. First, GP training is often inadequate. Whereas several years hospital training, and normally a further qualification, is required before a doctor can be appointed as a consultant, the would-be GP can go straight into general practice as soon as he has completed his pre-registration clinical year. The undergraduate education of doctors gives relatively little emphasis to experience in the community yet, in contrast to the hospital specialities, there is no requirement for GPs to undertake extensive post-graduate training. This will be largely remedied when the National Health Service (Vocational Training) Act 1976 makes post-registration training for GPs compulsory in 1981. The GP will then be obliged to spend three years in further training before becoming eligible for a post as an unrestricted principal in general practice. This will help to raise standards; but, as in other specialities, experience in itself will not be a sufficient indication of quality of performance; it will need to be tested and competence demonstrated. As with hospital specialities, possession of the post-graduate qualification of the relevant Royal College should become the norm for appointment as a principal in general practice. There are two aspects of the post-graduate education of GPs to which we would like to see prominence given; further experience and training in the psychological aspects of general practice and in clinical pharmacology.
7.30 Second, there is no mechanism for setting national standards in the selection of principals in general practice. GP partnerships choose their own new partners, subject to the formal approval of the FPC or health authority. In the case of single-handed vacancies, FPCs and health authorities set up committees on equal numbers of lay members and representatives of local GPs to advise on new appointments. For the most part the system seems to work reasonably well, but on some occasions selection committees have to choose between poor quality applicants and it may then be in patients’ interests that no appointment is made. The appointment of a poor applicant will simply tend to perpetuate a poor quality service. However, there is a statutory obligation on the MFC to make appointments to single-handed posts even if no suitable applicant is available. We recommend that consideration be given to this obligation being removed. We recommend, also that national or regional panels are set up to provide external assessors for each new appointment of a principal in general practice. The constitution of such a panel or panels should be discussed between the health departments, the RCGP and the BMA.
7.31 Third, GPs are often isolated and lack the close contact with professional colleagues which is available to those who work in hospitals. There are no mechanisms for ensuring that their standard of work is high, and their earnings depend mainly on the amount, rather than the quality of care GPs have in the past rejected an extension of the distinction awards system to general practice. By contrast, hospital medicine provides elaborate financial inducements. In the training grades, doctors work towards a consultant appointment, for the new consultant there is the possibility of a distinction award, and for the consultant who already holds an award there is the prospect of one at a higher level.
7.32 In some places forms of audit of GP services have already been introduced or are under consideration. Better record keeping, systematic self-criticism, and the inspection of training practices should lead to improvements in standards. In our view a more formal mechanism is required. We suggest that in each health authority area a “division” of general practice to which all GPs would belong should be set up. It might be developed out of the local organisation for post-graduate education, or it might take a form similar to that of the clinical divisions in hospitals. It would act as a forum for medical audit and other methods of raising professional standards. The health departments and health authorities have a duty to encourage good standards of practice and should check progress, but the detailed arrangements should be a matter for local professional decision and experiment. We recommend accordingly.
7.33 We had evidence which suggested that in many practices the system of record keeping was antiquated. Reliable and comprehensive records are vital to the primary health care team and to health service planning. Data are required for identification of populations at risk, and for screening and GP records need to be brought up to a high standard and to be in a form which facilitates linkage with hospital records and those kept by other health workers in the community. Better record keeping would encourage practice-based research and assist in peer review. We recommend that the introduction of the A4 records system should be given high priority.
7.34 The GP is ideally placed to study the natural history of disease, the family setting of illness, and recurrent or chronic conditions. The RCGP has made notable contributions to research, particularly in studies of morbidity and multi-centre treatment trials. Individual practitioners have also made important observations, and more can be expected from the departments of general practice which have been set up in many medical schools. Until recently the lack of an established post-graduate training programme for GPs, and the fact that the GP’s contract makes no financial provision for research, has meant that much less research has been carried out in general practice than in hospitals. However, the spread of health centres and group practices should provide a better base for collaborative studies, and the increasing numbers of GPs with post-graduate qualifications should lead to an expansion in research. Neither the Medical Research Council nor the health departments earmark funds for research in general practice, but there is no doubt that good quality projects will be supported. Further research is required into for example, the functions of primary care teams, the use of drugs, the relationship between hospital and community care, the size of GP lists (referred to in paragraph 7.16).
