Discuss the changes that have occurred in primary care in England during the last 10 years. What has been the impact on patients? How might developments in general practice continue over the next 10 years?
Philippa Callegari
General Practice is a well-used and valued public service. Eight out of ten people visit their general practitioner (GP) every year 1 and 99% of the English population are registered with a GP. The service costs £8.2 billion (including prescribed drugs), which is one fifth of the NHS total expense.2
The main development in health care policy has been the introduction of market mechanisms within the NHS 3. This move was the initiative of the Conservative Party and aimed at giving the Primary Health Care Team (PHCT) more say over the delivery of secondary care. Its purpose was to increase efficiency and limit increases in expenditure. The development of general practice (GP) fundholding which began to appear in 1989 4, was also part of this plan to have the NHS run from a primary care outlook and was articulated as such in 1994 5.
As a result of increasing demands and rising costs in the early 1990’s, the Conservative government split the NHS up into providers (i.e. hospitals) and purchasers (i.e. local health authorities and some fundholders) 4. The government encourages this development as GP fundholding lowered prescribing costs. By 1998, over half of the English population was covered by some form of fundholding arrangement.
However, there was much concern amongst GPs at some aspects of the fundholding scheme. It was felt that if they were responsible for “buying” services for their patients from their budgets, then their position as a clinical advocate for individual patients would be compromised 6. Once the Labour government was elected, many people thought it would bring to an end to fundholding and pay GPs to take on locality commissioning, but it didn’t. The 1997 White Paper for England asserts that, “decisions about how best to use resources for patient care are best made by those who treat patients.7” As a result, the number of managers in health authorities has diminished and been replaced by members of the PHCT in Primary Care Groups (PCGs). These groups now involve all GPs (unlike fundholding which just included GPs who chose join in). Thus around 500 PCGs, each covering populations of around 100,000, took over from nearly 4000 current organisations such as local health authorities and fundholders, to become Primary Care Trusts (PCTs). A trust has the responsibility to develop and commission local health services in line with the health improvement programme 8. PCTs are local and autonomous organisations and have control of up to 80% of the local health budget. They are run by committees, having as many as nine health professionals (including up to five GPs) from a total of 13 members. Other members include community consultants and health professionals allied to medicine, such as physiotherapists, nurses or occupational therapists, as well as some members of the public. PCTs however do not have the purchasing power of single large health authorities and as a result, have limited annual prescribing budgets for providing medical services and developing primary care 9.
Since 2001, changes in primary care have continued unhindered. There have been changes in the way funds are allocated across the PCTs, the overall level of funding has increased, and there are also plans to introduce a new General Medical Services contract that puts more emphasis on performance related pay and quality incentives. Recent policy changes will have a great effect on general practice; this change in allocation of funds for the PCTs will mean that money for their practice will follow the needs of the patients, instead of investment decisions for the doctors. The new GP contract recommends more flexibility in the workload for individual practices and gives greater emphasis to quality. Practices have also made other changes in recent years; these include out of hours services, with many GPs forming groups to share the responsibility between practices. Another advance is the growth of large practices. The number of GPs working in practices with six or more GP partners has grown from 1 in 5 practices in 1988, to 1 in 3 in 2001 2.
The real question is how all of these changes have affected doctors and their ability to treat patients. Since 1987, many evaluations of GP job satisfaction following changes in primary health care have been conducted. These have showed that job satisfaction fell after the introduction of the 1990 contract but had partially recovered by 1998 10. Between 1998 and 2001, satisfaction fell once again; this could be due to the termination of fundholding, the implementation of clinical governance to improve quality of care, the introduction of walk-in centres and NHS Direct. As for the effect on patients, even the most sophisticated form of fundholding, “total purchasing”, has had little effect on clinical outcomes, the shape of secondary care or overall costs. Specific targets in the NHS Plan for patients to see a GP within 48 hours has resulted in people waiting less time for an appointment.
General Practice is currently under a lot of pressure. This is partially due to other changes within the NHS; there has been a reduction of 21,000 hospital long-stay beds since 1983 and the average hospital stay has decreased from 16 days in 1990 to just 7 days in 1999 2. As a result, the management of patients has shifted from hospitals to GPs 11, as more patients are looked after at home. Also, there is a rapidly increasing number of much older patients, usually requiring treatment for multiple illnesses: by 2024, there will be 40% more people aged over 85 years. Money spent on general practice has risen by 20% during the last decade; however, money spent on hospitals has increased by more than 60% in the same time period. Because of this added pressure facing general practices, changes are essential.
One major simple change for the future that has proved to be very helpful is the introduction of nurse practitioners to provide care at the first point of contact in a primary care setting. A systematic review by Sue Horrocks et el 12 involving 11 trials and 23 observational studies concluded that the availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.
I also see the future of primary care within the NHS to be highly supported by information technology (IT). In a BMJ article (January 2003) 13, a professor for primary care made a list of how he could foresee IT changing primary care for the better. Some of his ideas were to send discharge summaries and clinic letters electronically, to allow hospital diagnostic codes to be sent to practices electronically and to allow the electronic transfer of records between practices. I believe the NHS is going to have to invest a lot of its budget into IT, as the demands of GPs are now so great, one of the only viable solutions is to have IT at their fingertips.
There are many changes the NHS must make in the future in order to become more primary care led. Although the White Paper is very confident of this primary care led future, there is evidence to suggest that GPs feel otherwise. Their attitudes to the policy suggest that progress towards a primary care-led NHS will continue “to be patchy 14”. The limited shift from hospitals to general practice so far in addition to evidence of unsure attitudes to the shift on the part of GPs, lead me to believe that this is a policy objective that may never be achieved.
References:
- Malcolm Law. The Health Service in Britain. Wolfson Institute of Preventative Medicine. Jan 2003. At: (Accessed on 11/11/03)
- Audit commission. A Focus on General Practice in England. July 2002 At: (Accessed on 11/11/03)
- K Rummery. Changes in primary health care policy; the implications for joint commissioning with social services. Health and Social Care in the Community 6 (6), 429-437
- Secretaries of State for Health (1989), Working for Patients. Cm 555: HMSO
- Developing NHS purchasing and GP fundholding towards a primary care led NHS. NHSE (1994)
- Singer, R et al. GP Commissioning: an inevitable evolution. Radcliffe Medical Press, 1997.
- Secretary of State for Health. The new NHS, Modern, Dependable. London: The Stationary Office, 1997
- Peter Aquino. Working for a primary trust. BMJ 2003; 326: S73
- Majeed, A et al. Unified budgets for primary care groups. BMJ 1999; 318: 772-776.
10.D Whalley et al. GP satisfaction survey 2004. At:
(Assessed on 11/11/03).
11.Harrison, A. The NHS: Facing the future. London: The King’s Fund, 2000.
12. S Horrocks et al. Systematic review of whether nurse practitioners working in
primary care can provide equivalent care to doctors. BMJ 2002; 324: 819-823
13. Majeed, A. Ten ways to improve information technology in the NHS. BMJ 2003;
326: 202-206
14. P Miller. Measuring progress towards a primary care-led NHS. British Journal of
General Practice 1999 July; 49(444); 541-5
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