Primary and Community Care: Improving Patient Outcomes
(1 year, 7 months ago)
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Lord Patel
To move that this House takes note of (1) the role of primary and community care in improving patient outcomes, and (2) the need for reform.
Lord Patel (CB)
My Lords, I am pleased to open the debate today. I thank the Minister and all noble Lords who have their names down to speak and look forward very much to their contributions. This debate takes place at a time when the whole NHS is under immense pressure, with media headlines such as “NHS in crisis”, “End of general practice as we know it” and “Will we have an NHS in the future?”, to quote a few. The focus of today’s debate is primary and community care—the backbone of our health service—how its performance affects patient outcomes, and whether there is a need to reform the primary care service.
Primary care has been the bedrock of the NHS since its inception in 1948. It has been revered by patients and has delivered huge health improvements. When Nigel Lawson—now the noble Lord, Lord Lawson of Blaby—said that the NHS was a national religion, it was because of patients’ love of its primary care services. The two professional groups worshipped by the people were the general practitioners and nurses in primary and community care, not the brilliant obstetricians, colorectal surgeons, palliative care doctors and—I say on behalf of the noble Baroness, Lady Murphy, who had to withdraw because of cataract surgery yesterday—not even the psychiatrists. Primary care is now in a different place. It is still the bedrock of the service, but the foundations are shaky, even crumbling. Unless fixed, the whole system will collapse.
What is primary and community care? It is the first point of contact for healthcare and is provided mainly by GPs, but also increasingly by nurses, dentists, optometrists, pharmacists and many other allied health and care providers, including physiotherapists, mental health nurses, care co-ordinators and, in the community, health visitors, specialist nurses, midwives and end-of-life carers. The system is about caring for people rather than treating specific diseases. A system designed to work as an integrated team, with the patient as its centre and focus, has now been broken through incoherent policies, being starved of resources, and a lack of attention to the need in primary care to develop a technologically driven healthcare system and the infrastructure and professionals needed for an efficient and effective system to run.
Primary care is the setting for 90% of patient contacts, involving some 26 million patients a month. Huge increases in demand are putting pressure on the whole system and leading to long waits in general practice, emergency care and planned care. These pressures have created the biggest single fall in public satisfaction with the NHS in decades. A recent survey suggests 68% of patients do not feel they will receive timely treatment if they fall ill, 50% think it is harder to get a GP appointment and 40% think the service has deteriorated. With general practice under immense pressure, recent data from the GP Patient Survey and the British Social Attitudes survey suggest two-thirds of people are dissatisfied with service provision, with the quality of care received perceived to be an issue.
If the problems in general practice and its performance are not resolved, it will lead to the demise of general practice as we know it and, in turn, the collapse of the whole system of primary care and the wider healthcare system. We will see a repeat in general practice of what has happened in dentistry, where 90% of NHS dentists are not accepting any new adult patients.
Putting aside the rhetoric, GP numbers are declining, despite higher numbers in training. Recruitment and retention are poor. More GPs are retiring early, with pressures of work, bureaucracy and pension rules cited as reasons. Reports of nearly 57% of GPs working three days a week or less and increasing numbers doing only private work—approximately 1,500 at the most recent count—are a worry. The service may become more privately driven.
Contracts and the independent status of general practitioners dominate all discussions related to primary care. The small-business model of GP contracts is still favoured by professional organisations, but a House of Lords report suggested that model is not fit for purpose. A recent Policy Exchange report, At Your Service, advocates a universal shift to a fully salaried model over time as part of wider reforms in primary care. More and more younger general practitioners are choosing to be salaried.
Of course, no change in service delivery can occur without general practitioners being part of it and, importantly, playing a leading role. General practice can and should provide that leadership, but at the same time recognise that strong leaders remain strong and gain respect by at times letting go of some strongly held values, such as their gatekeeper role or even their responsibility for minor contractual issues. I am sure GP professional organisations are aware of this: my conversations with them suggest that they are not averse to change, but wish to be involved in any policy developments. The workforce issues are not confined to general practitioners. Similar problems exist with nursing, health visitors and community care professionals, all of whom are a crucial part of an effective system of primary care.