7.35 FPCs and health authorities have power to ensure that the provisions of GPs’ contracts are complied with, and to inspect their premises. During our own visits to primary care services in different parts of the UK we saw some premises which were clearly unacceptable. We recommend that FPCs and health authorities should use their powers vigorously to ensure that patients are seen by their GPs in surgeries of an acceptable standard. More generally, FPCs and health authorities should monitor carefully the way in which GPs’ contracts are discharged.
Prescribing
7.36 In 1977-1978 the total cost of drugs, dressings and appliances prescribed by GPs in the UK was f 539.5m. The cost of all other prescriptions was about £127m, most of which was incurred in hospitals. The bulk of the £539.5m went on drugs. Although international comparisons suggest that the health departments have been fairly successful in keeping drug prices down, we have been concerned at the size of the GP drug bill. Total prescriptions dispensed and the average quantity of drugs prescribed have been rising steadily; and there are indications of over-prescribing, particularly of psycho-tropic drugs. There is a particular problem of high levels of GP prescribing costs in Wales. Some figures are given in Table 7.2.
TABLE 7.2 Number and Cost of Prescriptions: Great Britain 1949-1977
| Unit | 1949 | 1959 | 1968 | 1969 | 1970 | 1971 | 1972 | 1973 | 1974 | 7975 | 1976 | 1977 |
| Number of prescriptions Thousands | 219,188 | 236,055 | 295,875 | 292,339 | 295,462 | 294,389 | 304,944 | 313,797 | 326,019 | 334,648 | 348,490 | 351,331 |
| Total cost £thousand | 33,838 | 81,336 | 169,550 | 182,386 | 200,865 | 224,266 | 255,270 | 279,465 | 327,497 | 431,613 | 542,251 | 665,200 |
| Net ingredient cost £thousand Persons on NHS | — | 51,777 | 122,742 | 134,714 | 148,339 | 164,674 | 186,486 | 205,581 | 245,857 | 317,611 | 412,255 | 520,600 |
| prescribing lists Thousands Average | — | 47,590 | 52,072 | 52,065 | 52,796 | 52,903 | 53,126 | 53,279 | 53,609 | 53,544 | 53,566 | 53,696 |
| prescriptions per person on list Number | — | 4.96 | 5.68 | 5.56 | 5.60 | 5.56 | 5.74 | 5.89 | 6.08 | . 6.25 | 6.51 | 6.54 |
Source: health departments’ statistics.
Note: these figures represent the number of NHS prescriptions for drugs, medicines and specified appliances dispensed by retail pharmacies, drug stores and suppliers of surgical appliances in contract to FPCs and health authorities; most of the items are supplied on NHS prescriptions given by family doctors (other than doctors who themselves dispense for their patients) but a small number are given by dentists and at NHS hospitals and clinics at such stations of Service Departments that have no dispensing facilities.
7.37 The GP controls what is prescribed, but patients’ expectations may encourage him to prescribe even though there may not be a clear clinical need. Medicines prescribed in hospitals are set against health authorities’ cash limits, but there is no such limitation on GP prescribing; in effect the NHS has an open-ended commitment to meet the cost of whatever GPs prescribe. This can encourage GPs in bad and expensive habits, such as leaving repeat prescriptions to be handed out by receptionists and prescribing drugs by brand name when cheaper therapeutic equivalents are available.
7.38 GPs are also subjected to massive pressure from the drug companies. A study in 1974-1975 showed that a typical GP may be exposed to over 1,300 advertisements for 250 drugs each month. In 1977 the cost of sales promotion in the UK by drug companies was about £71m, most of it aimed at GPs. The relative isolation of many GPs from pharmacologist and clinical colleagues adds to their problems in evaluating this mountain of material.
7.39 From time to time, health ministers have exhorted the public not to ask for medicines which they feel they need and for which a prescription is unnecessary, but most of the effort in keeping down the GP drug bill is rightly directed at GPs themselves. It consists of a mixture of information, exhortation and threat.
