Future of primary care
This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Future of primary care.
Year of challenge
Thank you. I am really grateful to the King’s Fund for inviting me today and indeed for staging this conference. Without a profound reform of out of hospital care the NHS will be simply unsustainable, so this is an issue of critical importance.
I would like to begin with a general comment.
This has been a year of challenge for the NHS.
Whilst the institution rightly remains the single biggest reason why people are most proud to be British, we have had to confront tragedies at Mid Staffs, Morecambe Bay, and failures at fourteen hospitals with high mortality rates. Unprecedented transparency has shone a spotlight on poor care in a way that has never happened before.
In the face of that scrutiny, I want to pay tribute to NHS doctors, nurses and professionals who have faced up to that pressure with great determination and courage. It would have been easy, in the face of so many media stories, to point fingers elsewhere or duck difficult questions.
We could have pretended that the problems of poor care were restricted to just a few places, and had no relevance elsewhere.
Instead of which, something remarkable happened.
The whole service has united to confront these problems head on.
There has been a widespread welcome for Professor Sir Mike Richards in his new role as Chief Inspector of Hospitals, even though his inspections will be tougher and more independent than ever before.
Likewise for Professor Steve Field, the new Chief Inspector of General Practice, and Andrea Sutcliffe the new Chief Inspector of Social Care. Their inspections will confront poor standards as well as showcasing and celebrating the best care.
Indeed when 11 hospitals were put into special measures following the Keogh review, this wasn’t criticised as draconian - even though it was unprecedented.
When Don Berwick, Professor Obama’s safety expert, called for a fundamental change in culture, again it was widely welcomed.
We cannot hope to give people the healthcare they need and deserve if we refuse to face up to difficult realities. So this widespread willingness to accept more transparency and more accountability is extremely heartening.
At the same time, thanks to the extraordinary efforts of people on the frontline, on broadly the same budget as 2010 we are:
performing 400,000 more operations every year
seeing a million more people annually in A & E
delivering over 3 million more outpatient appointments every year
This is a tribute to the dedication of a great many people. In a climate where some are quick to criticise, I am pleased to once again to put on record my personal thanks and admiration for NHS and social care staff who have never worked harder.
A sustainable NHS
All this is highly relevant to the debate on primary care. Because underneath the angst caused by long-suppressed tragedies finally coming to the surface has been a deeper worry. Just how sustainable is the NHS? Is the problem about raising standards, or more profoundly about whether we can actually afford to raise standards to the levels we would like?
My answer to that is straightforward.
We can afford good quality care for everyone – but only if we undertake a bold and radical transformation in the way out of hospital care is delivered.
Why out of hospital care?
Because the central challenge facing the NHS today is an ageing population. The over -85s are the fastest growing population group in the world, and will double by 2030. Sooner than that, we are likely to have 1 million people with dementia in this country.
And already one-quarter of the population, mainly elderly, have long-term conditions such as arthritis or chronic lung disease. For these people, quality of care at home is just as important as quality of care in hospital.
Hospitals, of course, will always be there for the most complex treatments and the most specialist care. But getting the best possible care outside hospitals means we enjoy a higher quality of life, spend fewer days in hospital, and keeps people happy, healthy and safe at home.
Not only is this better for us as patients, it is better for the NHS. It saves precious hospital resources for people who really need them. And it saves money overall - so that as we get older and need more care, we can be more confident the NHS will be there to deliver for us.
This is already happening.
In Newquay, the NHS and Age UK have worked together with a cohort of frail elderly people that are particularly vulnerable to crisis episodes that require admission to hospital. Their proactive care has reduced emergency admissions by 23%.
In Kent, predictive models are employed to identify the cohort most in need of preventative social care. Then ‘anticipatory care plans’ are made which include input from the patient. This stops them from slipping between health and social care and means that they spend less time in hospital.
Best international practice supports this conclusively. Age-adjusted hospitalisation rates for Kaiser Permanente were found to be a third of the NHS because of more comprehensive primary care services. Following a similar model, GroupHealth’s Medical Home Pilot – which we heard about today - reduced their emergency admissions by 29%.
Better care and a more sustainable NHS. So if my focus has been on delivering that inside hospitals in my first year as Health Secretary, transforming out of hospital care will be my focus in the second.
4 year transformation
I don’t underestimate the scale of the changes necessary. I believe it will be a four-year process based on the four major groups of people the NHS has to look after: vulnerable older people; other people with long-term conditions who need help managing their condition; mothers and young children; and those of us who are normally healthy and well and need the NHS to help keep us that way.
Whilst we will make changes that will benefit all of these groups from next April, I have deliberately chosen to make vulnerable older people my primary focus for the next twelve months.
I’ll never forget seeing an elderly woman with dementia arriving at the A & E department at Watford General Hospital. The staff did their best, but in truth they knew nothing about her. They didn’t know if she was normally speechless or whether that was because of her fall. They didn’t know her medical history. And if they felt helpless, how terrified she must have been. We have to do better.
Vulnerable older people may only be a small proportion of the population. But they represent a significant cost to the NHS.