Of course, there have been efforts to try to improve the system and deliver patient care. The establishment of primary care networks, starting in 2019, is one key example. While the majority of general practices belong to them, not all do. Success at delivering service at scale in primary care—that is the important point—by PCNs has been variable, and now the BMA is threatening to withdraw its support, with lack of resources and contractual issues given as the reasons for doing so. Some other measures undertaken to improve service are the recently established diagnostic hubs and the recent involvement of pharmacists in blood pressure monitoring.
I was impressed that the voluminous briefings we have all received all cry out for a need for change in primary care that delivers three things: workforce, infrastructure and technology, including IT. Various recent reports have come up with suggestions for improving the primary care system: the report Fit for the Future: A Vision for General Practice, produced by the Royal College of General Practitioners; the At Your Service report I mentioned from Policy Exchange; and the Fuller Stocktake report by Dr Claire Fuller, an eminent general practitioner, which was commissioned by NHS England. All of these reports have suggestions for an integrated system that delivers primary care at scale. In commenting on some of the reports, the King’s Fund has suggested that tinkering with “more of the same” will not produce results. Reforms need to be driven from the bottom up, by the people who do the work.
Undoubtably, we need a primary care service that delivers at scale, is fully integrated with other parts of the health and care system and, above all, is responsive to patient needs and delivers better patient outcomes and health improvement. So what is the way forward? My personal view, which I hope noble Lords would support, is that first and foremost we need political recognition that an effective primary care system is a prerequisite to a sustainable NHS. To this end, proposals for change to make future primary care fit for purpose have to be led by the Secretary of State for Health and Social Care. The words from the Prime Minister and the Secretary of State hitherto are encouraging and I hope they will be followed by some actions.
On the other hand, this House has an opportunity to play an important role by setting up a special Select Committee to report on the future of primary and community care, identifying possible barriers and solutions that could make important contributions to making primary and community care fit for purpose and fit for the future. I hope this gets support from noble Lords.
As for questions for the Minister, I have only one: is there a recognition by the Government that primary care is now in intensive care? None of the piecemeal reforms, mostly of process, will work. Strong, bold leadership is needed to bring about the system change it needs. Otherwise, it will die, and with it the NHS. I beg to move.
Lord Bethell (Con)
My Lords, I thank the noble Lord, Lord Patel, for bringing about this important debate. As ever, he has a canny nose for the timing of these things and he is absolutely spot on. I know from my time in office that the pressures on primary and community care are intense and I agree that we need an urgent rethink. That is why I will put my name to any forthcoming proposal from the noble Lord to the Liaison Committee for a Select Committee on primary and community care.
The NHS has experienced long waits in hospital care before, which are extremely distressing, but it has never faced such a grave challenge in general practice—and as we know, general practice is the bedrock of the NHS. This is the right moment for noble Lords to distil complex recommendations for primary and community care into succinct, wise counsel for the Government to consider. I will share a few thoughts on how that might work. First, primary and community care is the first point of contact with the care system for the public. When we consider the remit of this Select Committee, we must remember that for many people this is not a GP. It is likely a website, an app, a school nurse, a community hospital or a pharmacist.
Secondly, there is definitely a workforce crisis—briefings from the Royal College of GPs, the Royal College of Nurses, the King’s Fund and others make that very clear, and I am grateful for their persuasive statistics—but the crisis in primary and community care is not just a workforce crisis that can be answered through solving recruitment, retention, workload and the GP contract, although those are extremely important challenges. Anyone who listened to the Minister’s answer yesterday to the OPQ about GP training will be clear that there is no massive new wave of GPs set to save the day. As the noble Lord rightly pointed out, only one in four GPs are currently working full-time, and training numbers are going sideways, so we should assume that there will be fewer GPs rather than relying on imaginary regiments of doctors riding to the rescue. Rather than deluding ourselves, we should make our plans accordingly.