7.40 Last year the health departments agreed with the drug industry that advertising material would have to contain specified information on the active ingredients of the drug, the circumstances in which it should and should not be used, dosage, side effects, precautions and cost. Approved fact sheets have to be given to a GP when he is visited by a drug company representative. The amount of tax deductible sales promotion expenditure allowed to drug companies is also to be reduced, a measure which we support. More positively, the health departments distribute the British National Formulary (BNF) and the Prescribers Journal free to all GPs, draw up charts which compare the costs of similar drugs, and, except in Scotland, help the Consumers Association to distribute the Drug and Therapeutics Bulletin to young doctors at no cost. We recommend the early re-issue of the BNF in portable loose-leaf form. It should be kept up-to-date and should include separate information about costs.
7.41 GPs’ prescribing is monitored but subsequent comment reaches individual GPs very slowly. In England and Wales if analysis shows a GP’s prescribing habits to be markedly out of line with those of other colleagues in the area, a regional medical officer of the health department may visit him and discuss his prescribing. However, in England about 7% of GPs are visited in this way each year although some 10% prescribe at a cost of 25% or more above the average per person for GPs in their FPC area. In principle, excessive prescribing may, if it persists, lead to the GP having part of his remuneration stopped but in practice this rarely happens and no GPs in England have been “fined” in this way since 1972.
Controls and incentives
Charges
7.42 We discuss the general question of charging for NHS services in Chapter 21. At present prescription charges are made at a flat rate of 20p for most items although 60% of all prescriptions are dispensed at no cost to the patient. It is often suggested that charges should be adjusted to reflect the full cost of prescriptions to bring home to patients and GPs the cost of their treatment. It seems clear that the benefits of a scheme of this kind are likely to be outweighed by the drawbacks. In any case a patient cannot get a prescription unless a GP agrees to give him one.
Limited list
7.43 Some countries have drawn up lists of essential and effective drugs. In Denmark, Australia and New Zealand listed drugs are prescribed free or at low cost, but patients are charged in full for drugs not on the list. This means that the GP is free to prescribe what he thinks is best for the patient but the cost of prescriptions is transferred from the taxpayer to the patient if a drug not on the list is prescribed. A limited list should lead to improvement in the quality of prescribing by the elimination of ineffective and unnecessarily expensive drugs. It is difficult to estimate the potential savings that would result as much would depend on the composition of the list but a reasonable estimate is of savings of the order of £ 10-£20m per annum.
Generic prescribing
7.44 Another approach is to require GPs to prescribe by the generic name of the medicine, as opposed to its brand or proprietary name. Some GPs do this already but in 1977 only about 14% of NHS prescriptions in the UK were non-proprietary. If there is a good deal of difference in the price of drugs whose therapeutic qualities are virtually identical, generic prescribing should yield some savings. Adoption of this measure would be likely to reduce the amount of promotional literature from the drug companies to GPs. However it seems uncertain that savings would be considerable and it might be necessary to recast the level of payment to chemists to take account of the new prescribing patterns.
Quantity limitation
7.45 A further possibility is to require GPs to prescribe for a limited period. In New Zealand, for example, GPs are generally restricted to a week’s supply per prescription. But one result might be an increase in repeat prescriptions, and unless GPs were strict in checking them the benefits would be slim.
7.46 The measures listed above are generally applicable both in hospitals and general practice. Improvement in the quality of GPs’ prescribing probably depends most on their being given the training and information necessary to make sensible choices. In this the educational role of university departments of clinical pharmacology and post-graduate medical education committees is of great importance. There is no evidence that patients benefit from the flood of promotional literature which descends on GPs each week. The most promising of the methods of securing a greater economy and effectiveness in GPs’ prescribing which we have considered are the limited list and generic We recommend that the health departments should introduce a limited list as soon as possible and take further steps to encourage generic prescribing.
Health Centres
7.47 A recent DHSS circular defined health centres as:
“premises provided by an area health authority where primary health care services are provided for patients by general medical practitioners, health visitors and district nurses and possibly other professions.”
Although not every health centre provides all these services, ante-natal, preschool and school health services, immunisation and vaccination are usually provided in health centres in addition to GP and community nursing services. The circular suggests that health centres may also provide facilities for:
“health education, family planning, speech therapy, chiropody, assessment of hearing, ophthalmology, physiotherapy and remedial exercises, and community dental services; general dental, pharmaceutical and general ophthalmic services, hospital out-patients services and supporting social work services may also be provided.”
