Select Committee on Health Minutes of Evidence


Memorandum by The Royal College of General Practitioners (PH 74)

PRIMARY CARE AND THE PUBLIC HEALTH FUNCTION A DISCUSSION DOCUMENT IN RESPONSE TO "SAVING LIVES: OUR HEALTHIER NATION"


INTRODUCTION

  This year has seen:

    —  the end of fundholding;

    —  the creation of primary care groups;

    —  the arrival of Health Improvement Plans; and

    —  the publication of Saving Lives: Our Healthier Nation in England.

  All these changes affect the relationship between primary care and the public health function of the health service. This document sets out the nature of those changes and their implications. Although the same issues apply in Scotland, Wales and Northern Ireland, this document directly addresses Saving Lives: Our Healthier Nation which is an English document.

BACKGROUND

  General practice is and always has been based on the concept of personal doctoring. The unique doctor-patient relationship is at the core of our discipline. Often developed over sustained period of time, it is built on the care of the patient, the trust that the patient has in their doctor, their doctor's advocacy for them within the health and social care services, and the doctor's understanding of that patient, their family and their community.

  When the NHS was formed in 1948 general practitioners did little more than personal doctoring, focussing on presented acute and chronic illness. In the last 50 years we have seen a widening of the scope of the discipline of general practice and primary care. After the GP Charter in 1966, general practice saw the advent of primary health care teams and an expectation that they would play a role in prevention of illness. General practitioners moved from being reactive to patients to, in addition, identifying and meeting individual patient needs proactively. The continuing long-term care of patients with chronic disease became an intrinsic part of general practice.

  General practice, through its registered patient base and right of referral, holds the only complete life long health record. It has experience of looking at the health needs of individuals and populations, and striving to match services to those needs. General practitioners and members of the primary care team are part of their local community and have an understanding of that community's needs, culture and expectations.

  Fundholding involved general practitioners and primary care teams in a range of activities from purchasing to contracting to commissioning. Those who were involved in commissioning required to identify the health needs of their population and to use the mechanisms of fundholding to ensure the provision of services that most appropriately met those needs.

  Personal doctoring has not reduced. General practitioners undertake about 300 million consultations a year in the United Kingdom—about 90 per cent of all consultations within the NHS1. The continuing development of primary care places new and additional responsibilities within it.

PRIMARY CARE BASED PUBLIC HEALTH

  The Black Report2, The Health of The Nation3, the Report on Variations in Health4, the Acheson Report5 and now Saving Lives: Our Healthier Nation6 (and its accompanying paper on health inequalities7—a response to the Acheson Report) all reinforce the imperative to address inequalities in health care. The Royal College of General practitioners has repeatedly and urgently stressed the need for co-ordinated and effective action to address health inequalities—our concerns have not yet been met.

  Some illnesses are genetically inherited and others are acquired by chance. However, there is now clear evidence that education, socio-economic status, ethnicity, gender, housing, life events, lifestyle, life choices (including high risks, ones) and the environment all influence health status and health outcomes. Many of the major gains in life expectancy achieved in the past century have been due to improvements in "public health"—supplies of clean, safe water; sanitation; better housing; clean air; reduction in smoking; seat belts; motorcycle crash helmets; road design; smoke alarms . . . While clinical care has made its contribution (witness the improved survival for many cancers), the significant effects in population terms, especially in the first half of this century, have been in the public health field.

  In recent years there has been an increasing conjunction between clinical primary care and the public health agenda. There has been a growing involvement of general practices in immunisation, cervical cytology, advice on smoking, alcohol, diet and weight, early detection and treatment of hypertension and dyslipidaemias, and the secondary prevention of the complications of ischaemic heart disease and diabetes.

  Clearly such an ambitious agenda is not solely one for the medical profession, whether in general practice or public health. It crucially involves patients in understanding their personal responsibilities for their health and the health of those around them. Such empowerment can best occur within a long-term personal relationship, as occurs in general practice. The emphasis on personal responsibility for health in Saving Lives is very welcome.

  Some of these activities have addressed, mainly in passing, health inequalities. However, many have, perversely, widened the divide since their effect is greatest on those with currently the best outcomes. Better educated patients attend well person clinics and undergo more screening procedures. The better off have stopped smoking more than the poorer. Asian patients may experience linguistic barriers in accessing diabetic care—and they have a higher prevalence of diabetes.

  The new paradigm of primary care based public health calls for general practice to move from action "down stream", where the effects of a problem are seen, to "upstream" where the causes are, whether those causes are strictly within the disease model or within the wider social, economic or environmental models. (See Annex for examples.)

  To achieve this we must have access to training for established general practitioners. Perhaps more importantly, such training must be offered to general practice registrars and to young principals. The opportunities should include public health posts within vocational training schemes and attachments for general practitioners. Places should be funded for general practitioners to attend MPH courses.