Thirdly, we should not over-romanticise relational-based care when the role of the GP is evolving as quickly as that of the bank manager or the priest, and when many patients never ever visit the practice. We got through much of the pandemic with most practices shut, after all. People have extraordinarily diverse needs, from the long-term sick who certainly need regular clinical, face-to-face care to those at the other end of the scale, the occasionally sick or injured who might need a more transactional relationship. We must avoid lazy generalities, and we need a modern service that is flexible enough to meet different needs. That is why I would like any Select Committee studying primary and social care to look at four issues in particular.
The first is the importance of prevention. Too much traditional thinking around primary and community care assumes that patients turn up with symptoms and are guided by the GP on to some care pathway. These days, though, by the time patients have symptoms, it is often too late for the best treatment. This system-wide focus on late-stage acute medicine is costing the country a fortune in hard expenses and opportunity costs: expensive procedures, long recovery times, falling longevity, falling workforce productivity, and hefty social care and welfare bills. It is a huge price to pay. Primary and social care should play a much more proactive role in achieving “domain one” of the NHS outcomes frame- work, which is preventing people dying prematurely.
Secondly, technologies to “transform” healthcare are at our fingertips. I saw the power of digital transformation in primary care from my experience during the pandemic, with virtual wards, testing, the vaccine rollout, surveillance through the REACT survey, the prompt delivery of antivirals, and so on. We should study how primary and community care put digital first and become the foundational layer for scaling digital healthcare through the NHS. This approach is outlined in the persuasive policy paper from Policy Exchange that the noble Lord, Lord Patel, mentioned, At Your Service, by Dr Sean Phillips, Robert Ede, and Dr David Landau. They rightly argue that there is much to do to enhance the existing infrastructure and clarify the legal regulation of data. That is why I am interested in their recommendation for a digital health and care Bill, and in a “smart” first contact navigation programme—an “NHS Gateway”—that can deliver a more personalised “front door” to the NHS. We also need to address the use and sharing of data in primary care for management, clinical and research uses, with suitable resources allocated for this absolutely invaluable work.
Thirdly, I support the recommendation by Dr Rebecca Rosen at the Nuffield Trust for embedding more non-medical clinicians—such as pharmacists and dieticians—into primary care, an approach that worked well for us in the pandemic. There are lots of great examples already in primary care of working differently, from community health worker models in Westminster to the Healthier Fleetwood approach. The question that arises from these experiments is: how do we make innovation in primary care the norm rather than the exception?
Lastly, I will say a word about diagnostics. The pandemic demonstrated the value of consumer diagnostics, attached to digital reporting and used at home or on the high street. These tools engage people with their own healthcare, improve personal responsibility and relieve the pressure on overburdened healthcare systems. It makes no financial or clinical sense that people book a hospital or GP appointment for often extremely simple procedures such as swabs, serology, and faecal and blood pressure tests. During the pandemic, the Lighthouse Lab processed 150 million PCR non-NHS test samples, lateral flow tests were shipped at up to 4 million a day at their peak, and over 2 million blood samples were taken at home by finger prick and posted to labs to maintain the ONS infection study. I give a loud cheer to our new diagnostic hubs, but I fear that on diagnostics we are going back to the old-fashioned, cottage-industry-based pathology mindset rather than embracing the opportunity presented by the consumer diagnostic revolution.
Let us not fight the last war or try to recreate Dr Finlay. This Select Committee must examine the opportunities presented by this crisis for moving away from cumbersome paternalistic models towards a data and diagnostic-empowered citizen patient. That is what a Beveridge 2.0 could look like. That is the way to grow the economy and protect our people.
Lord Hunt of Kings Heath (Lab)
My Lords, it is a great pleasure to follow the noble Lord and to thank the noble Lord, Lord Patel, for his speech. I fully echo his desire to see a special Select Committee created; I hope that the Liaison Committee members present will take note of that.