7.48 Health centres represent a departure from the traditional pattern of general practice. Their supporters emphasise the opportunities they offer for providing integrated services and closer links with hospitals. Their opponents see them as undermining the independence of the general practitioner. In a rapid expansion of the health centre programme in recent years in England and Wales there has been an increase from 212 in 1972 to 731 health centres in 1977 with more than 200 planned for the future. Development has been even more rapid in Scotland and Northern Ireland. However, there is evidence from a recent survey that health centres are by no means universally popular with either GPs or patients.
7.49 The increase in health centres has been less rapid in the conurbations where they are most often needed and is slowing down in places where there is already a high concentration, in Northern Ireland, for example. Only 15% of GPs in the metropolitan counties in England work in health centres against a national average of 17%, and at the end of 1975 Greater London had only 54 health centres, hardly more than Greater Manchester. Some health centres are being provided in inner city areas through the current inner city area partnership scheme. Under this scheme, government and local authority provide new facilities in a number of inner city areas with additional resources provided by central government.
7.50 Doctors, nurses and the other professions who together provide care in the community do not necessarily require purpose-built premises to work together efficiently. Nor does working under the same roof guarantee good But it seems to us that health centres serve several purposes: they can set standards, they can make it easier to experiment with different methods of providing primary care and they can house a wide range of services – for example, consultant out-patient clinics, diagnostic and paramedical services. In our view they can significantly improve the quality and accessibility of services to patients. GPs are not obliged to work in health centres although the recent rapid expansion suggests that many find them attractive. Improvement grants are available to those practising from their own premises, but health centres require no capital from the GP and the rent (but not running costs) is fully reimbursed by the FPC or health authority. They appear to offer clear financial advantages to GPs but in some cases a rapid rise in running costs has led GPs to withdraw from participation in proposed new or existing centres. We recommend that the health departments consider whether high running costs are acting as a significant disincentive to GPs to work in health centres. We understand that in Northern Ireland a standard charge is being introduced and that a similar arrangement is under consideration in Scotland.
7.51 It would be foolish and unprofitable to try to force general practice into one particular mould. There is no reason why standards should not be as high and facilities as good in premises which are owned by GPs as they are in the best health centres. However, the development of health centres or other suitable premises to attract GPs to London and other inner city areas where sites are particularly expensive and difficult to obtain, must be given priority. We recommend that the health departments consider urgently how best this can be done. In some places local authorities can assist health authorities by releasing land for new development. An increase in the current level of improvement grants for practice premises, and better terms for loans from the General Practice Finance Corporation might also help.
Problems of Rural Areas
7.52 We received some evidence, in particular from the National Federation of Womens’ Institutes, which suggested that both patients and health workers face particular problems in remote rural areas. We mention the difficulties of providing pharmaceutical services in country areas in Chapter 8. Public transport in rural areas is dwindling. Many GPs are single-handed and often cannot find locums to enable them to leave their practices for postgraduate education or holidays, or even to substitute for them when they are ill. A research project commissioned by the Scottish Consumer Council highlighted the special difficulties of providing a full range of primary care services in the Western Isles. An inducement scheme to attract GPs to the remoter areas already exists and similar measures may be required to attract other health workers. We are aware of the impressive contribution made by those who work in these areas, often under difficult conditions, and we urge the health departments to improve conditions of service for them, particularly in the provision of locums.
Problems of Declining Urban Areas
7.53 There are problems, also, in providing health services in declining urban areas. Many arise in industrial towns and peripheral post-war council housing estates as well as in decaying inner city areas. Obviously, not all cities suffer from the same problems. The White Paper “Policy for the Inner Cities” drew attention to a number of symptoms common to the decline of many inner city areas. These include high unemployment due to firms closing and moving out of the city centre, high concentrations of semi-skilled and unskilled workers, old and poor housing, high population density, and concentrations of the homeless and destitute and of members of ethnic minorities. Some of these symptoms are due to economic decline and the accompanying poverty and social problems, but others may arise from the high cost of accommodation or the special demands of an aged, migrant or homeless population.
