Asking tough questions about primary care

Health care reformers tend to focus attention on hospitals and payment systems and yet primary care, where most patients are seen, receives comparatively little attention.

While it is acknowledged that hospitals are now poorly suited to the different types of patients they have to treat, the fact that primary care faces similar problems is rarely acknowledged. The recent Nuffield Trust European Health Summit, supported by KPMG sought to redress this balance.

Across Europe, primary care is often characterised by small and isolated practices, with few support staff, limited access to diagnostics and offering relatively short appointments with a doctor.

This looks increasingly unsuitable, and a number of countries report that primary care is struggling to act as the care coordinator for more complex patients.

For this reason, many countries have been investing in primary care and there has been an increase across Europe in the number of family doctors and support staff. Common trends include:

• The development of family medicine as a specialty;
• The encouragement of group practices;
• Increased teamwork between different health professionals;
• Increases in the range of services provided by primary care professionals;
• Introduction of additional payment for some services, particularly prevention.

However, the question remains: is a new model of provision required, and is primary care the right answer to today’s problems? Participants at our recent summit were largely drawn from primary care, and might have been expected to be supportive of its potential.

They were, but they envisaged some quite different models of primary care-based services from those we have known to date. Some of these are already in operation, and we explored them at the summit. These new models of care take different forms but have a number of things in common.

Firstly, they are significantly larger than the traditional practice and offer a range of health and other services that go beyond the usual scope of primary care including diagnostics, chronic disease management and, in some instances, social care and other related services.

Secondly, many were succeeding in attracting specialists to come and work alongside them. Another common theme was to resist the trend towards a single disease focus for care pathways and management, and instead to look at populations, the whole patient, frail older people and other more holistic ways of working.

A fourth theme was the creation of a more professional approach to the management of primary care, enabled by the larger scale of organisations. A key element in all these approaches was a sophisticated electronic patient record which increasingly is open to other professionals in the health system, although less frequently to the patient.

Interestingly, we heard quite a bit about the importance of continuity of care, and some practices were organised so that patients requiring continuity can see their own GP. This requires some quite different ways of working, but is it not possible to create continuity using the electronic record?

This provoked some interesting debate but there was a strong view that knowing the patient and their background intellectually from a record was not the same as caring about someone you have looked after for years. Not something often captured in the research.

There is more to do however. Better integration with social care and specialists is important but developing and managing these relationships has tensions. Patients need more help to take control over their own health and many of those at the summit were dealing with a rise in attendances, often from people with minor conditions who could care for themselves.

One solution to the problem of demand is the idea, dating back to Alma Ata, that primary care should get upstream and into social determinants of ill health, and health education.

This split summit participants and, apart from a small number, there was a feeling that perhaps primary care lacks the skills and capacity for this. I was left thinking that they have enough to do to sort out their own areas of responsibility before tackling education and social inequality.

There are some areas where more debate is needed. For example, how specialist should primary care become? A recent study suggests that generalist primary care is doing badly with acutely ill children and children with complex conditions. Multi-morbidity is very complex and time consuming – should there be specialists to deal with this within primary care?

Even more challenging was a view from India where the shortage of workforce means that creating a European model of primary care based on family medicine is out of the question. This delegate asked, isn’t this really about activities that could be done by different providers: one specialising in prevention, one in episodic care and the third dealing with chronic disease and multiple-morbidity?

There was a long and thoughtful pause, but no time for an answer.

Nigel Edwards is Director at Global Healthcare Group, KPMG UK. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.

This was was also published on the GP Commissioning website.