The noble Lord said that primary care is the bedrock of our health service, and I agree. If it does not function effectively, the whole healthcare system suffers, and it is clearly suffering greatly at the moment. It is not just workforce shortages or the crumbling estate. A recent Civitas report made for sober reading. It ranked the performance of the UK healthcare system with that of 18 comparable countries and, lamentably, it placed the UK second to bottom across a series of major healthcare outcomes, including life expectancy and survival rates from cancer, strokes and heart attacks. Recently, the Health Foundation has drawn attention to the UK having an astonishingly low number of MRI machines and CT scanners: fewer per person, according to the OECD, than any other developed country. That is besides having fewer doctors and nurses than our north European neighbours and very poor uptake of new medicines.
We see England’s hospitals being caught in a vice. On the one hand, the race to work through the enormous backlog of care means an unceasing stream of new patients into fewer beds. On the other hand, a decade of flatlining, at best, funds for social care means that even when treatment is concluded, thousands of patients remain in hospital beds waiting for follow-up care. Emergency departments have no beds to send new arrivals to the wards, patients with urgent needs wait for hours on end, ambulances cannot hand over patients, and are stuck in a queue outside A&E. We have to see the inadequacies of primary care in this much wider context.
The pandemic has accelerated the move to online booking and phone consultations with general practitioners. That has made care quicker and easier for many people, and we should not ignore that. On the other hand, it has led to many other patients facing enormous difficulties in getting face-to-face access to their general practitioner. The NHS England stat last October which showed that over 15% of practices recorded less than 20% of their GP appointments being held face-to-face is very worrying indeed. Last month, Pulse magazine reported that 1.5 million patients had lost their GP in the last eight years after the closure of almost 500 practices. Recruitment issues were part of the problem but we should not ignore the issue of workload, inadequate premises and sheer morale issues.
The noble Lord, Lord Patel, mentioned Dr Claire Fuller’s very interesting report to the NHS England CEO. She concluded that patient satisfaction with access to general practice is at an all-time low and described the 8 am Monday scramble for appointments as synonymous with huge patient frustrations. She said:
“left as it is, primary care … will become unsustainable in a relatively short period of time.”
We have all had evidence from the Royal College of GPs, which says that despite a government agreement to an increase of 6,000 in GPs, the number of fully qualified full-time equivalents has actually fallen by 1,622 between September 2015 and 2021. I mention again that I do not understand how the Government could have reduced the number of medical training places to 7,500 this year, following two years of there being about 10,500. It is amazing and extraordinary that the Government could have allowed that to happen. I had better declare my interest as a GMC member in that regard. The Health Foundation predicts that the shortage of GPs is set to become worse. It thinks that the current 4,200 shortfall will rise to more than 10,000 by the end of this decade.
Noble Lords have mentioned the recommendations of the Royal College of GPs: a new recruitment campaign, freeing up bureaucracy and investing in new technology—and I very much agree with the noble Lord, Lord Bethell, on that. But that is really not sufficient to tackle the fundamental issues we face. Noble Lords may be aware of a recent report by your Lordships’ Public Services Committee which looked at public service workforce issues generally. The stark conclusion is that every part of the public sector has targets for recruitment and none of them will be met. There is a lack of realism in accepting that and starting to do the work that needs to be done when faced with these acute problems. Again, I agree with the noble Lord, Lord Bethell, on that.
We need a realistic conversation about what we can expect primary care to do in future. Most of the evidence we have received says basically that we need more GPs but assumes that we carry on with the same 1948 model of primary care. That is not sustainable at all. We must be realistic and start talking about why that can no longer be the way we go forward.
Dr Fuller’s report to the NHS CEO was interesting. She argued for the streaming of services, with access to care for people who get ill but use health services only infrequently, and a distinction between their needs and those of people who are chronically ill and need care, to know their GP and access to multidisciplinary support. That is the start of thinking more fundamentally about primary care in future.