7.54 These features of urban decline add considerably to the difficulty of providing health services. A study of the Birmingham inner city area in 1975 recorded that local doctors considered that medical problems prevalent in the area, such as respiratory disorders, poor hygiene and anxiety, were directly connected with poor housing, environmental and, to a lesser extent, cultural Low take up of health services is common in inner city areas. Staff may be discouraged from working in them by poor working conditions and the effects of vandalism and crime
7.55 Many health professionals are coping courageously and effectively in these areas, but there is evidence in some places that services are inadequate. GPs, nurses, health visitors, social workers, receptionists and secretaries are no more likely than anyone else to want to live and work in unattractive urban areas. In England metropolitan AHAs have lower than average health visitor and district nurse staffing ratios in spite of their greater needs. Where health authorities can fund an agreed complement of nurses in the community it may still be difficult to fill vacancies. The GPs tend to be older and to have large lists. The accepted view today is that a GP will work most efficiently in a group practice or partnership with several other GPs and there may be some connection between the extent of single-handed practice and low quality of care although there are many excellent single-handed GPs. More single-handed practices are found in inner city areas.
7.56 In these areas, health professionals have an innovative part to play in reaching those people who do not make sufficient use of NHS services. This is particularly important in the care of children and here the health visitor’s role is highly important. The development of a special interest in paediatrics and the appropriate training among inner city GPs should be strongly encouraged.
London
7.57 London’s size, density of population and concentration of medical teaching facilities give rise to particular problems. We deal here with the city’s primary health care difficulties, and in Chapter 17 we recommend that an enquiry into London’s problems should be mounted, including the special difficulties of providing primary care services in the metropolis. Some of the problems of inner city areas are seen at their most acute in London. In 1977 31% of London GPs were single-handed compared with an average of 16% in England and their average age was 51 (1978). Many practices have small lists; 35% of London practices have fewer than 2,000 patients (against the national figure of almost 20%). Some London boroughs and health authorities are chronically short of social workers and nurses. GPs and other health workers generally live some way from where they work. This inhibits the provision of a 24 hour service by the GP and encourages the use of deputising services. In parts of London GPs’ involvement in private practice may lead to a restriction of NHS list sizes.
7.58 In some declining urban areas and in parts of London in particular the NHS is failing dismally to provide an adequate primary care service to its patients. While the NHS cannot be expected to solve all the problems of these areas we consider that it has a clear responsibility to improve the quality of its services in them and we outline below ways in which this might be achieved.
7.59 The complex and disparate problems we have referred to suggest that no single solution will suffice. Good practice premises are a vital incentive to staff of high quality to work where they are most needed. The NHS has a clear responsibility to ensure that adequate premises are provided. We were pleased therefore to note that recent DHSS advice urges health authorities to give priority to building health centres in “health deprived” localities and specifically allows the building of health centres, even where there is no assurance that local GPs will staff them. We recommend that health authorities, when establishing such new health centres, should experiment with offering salaried appointments and reduced list sizes to attract groups of doctors to work in them.
7.60 In some urban areas patients use out-patients departments of large district hospitals for primary care rather than local GP services. Many teaching hospitals are found in inner city areas. We think these hospitals have the responsibility, which they have not always shouldered, to foster and improve the quality of primary care services in their surrounding areas. One possibility, since they already give primary care in their accident and emergency departments, would be for them to provide teaching practices within their own perimeter to help to meet the needs of their neighbourhood. Professional incentives for GPs working in inner city areas are often lacking and teaching hospitals could do more to fill this gap by co-operating with local practitioners in providing teaching and research opportunities and encouraging hospital practitioner appointments. Consultant sessions in health centres would also help to promote the integration of hospital and community services.
7.61 A more imaginative approach to dealing with the special needs of inner city populations is needed. Homeless people in particular may find it difficult to use the NHS. The evidence we received from the Campaign for the Homeless and Rootless quoted a survey by a Liverpool CHC in 1976 which suggested that 6 out of 10 homeless people in Liverpool were without a GP. Experiments in providing services for them have been carried out in a number of cities, including Edinburgh and Leeds, and further research and experiment is required. Inner city area partnership funds could be a useful source of finance. The special needs of patients who come from ethnic minorities require sensitive handling by the NHS. The evidence we took from their representatives suggests that many NHS workers are not aware of cultural, language, literacy and dietary problems which may affect these groups. Training in their needs and problems for personnel who work with them is needed.