IMPROVING EQUALITY OF HEALTH STATUS AND HEALTH OUTCOME

  The health experience of patients depends on much more than primary care in its current form. Those practices undertaking a health needs assessment of their local population have uncovered issues that range far beyond health care. This is illustrated in the three examples in the Box. In one practice a rapid appraisal undertaken as part of a health needs assessment of the elderly revealed that the main problem was social isolation—loneliness8.

  However, we must not lose sight of the inequality that exists, whatever its origin, in health status and health outcome. Poorer communities experience more ischaemic heart disease and have fewer surgical interventions (angioplasty or CABG). Depression and other forms of mental illness are more prevalent in deprived areas. Black and minority ethnic communities experience poor access to health services. The "inverse care law" still holds true. We must strive for services to be linguistically, culturally and structurally appropriate for the patients we serve.

  The overall discrepancy in life expectancy with social class as illustrated in Saving Lives6 is striking and is unacceptable. In the early 1970s men of working age in social class V had approximately twice the mortality of men in social class I. By the early 1990s the difference was three-fold9. There is a clear leadership role for general practice in addressing these differences and this trend.

IMPROVING EQUALITY OF PRIMARY CARE SERVICES

  One insidious form of rationing is through reduced access to high quality primary care services10. This can occur when all the local GP lists are closed, and may be worse when recruitment problems lead to a failure to fill practice vacancies, especially in deprived areas. Reduced access can occur when:

    —  demand overwhelms supply and appointments are unavailable;

    —  demand results in shorter and less effective consultations;

    —  interpreting facilities are not available;

    —  choice of male or female general practitioner is not available;

    —  a full range of team members is not available;

    —  clinical skills are not maintained;

    —  clinical options are not made available to patients, including appropriate range of services in the primary care setting;

    —  primary care clinicians do not know of local secondary and social services;

    —  funding constraints deny access to necessary treatments;

    —  waiting lists are lengthy;

    —  premises are poor; and

    —  refugees and "difficult patients" are offered temporary registration.

  All those working in primary care have a responsibility to ensure that all patients have access to high quality general practice. As a College we will do this through support for:

    —  high quality vocational training;

    —  effective end point assessment of vocational training;

    —  continuing Professional Development;

    —  revalidation;

    —  clinical governance;

    —  membership by Assessment of Performance;

    —  Fellowship by Assessment;

    —  Quality Team Development;

    —  Quality Practice Award;

    —  Research Practice Accreditation; and

    —  leadership courses.

  As a profession we need to ensure that clinical governance works to improve care and services in all practices, encouraging CPD, risk management, availability of services and quality assurance. We will need to work with the postgraduate educational establishment to offer support to under-performing doctors and, if appropriate, nurses.

  However, we must ensure that services are not depleted in those areas with well-developed high quality primary care. The College argues for a "levelling up" not a "levelling down". Equality should not mean an equal share of poor service, but equality of excellence.

  Where equality can only be achieved through investment in local primary or social services, then we expect that funding to be made available. We cannot fulfil our part of this action programme, if the Department of Health does not ensure sufficient high quality general practitioners, practice nurses, community nurses, health visitors and other primary care team members. In particular we recognise major problems in recruitment and retention in deprived and disadvantaged areas, problems that are likely to become more intractable with time and that require urgent and systematic action.

IMPROVING EQUALITY OF HEALTH AND SOCIAL SERVICES ORGANISATION

  The quality of the local health service organisations, and the priorities they put on public health issues, has a substantial effect on the health care delivered to a population. Primary Care Groups and health authorities must create effective Health Improvement Plans that target resources at these issues.

  By involving all organisations in local (the locality may be a practice, a town, a county, or a region) health needs assessment, the inequalities in health status and outcome can be made explicit and then, subsequently, monitored. If we are to meet the four key targets for improving health in Saving Lives6—for a reduction in mortality from cancers, heart disease and stroke, accidents and suicide—we must combine clinical care with a population perspective, medical interventions with social action, early detection with community based prevention of the underlying causes. This will require high quality local organisations.

THE PRE-REQUISITES

1.  Commissioning based on an understanding of the local health need and local service provision

  Over the last 50 years, and particularly the past 10, general practice has taken a lead in health needs assessment and locally sensitive commissioning. Such skills are key to the new public health agenda. Developments in public health must acknowledge and build on the current expertise in primary care.

  Understanding health needs requires an understanding of the local culture and the barriers to better health. Some of these barriers exist in the provision of primary and social services. Many are social, cultural, economic and environmental. Those who try to understand health needs from a distance, especially through the use of mortality statistics, will not grasp the realities on the ground.

  General practice holds an increasing clinical and social database that offers greater insight into health needs than traditional statistics. For example, we know how many of our patients smoke and how much, what ages they are and what morbidity is associated with that smoking. We know what advise and help to stop smoking has been given. We know about the uptake of aspirin in patients with ischaemic heart disease or after a stroke. We know about the numbers of patients with depression, their treatments and recovery times.