And they often get the worst deal from the services we provide. Too often they receive uncoordinated care, stay too long in hospital and are treated not as a human being but as a mix of diseases.
Every life is precious, and we don’t lose value as we get older. But we do need more support - and our NHS must be there for us when we do.
So today I want to outline some of the detailed changes that are necessary to make this happen. First, though, some underlying principles.
Firstly - and this won’t be a surprise to anyone , prevention is better than cure.
An American health insurer once told this story to a bemused Department of Health official. “We are taught,” he said, “that if we get a new customer signed up for one year we lose money as they inevitably claim more in hospital fees than their premium. But if we get them for three years, we can assign a nurse to look after their long-term condition and you just about break even. Get them for seven and you encourage them to take exercise, eat healthily etc. and that’s when you really make money. I figure in your NHS you’ve got them for life…so what do you do?”
And I’m afraid the answer is not enough. For vulnerable older people in particular, it means we need a radical shift in our model from reactive to proactive care, from cure to care, from care to prevention and from paternalism to participation. So that’s the first principle.
The second principle is clinical leadership. Local doctors know what’s best for local patients, and they’ll be the drivers for change. The vision I am presenting would not have been possible without the reforms to commissioning, which placed budgets in the hands of GP-led commissioning groups. It is their ingenuity and enterprise which is already allowing trailblazers to deliver this vision in parts of the country already.
The third principle is accountability. If we are going to transform out of hospital care, we must ensure that someone in the system is responsible for making it happen.
Well-led multi-disciplinary teams are important – but as a member of the public I want to know who in the NHS is responsible for the overall care of my elderly mother or granddad.
The person who is responsible needs not just responsibility but the power to make things happen quickly in a large and complex system.
The fourth principle is that any changes we make must stay true to the founding principles of the NHS. The highest quality care and treatment for all, no matter who you are. This means a special focus on vulnerable older people who live on their own and at risk of social isolation. And a particular determination to ensure that those without a strong voice, without pushy relatives, without the money to buy better care also get looked after in the way that we would want for our own friends and family.
Those are the principles. What then are the big changes? We are currently consulting on our Vulnerable Older People’s Plan but emerging results from that consultation suggest major reforms in three areas in particular.
Proactive primary care
The first is moving to proactive primary care.
By 2016 we will have three million people with not one, not two, but three long-term conditions.
Many of them will be elderly. When they are discharged from hospital they will not be “cured” in the conventional sense. They will still need help, sometimes a lot of help, to manage a complex cocktail of illnesses and often disability and loneliness as well.
Sometimes we do primary care well. Many GPs pride themselves on good continuity of care and we have many extraordinary district nurses.
But often we fail. 15-minute homecare visits when there is time to dress someone or feed them but not both. Patients left stranded at home because they have slipped through the cracks of the system. Care homes that struggle to get GP visits.
A paper in the Journal of Public Health by Bankart in 2012 found that, “Being able to consult a particular GP, an aspect of continuity, is associated with lower emergency admission rates. As the proportion of patients able to consult a particular GP increased, admission rates declined.”
So from next April I’ve proposed in the draft NHS Mandate that there should be a named GP for all vulnerable older people. This is the first step in reversing the historic mistake made in the 2004 contract changes, which abolished personal responsibility by GPs for patients on their lists. Incidentally, this is something that many practices bravely refused to go along with.
But we need to go further than just having a named GP.
So from next April I would like to empower those named GPs to look after vulnerable older people on their lists in the way I think GPs always wanted to when they first joined the profession:
to take responsibility for ensuring these patients have proper care plans and are supported to look after themselves;
to have the time to contact their patient proactively and not just when they walk through the surgery door;
to be able to decide how best out of hours care should be managed in their local areas, including, for example, choosing to take back responsibility at a practice level for delivering out of hours care;
to be able to decide what support their most vulnerable patients get from district nurses.
Not all GP practices will be able to do this on their own. Many will choose to do so through federations or indeed through CCGs.
Nor will GPs personally administer services on their own. I recognise that GPs work hard and need time off.
But if they are not able to see a patient out of hours or do a home visit, they should make sure another clinician can – someone who is able, with the patient’s permission, to have full access to their notes, their medical history, their medication and their allergies.
In short, we need an accountable GP outside hospital just as the excellent Future Hospital Commission from the Royal College of Physicians talks about an accountable consultant inside hospital – someone who knows how their chronically ill elderly patients are at any one time.
Capacity of General Practice
So where will GPs get the capacity to perform these extra duties?
In the medium term we will definitely need more GPs. I have asked Health Education England to recruit an additional 2,000 GPs and increase the proportion of new doctors entering general practice to 50%. We will do further modelling, and it may be we need to increase those numbers still further.
But we also need to look at the burdens that we place on general practice and give them better support in managing demand.
The 2004 contract changes were well-intentioned. But they turned GP practices from proactive organisations responsible for their patients 24/7 into surgeries whose responsibility is essentially reactive – dealing as best they can with the people who walk through the door, often without the time or space to check up on people who don’t.