7.62 New financial inducements to attract GPs and other health personnel to work in inner London and elsewhere in severely deprived urban areas may be required. At present GPs, for example, do not receive a London weighting It might be feasible to provide differential capitation fees for GPs in such areas to take account of their heavier workloads. Other possible incentives are the provision of housing, a car, clerical support and a telephone.
7.63 Improving the quality of care in inner city areas is the most urgent problem which NHS services in the community must tackle. Many of the difficulties are severe. Additional financial resources are needed and, in the case of London in particular, this will involve hard choices. We recommend that they are provided. Many London health authorities’ expenditure is being squeezed as a result of the application of the RAWP formula. The London RHAs must make additional provision in distributing funds for primary care services to inner city AHAs to ensure that the improvement to services which we recommend is not impeded by lack of finance.
Conclusions and Recommendations
7.64 Changes in the structure of the population and in health care priorities mean that the demand on and for general practitioner, nursing and related services in the community will increase during the next decade. These services are generally provided to a good standard but improvements are needed in a number of directions. The development so far of the primary health care team has been encouraging, but there is a continuing need to encourage closer working relationships between the professions who provide care for the community. District nurses and health visitors have a particularly important part to play. There have been a number of promising developments which have enhanced the quality of general practice, but more should be done to improve the training and continuing education of GPs. Improvement of the standard of existing premises is required and so are more health centres. Better training is needed for receptionists, and deputising services should be brought under closer control. More research should be undertaken into a number of aspects of community services.
7.65 To a large extent GPs can control their own prescribing costs but they have little incentive to keep them down and they are subject to pressures from pharmaceutical companies and patients to prescribe expensively and often A more radical approach to this problem is required.
7.66 The major challenge to community services is the provision of services in declining urban areas. The health needs of patients who live in these areas are complex, and the health departments alone cannot provide all the answers. A much more flexible and innovative approach to improving services in them is needed.
7.67 We recommend that:
- the legal position regarding responsibility in the use of deputising services in Scotland should be brought into line with that elsewhere in the UK (paragraph 7.8);
- health authorities should keep under review the operation of the deputising services in their areas and, if they are unsatisfactory, improve or replace them (paragraph 7.10);
- where this does not happen already, the full costs of attendance of GPs’ receptionists at training courses should be met by the FPC or health authority concerned (paragraph 7.12);
- before a maximum or minimum list size is adopted, considerable research on an optimum range of list sizes should be undertaken (paragraph 7.16);
- there should be a review of the controls on the appointment of GPs exercised by the Medical Practices Committees (paragraphs 7.17 and 30);
- the health departments should consider offering an assisted voluntary retirement scheme to GPs with small lists who have reached 65 years of age (paragraph 7.18);
- the health departments should discuss with the medical profession the feasibility of introducing a compulsory retirement age for GPs (paragraph 18);
- the health departments should continue their current plans for the expansion of community nursing (paragraph 7.22);
- research is required into a number of aspects of primary care (paragraphs 7.27 and 7.34);
- national or regional panels should be set up to provide external assessors for each new appointment of a principal in general practice (paragraph 7.30);
- GPs should make local arrangements specifically to facilitate audit of the services they provide and the health departments should check progress with these developments (paragraph 7.32);
- the introduction of the A4 records system in general practice should be given high priority (paragraph 7.33);
- FPCs and health authorities should use vigorously their powers to ensure that patients are seen by their GPs in surgeries of an acceptable standard (paragraph 7.35);
- the British National Formulary should be re-issued soon in portable, loose-leaf form with separate information on drug costs, and be kept up-to-date (paragraph 7.40);
- the health departments should introduce a limited list of drugs as soon as possible and take further steps to encourage generic prescribing (paragraph 7.46);
- the health departments should consider whether high running costs are acting as a significant disincentive to GPs to work in health centres (paragraph 7.50);
- the health departments should consider urgently measures to assist the development as a priority of health centres or other suitable premises to attract GPs to London and other inner city areas where sites are particularly expensive or difficult to obtain (paragraph 7.51);
- health authorities when establishing health centres in inner city and deprived urban areas, should experiment with offering salaried appointments and reduced list sizes to attract groups of doctors to work in them (paragraph 7.59);
- additional financial resources should be provided to improve the quality of primary care services in declining urban areas (paragraph 7.63).