Primary care in the twenty-first century

Summary • The NHS remains one of the world’s better health care systems. But the proportion of the UK’s GDP allocated to health and social care is only about three quarters of that now spent by leading European nations. To meet changing needs health and social care providers in England must improve their capacity to offer convenient access to preventive and ‘common need’ diagnostic and treatment services to people of all ages, and also to provide well-coordinated social and health care to individuals at high risk of suffering avoidable episodes of serious illness and needlessly losing their independence. • If personal and public health is to be raised to the highest possible level improving primary health and health related social care – which together represent little more than a fifth of combined NHS and local authority social service outlays – is vital. Health care will in future move more towards professionally facilitated prevention and primary care supported self-care in the community, backed by the relatively infrequent use of highly specialised services supplied in hospitals. • The unique attributes of British general medical practice will allow it to serve as a central plank for continuing service development. The formation of local Health Federations and related primary care focused organisations could in future lend itself to holding single budgets for health and related social care along the lines proposed by advocates of the Primary Care Home approach to service improvement. This would offer significant gains for service users. Wherever cost effective, services ought to be ‘made’ by local care providers. Where necessary they should be purchased from other sources. • There is a large body of evidence indicating that Community Pharmacy can play an extended part in delivering accessible health care, alongside roles like reducing prescription errors and facilitating better medicines use. Increasing the number of clinical pharmacists working in GP practices is a valuable step. But it cannot substitute for a clear vision for the future of community pharmacies as ‘first contact’ health care providers. • If community pharmacists successfully extend their clinical care roles this would free general practice and linked community capacity to work towards reducing inappropriate hospital admissions and unduly long inpatient stays. Without well planned, pro-active, interventions pharmacy skills will be under-used and the established community pharmacy network lost. Yet if each community pharmacy in England were able to take on just 10 per cent of the average general practice’s existing workload over the next five years, this will release approaching 5,000 GPs and similar volumes of practice staff for additional service provision. • Responsibility for achieving more effective primary care working arrangements lies mainly with GPs, nurses, social workers and pharmacists themselves, because only they are in a position to adequately understand the tasks with which they are engaged and the detailed needs of the people they serve. However, individual professionals alone cannot transform the NHS. Excellent national leadership and appropriate funding and governance systems are also vital for nation-wide success. • Nine out of 10 people in England currently live within a 20 minute walk of a community pharmacy. Some planners may wish to see savings made via concentrating dispensing in warehouse-like facilities and increasing the use of medicines home delivery services. Yet at a system-wide level a potentially more desirable way forward could be to extend pharmacist prescribing and improve shared health record systems. This would combine convenient local medicines supply with more accessible forms of ‘pharmacist first’ care in areas ranging from managing blood pressure to providing better chronic obstructive pulmonary disease (COPD) and type 2 diabetes prevention and care. • The health and social care system in England has been affected by imbalances that are linked to the fact that social care is means tested while NHS care is free. This has created perverse incentives that may in the past have undermined services such as community nursing. Inadequate high level leadership also impairs service quality. But if health gain focused co-operative professional enterprise can be combined with well-informed decision making and robust national and local resource allocation strategies that effectively support the delivery of well-coordinated primary care, further improvements in individual and population health will be achieved.