  As we learn to link this information to socio-economic data, perhaps through small area statistics11, and ethnicity12 we will be able to provide a continuous, monitored insight into the health needs of our populations. Since the effects of interventions now (such as the use of aspirin or stopping smoking) will be long-term, the monitoring needs to be long-term too.

  When general practice values its role in addressing inequalities, it will need the means to act, the resources to act with and the information with which to monitor change.13 It will also need resources for the commissioning process—we are now aware that liaison with colleagues and with public health specialists takes protected time. If local decisions on priorities, the nature of services, their provision, and their funding can be used to focus general practice on this issue, change will occur.

2.  Independent public health advice

  Primary care cannot deliver this alone or in isolation. While general practitioners, nurses and health visitors have been quick to take on the basic elements of needs assessment and the commissioning of locally sensitive services, much expertise currently lies with public health physicians. In most areas they have become isolated from general practice and we need to re-establish communication with them. Both disciplines have unique skills and expertise that are complementary.

  However, public health physicians have moved into the field of "management" and as a result are closely associated with the culture, priorities and practises of the health authorities. Although their advice should be impartial and evidence based, fundholding practices have found it difficult to accept that their advice on commissioning decisions was fully divorced from health authority pressures.

  As Primary Care Trusts (and their equivalents outside England) are created there is a risk that public health physicians will become isolated in health authorities. In order to re-establish their role in the emerging primary care-based public health function, public health physicians should become independent of health authorities.

  All health service bodies—primary care, community, secondary care, health authorities—should be able to contract for the impartial expert advice of these important health professionals. The RCGP welcomes the acknowledgement in Our Healthier Nation of the important role to be played by non-clinicians in the public health function, and the RCGP would wish to work closely with all experts in the public health field.

3.  Independent public health monitoring

  If the government, the NHS Executive, and the public are to understand the health needs of their populations and to monitor changes, they must have access to impartial evidence derived from independent monitoring. For this reason the RCGP welcomes the creation of the Health Development Agency and the public health observatories. It looks for general practitioner representation in these new structures.

  The public health specialists in these observatories should be able to use their monitoring, insight and understanding to inform the health service and the public of health needs, health status and health outcomes; and to offer advice to those who seek help in improving the health care for their populations. They should require local equity audits within Health Improvement Plans.

4.  Primary care involvement in the social dimensions of health

  General practice and primary health care teams have always been involved in social dimensions of health at an individual level. The new challenge is to be effectively involved in these social dimensions at a population level. As the three examples in the Box show, the scope is large. Many practices are already involved at this level; there is a need to extend this expertise to all practices. The arrival of new primary care organisations provides an opportunity to extend primary care tasks to fully encompass the public health function.

5.  Resources

  Saving Lives: Our Healthier Nation6 lacks specific information or comment about resources and this is a considerable concern to the RCGP. If we are to address inequalities through "levelling up", we in primary care—and elsewhere—will need additional skills, new alliances, and more resources. If targets are to be met, if communities are to be involved, if risks are to be managed and health equality promoted, then resources must be appropriate to the task.

  Identifying inequality, consensus building, effective consultation, priority setting, commissioning services, providing the services themselves, and monitoring all require resources—in terms of money, skills and time. Perhaps the greatest resource required is a societal investment in the reduction of socio-economic differentials. Primary care, if adequately supported, can mitigate some of the effects of deprivation, but the reduction of deprivation itself must be a high political priority. There is a need for the Department of Health to be open with the public and the professions about how these changes are to be funded.

6.  Research, development, dissemination and evaluation

  There is a need for high quality primary care-based research into the impact of socio-economic inequalities on the task of primary care; research into methods for addressing inequalities effectively; dissemination of good practice in commissioning and delivering the public health function; and evaluation of the policies and targets in Saving Lives.

CONCLUSIONS

  The Royal College of General Practitioners broadly welcomes the new White Paper, Saving Lives: Our Healthier Nation. Its thrust is in keeping with the historical development of general practice. Many practices are already actively involved in delivering this public health agenda.

  If we are to succeed in transforming the ideas of this paper into action, we must see:

    —  commissioning of services based on an understanding of local health needs and local service provision;

    —  an independent and local public health service;

    —  independent monitoring of the public health;

    —  increased primary care involvement in the social dimensions of health; and

    —  resources appropriate to the task.

  Primary care has the registered patient base, the information systems (based on the lifelong health record), the experience of commissioning and an understanding of the local communities. These are sound reasons for general practice being at the heart of the public health agenda, working in close collaboration with public health physicians.

  The RCGP deplores inequalities in health. It wishes to work with all parties to ensure that inequalities are recognised, addressed and reduced. Saving Lives: Our Healthier Nation offers a real opportunity to do this.

October 1999


 
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