We must ask ourselves about the role of gatekeeper. People are wedded to the idea of the GP as gatekeeper—or, let us be truthful, as rationer of services. But when we look at outcome figures for, say, cancer, we must ask whether the lack of direct access to specialist care is one of the reasons that our outcomes are so poor. I do not know whether that is true or not, but we certainly need to ask the question.
How can we increase GPs’ job satisfaction? We must do something to give them the confidence to carry on in primary care in a way in which they get job satisfaction. We have many overseas doctors coming to work in the hospital sector. Can we change some of the rules and understandings in primary care to enable them to work there as well?
Finally, is the organisational model fit for purpose? We know that many GPs no longer aspire to partnership. What ought to take the place of that? If we are moving to a salaried service, partly in the employ of private-sector providers, how can we ensure that those GPs are getting the support, professional leadership and confidence to wish to stay in the sector in future?
I look forward to the Minister’s response. We do not need a lot of statistics, which, frankly, is not the answer to the fundamental issues we face. If ever we needed a special Select Committee, this is it.
Baroness Masham of Ilton (CB)
My Lords, I thank my noble friend Lord Patel for this necessary debate, and I declare an interest. In November 1981, I was given an honorary fellowship award by the Royal College of General Practitioners, and I have been and am a user of the NHS, being a high-lesion paraplegic. I ask the Minister: how is the NHS going to be improved without an adequate workforce?
We have a growing elderly population, with many complex conditions, who need treating. I am absolutely perplexed that many well-qualified students with many A and A* exam results, and who would like to study medicine, are being turned away by universities because the universities do not have an adequate number of places or because they are too expensive to train. This seems ludicrous when there is such a shortage of GPs and specialist consultants. This is a frustrating situation. What can the Government do to rectify it? Should we not try to be self-sufficient for the future years by training our enthusiastic young people, not training just half of what we need? We must invest in our future.
I bring to the notice of your Lordships and the Minister the situation of sick notes. It seems to be a difficulty for small businesses when an employee goes off sick and keeps getting repeat sick notes. Because of confidentiality, an employer cannot get advice from the GP. Are these repeat sick notes being given over the telephone, and for how long can they keep coming? Since the coronavirus epidemic, many GPs prefer telephone calls to face-to-face visits to surgeries. Small businesses need advice, as they have to put in staff to cover the absent staff who are off sick. At this difficult time, it may be the last straw which breaks the camel’s back.
Bed-blocking is well known and seems to be getting worse. This is not the fault of patients but it is very serious. Ambulances are being held up by multiple patients needing beds and waiting to get entrance to hospital. One of the main problems is that many elderly people have serious falls and cannot leave hospital until there is a care package in place at home so that it is safe for their return, otherwise they will be back in hospital. There is a desperate need for carers and a community team of physiotherapists, occupational therapists and speech therapists for patients who need to be safe at home. This does not come cheap. More funds are needed in both home care and hospital. It is no good robbing Peter to pay Paul; we need both.
My noble friend Lord Patel is asking for a House of Lords Committee on this important matter. It cannot wait: something should be in place before winter sets in. Whatever is set up needs to start the moment Parliament returns in October.
I end by saying that dentistry in the NHS is in crisis. Something must be done to save many people from agony and frustration. Dentistry has not caught up after the Covid epidemic. I have every sympathy with anyone who has toothache from an abscess, having had one myself last week. The conclusion is that reform of the dysfunctional NHS dental contract is now a matter of urgency. A reformed service will not work if there is no workforce left by the time it is finally introduced.
Viscount Eccles (Con)
My Lords, it is a great privilege to follow those four opening speeches. However, I knew that I was getting myself into quite unnecessary trouble by putting my name down for this debate. Having had no internal experience of the National Health Service, I cannot follow the catalogue of problems which we have so far heard.
I start by declaring an interest: I am in receipt of community care. I will not go into detail, but I was in hospital two or three times and the NHS picked up that this would probably lead to the need for aftercare. Lo and behold, community care appeared. It has been very interesting and extremely helpful, but it raises two matters.
