A key report has been taking a look at primary care and there are good things in it about pharmacy

It may seem alarmist, but I am seriously worried about the future of primary care. The organisation and delivery of primary care in Britain has changed little since the 1960s. Pharmacy is part of primary care, so we are closely affected, but we have to be realists – primary care revolves around GPs, and that’s where the problems lie: there are too many patients and too few GPs – many of whom are over 50 with not enough young doctors wanting to take their place. I see clinical commissioning as part of the problem: it gives GPs perverse incentives to take on increasing workloads because by doing so it increases their incomes.

But the bubble has to burst sometime and when it does it may be as cataclysmic as the bursting of the banking bubble in 2008. I have always had the suspicion that the health ‘reforms’ of the current government were intended to achieve exactly this so that the door could be opened to widespread privatisation of the NHS.

Problems

The problems facing primary care have become so acute that KPMG and the Nuffield Trust have compiled a joint report – The Primary Care Paradox*. It pulls no punches and starts by stating that “small scale practices which deliver relatively inflexible and reactive healthcare cannot optimally serve patients, citizens and tax- payers in the twenty-first century”, and goes on to say that general practice “is insufficiently connected to . . . community based services (eg, pharmacy) and other resources that could help it to function more effectively.”

On page 7 it tells us: “Pharmacists are increasingly providing advice on self- management of self-limiting conditions and some offer support on chronic disease management and public health interventions such as smoking cessation and weight management.”

On page 14 it identifies the key problems: that primary care is “locked into an old model of service provision which does not serve the needs of modern users”, with “too many inappropriate payment mechanisms that incentivise the wrong type of behavior [sic] by clinicians”; and “the much-vaunted strength of primary care as coordinator of comprehensive care over time is often not a reality.”

In short, GP services are too self-centred, are not aligned with the lifestyles of their patients, and do not offer sufficient continuity of care to those who need it most.

Dogma

So what is the answer? It seems obvious that throwing more money at these problems is not going to work (even if there was more money to throw).

There are not enough GPs, and their numbers are falling – so the situation will only get worse until we think about redesigning primary care based on meeting the needs of patients rather than on vested interests or political dogma.

The report says quite clearly that there are dangers in policy-makers trying to re- shape the system from the centre, because decisions which may seem to make sense nationally may turn out to be quite wrong in a local context.

Localism turns out to be crucial to any redesign. The report favours primary care being run by ”independent (my emphasis) businesses and vibrant networks of enthusiastic practitioners from a range of health professions” to unleash “innovation and creativity”.

Rather than trying to specify particular models for organisations or care delivery, the report says any redesign should instead specify what the attributes of primary care should be and allow local variations to develop in response to local needs. The starting point should be multidisciplinary working in which full use is made of all the team members. This means that primary care needs to extend beyond GPs’ surgeries and involve and offer access to a wider range of health professionals in an integrated way.

There should be easy access to appropriate expertise and diagnostics, with well-coordinated continuity – what might once have been called ‘a joined-up service’ – with patients encouraged and educated to manage as much of their own care as possible, particularly those with long-term conditions.

Care should be ‘anticipatory’ – with preventative care and the early detection of serious illness an integral part of the service and it should be centred on what patients value rather than on test results and blood levels.

Single record

From the perspective of systems and management, there should be a single electronic patient record that can be accessed by the patient, and information about quality and outcomes should be publicly available in real time. Crucially, primary care should have expert professional management and organisational support, and payment should move away from block contracts or activity to be based on outcomes. I can only give the general flavour of this report here, but I urge you to read it. I was surprised and pleased that pharmacy gets a prominent mention. We have much to offer – and to gain – from such a model of primary care. All we need now is for our politicians to see the sense of it.

*www.kpmg.com/Global/en/IssuesAndInsights/ArticlesPublications/primary-care-paradox/Documents/primary-care-paradox-v1.pdf

Pen name of a practising independent community pharmacist. Withering’s views are not necessarily those of ICP