These changes not only undermined the ideal of family doctoring, they damaged the doctor-patient relationship that is at the heart of general practice.
QOF, DES, LES and myriad other targets were all introduced with the best of motives. But they’ve created a bureaucratic overlay to the work of a GP which means there is often a conflict between the requirements of a patient and the needs of a practice to generate income.
So we need a dramatic simplification of the targets and incentives imposed on GP surgeries – to give them back the professional discretion to spend more time with the patients who need it the most.
And finally, we need to recognise that if more proactive general practice is going to save the NHS money by reducing unplanned admissions to hospital, then some of that saving needs to go back into general practice to pay for the higher levels of care.
Precisely how will be a matter for detailed negotiation later in the year, but we need to be ready to go with a new approach for vulnerable older people in April 2014.
Transforming out of hospital care is not, though, just about primary care. Which is why the second big change we need to make – and something that the King’s Fund has nobly talked about for many years - is around the integration of the wider health and social care systems.
We must recognise that the needs of vulnerable older patients are so complex that they will often need to access different parts of the system on a regular basis. Providing proper continuity of care means closing up the gaps that can see people pushed from pillar to post, with one part of the system completely unaware what another part is up to. This is never more frustrating than when patients are delayed from moving to the right place because of wrangling over budgets.
Norman Lamb – my excellent care services minister - is spearheading the work to make this change happen, in particular with a programme of 10 – 15 integration pioneers.
Building on this, the Chancellor announced in July a £3.8 bn Integration Transformation Fund for health and social care in 2015-16.
In order to access this – and we have deliberately made it such a large sum of money that everyone will feel they have to access this - local authorities and the local NHS will have to commit to joint commissioning, better data-sharing using the NHS number, seven-day working in health and social care, protecting social care services and having an accountable lead professional for integrated packages of care.
Because this is so important, I can announce today that all integration plans will have to be approved and put in place not by April 2015 but by April 2014. Although the new funding will not become available until April 2015, in many cases we believe local authorities and CCGs will want to press ahead next year anyway so that we start to see the benefits of improved care much earlier.
And these changes are already starting to happen.
In Bedfordshire, the Clinical Commissioning Group has brought down the number of emergency admissions from care homes by 38%, by implementing a care team to deliver more intensive care to patients in nursing and residential homes.
In Bath, there has been a 40% reduction in admissions to the local district hospital, thanks to a pilot scheme involving regular visits to a care home. I am going to see this in Bath for myself tomorrow.
In Blackpool, when people visit A & E the front desk is manned by primary care staff. They assess whether they need emergency care or out of hours primary care. The result is that over 20% of people who visit are sent to the out of hours service, freeing up resources in A & E and, in the long run, saving money.
And in Witney patients with long-term conditions are offered a 24 hour helpline, with people trained to listen to their problems and prevent a medical crisis. In short – more support means a better experience for patients and a more sustainable healthcare system.
Having been talked about for so many years, integration is finally becoming a reality. Patients are at last being treated in these complex systems as people - with a seamless service responding to their personal needs - rather than as objects being processed by various disjointed systems. And I hope we will see a step-change in the progress we make from next April.
Electronic health records
The final change we need to make to out of hospital care concerns electronic health records.
The last government may have got the implementation of NHS IT contracts wrong, but they were right to try. We must not let the fear of making the same mistake again deter us from making vital and necessary changes.
It is shocking that when a vulnerable older person is admitted to A & E, the hospital typically knows nothing about their medication or medical history. 44 people died last year in the NHS because they were given the wrong medicine – and we know we could reduce this significantly if prescription histories were available in hospitals.
Equally shocking in this day and age is that a paramedic can pick up someone on a 999 call without knowing if they are a diabetic or someone who has dementia – information that could be critical in giving that person the right care or treatment.
Nor should the social care system be operating in a technological silo that is unable to speak to the NHS. Medical notes and histories should be available anywhere in the system whenever a patient gives consent – whether a care home, a hospital, a GP surgery or indeed 111.
I’ve said the NHS must be paperless by 2018 – and last week announced we will be increasing investment over the next two years to £1 bn. But let’s be clear: we won’t repeat the mistakes made before. I will not be signing any contracts at the Department of Health, you’ll be pleased to hear. Instead we will be supporting local initiatives.
But as a result of that investment, I expect to see a transformation in the number of vulnerable older people whose records and care plans can be accessed in different parts of the system – and a transformation in their care as a result.
Proactive primary care, integration of health and social care and proper use of electronic health records and care plans: taken together these will transform the quality of care received by vulnerable older people in the NHS over the next two years.
And we then need to ask what equivalent changes are necessary for the other groups of people, people with long-term conditions, for mothers and young children, and for the usually healthy. I will return to these at a later date.
But for now let me reiterate my certainty that with ambition, vision and courage we can protect the NHS’s sustainability even at a time of unprecedented financial pressure – and significantly improve care for vulnerable older people at the same time.
And I want to thank everyone in the room for your help in making this happen.