First, there was no explanation for why this was happening; it just happened. There has been no explanation which might lead one to understand the objectives or the value of the work, and possibly even the value for money of the work, being done in what is undoubtedly an endeavour to ensure independence—an endeavour for which I am very grateful.
The second matter that has arisen is that I cannot any longer understand whether there is a borderline—and if there is, where it is—between primary care and what might loosely be called hospital-based care. Because of my short stays, two hospitals have picked me up and are determined to monitor all sorts of aspects of what they found during their investigations. A lot of that work is what I would describe as primary care. I will not go into details, as that is not the point of such a presentation, but, for example, skin trouble, which has been persistent and different and has apparently quite complicated causes, seems to have moved away from primary care.
The other aspect of these experiences means that, for various reasons, I have not been able to create any personal relationship with a general practitioner. I have been responsible for some of the changes that have led to that, but so has the medical centre, where the people change quite rapidly.
When thinking about these experiences and about what I do not understand about the National Health Service and how it is organised and run, I am very thankful for what has happened in the delivery of my medical services; I have every reason to be grateful. There have been glitches along the way—a rare side effect, which affects only 1% of the population, but that just proves that I am an awkward person, as so many people are. I am truly grateful for the way in which the NHS has dealt with the various problems that I have had—and here I am, past my sell-by date.
When thinking about that, I reflect on my two grandfathers. They were both medical men, and they were both involved in the negotiations which led up to the Aneurin Bevan health service Acts. If they were with us today, they simply would not understand what is going on. The changes have been so radical—in society, in the behaviour and reaction of people in society, in the medical profession, and in the technology that has come over the past 74 years—that they would not understand what is going on and why it is going on in the way that it is. This leads me to think that we must be coming to a need to discuss, rethink and maybe alter the Aneurin Bevan settlement.
There have been so many efforts over that time, and yet we have heard the catalogue of the first four speeches of this debate. It is clear that something is amiss and that we need to think about this very big organisation, with its huge difficulties. The gearing in such a large organisation and the importance of that fact that, when medical services are delivered, it is very personal—they are essentially between two people; you and some medical practitioner who has been through a long training and has the knowledge—means that it will either work as it should or will run into troubles.
In thinking about where we are, I hope that the first thing that we will consider very carefully is the relationship between the political sector—this is a nationally provided service, funded from taxation and free at the point of delivery—and the medical profession. There is no natural fit between politics and medicine. There was not at the beginning of the health service, and indeed there were compromises made at that time which we still live with. In starting a discussion, we must go back to fundamentals, and we certainly need the medical profession to stand up and be counted on how it sees the way in which the delivery of medical services should be shifted. What is the borderline between primary care and secondary or hospital-based care? What are the fundamental questions which must be asked and answered if we are to go forward?
Baroness Pitkeathley (Lab)
My Lords, I am grateful to the noble Lord, Lord Patel, for leading this debate and, beyond that, for the leadership that he provides to this House on all matters health related. Although he used the words community care to refer to community care health services, I know that he will forgive me if I slip over into the other bits of community care, which are so vital when we consider healthcare and which work in collaboration with primary care.
Patients and carers must be the focus of this debate, because improving outcomes for them is what primary and community care services are all about. But I must put in a word of warning here on behalf of those patients and carers: if you ask a typical patient or carer to define primary or community care, they would struggle, as the noble Viscount so ably and vitally reminded us. I must say it is a pleasure to see him with us, not at all past his sell-by date. A typical patient simply does not know the difference and why should they? They refer to “my doctor”, “the hospital” or “the carers who come in to see my mother”. They do not know about different streams, different types of training or regulation; they are puzzled only by why test results take so long to reach their GP, why some care is free and other care has to be paid for.
I have lost track of how many friends and neighbours I have advised should be in receipt of NHS continuing care funding for their elderly parent, when they have immediately been advised to seek a place in a private and very expensive nursing home, without any reference to possible alternatives. What puzzles patients and carers most of all is the lack of communication and integration between services. “Why on earth do they not talk to each other?” they say. “Why do I have to tell my story all over again to every new person I see? Why did my GP not know that I was being discharged from hospital?” Every time I speak to a patient or carer, I find myself at a loss to explain why these things happen.
It is not as though they are new problems or that we do not know how to solve them. We know about integration, shared budgets, joint training initiatives, more realistic funding and better workforce support. We had great hopes when the integration White Paper was published earlier this year: it promised shared planning and delivery for health and social care and making access easier. But there was little to explain how a joined-up system would be managed, be accountable to the public and balance what is delivered locally with national standards and entitlements. That is another cause of bewilderment among patients: “Why does my sister in Devon or Doncaster get something that I have been told I can’t have where I live?”
I must turn to the disaster area of social care, because you cannot focus on any problems in the NHS without fixing social care. I was amazed, as many of your Lordships would have been, to hear the outgoing Prime Minister claim, on Tuesday, that he had fixed it. You could have fooled me or anyone else who works in the system. Why are ambulances in short supply and taking longer to reach those in need? It is obvious: they are queuing at hospitals because there are no beds to move people into from A&E. One in seven hospital beds is now occupied by a patient who is fit to be discharged but cannot be, because there is nowhere for them to go, because of chronic underfunding in the system. With such long-term shortages in the workforce, even those who have a care home place may be neglected, while unpaid carers carry even more burdens, as I have reminded your Lordships on all too many occasions.
I was grateful that the Minister was able to secure a concession for carers in the recent Health and Care Act, enabling them to be consulted at the point of discharge. However, all too often, local services to support them are sparse or non-existent. The charitable sector, which is often the main source of support, is also under severe pressure.
One reason is Brexit—so many former employees were from the European Union—while another is poor wages and another is lack of respect for the social care professions, which are always seen as the poor relation when compared with health services. The Minister referred to that in his Answer to a Question earlier.
The new Prime Minister said that she will stop the health and social care levy, which was meant to fund, first, backlogs in the NHS and, secondly, social care. Will she now give all that money to social care? If so, how much will it be and how many constraints will be placed on how it is used?
The lack of attention to and funding of preventive services is a constant problem, as the noble Lord, Lord Bethell, reminded us. Small amounts of money spent early in a patient journey can head off many problems, but too often we wait for a crisis, which requires far more resources and has poorer outcomes anyway. GPs can be vital in identifying such early-intervention opportunities, but are often denied the opportunity to do so. We must remember too that the cost of living crisis will only make problems of access worse and there will be more demand because of cold homes and inadequate diets.
Many have mentioned problems with primary care and the supply of GPs. The reason there are so many patients who walk into A&E is often the difficulty they experience getting a GP appointment. I know this is a major problem in many areas, but I must put in a word for some GP practices, such as my own, which provide services way beyond those we expect and attempt to support their communities with services and initiatives for the homeless, the lonely and those with mental health problems.
I turn to the reforms needed. We need more progress on integration, taking note of some of the local initiatives, which are fine examples, and not being constrained by the “not invented here” syndrome, which is a problem for many people who work in the health service. We must also face up to the workforce crisis. The Public Services Committee, on which I serve, has been mentioned, and it showed that no recruitment targets are being met. It was a great pity that the Government did not accept the amendments for regular reviews of the workforce put forward by the noble Baroness, Lady Cumberlege, when the Health and Care Act was going through. To address shortages, Governments, regulators and employers must succeed in retaining existing professionals and recruiting and training additional ones. This may mean that they have to challenge conventions about education and training and be far more flexible in how we deploy that workforce. How many times have I heard calls in this House for integrated training across health and social care, but has any real progress been made?
Being more flexible about patient need requires some professions to give up their protected status and to recognise that a nurse, physiotherapist, pharmacist or healthcare assistant can meet patient needs as well as or—dare I say it?—even better than a doctor. It is a pity that radical reforms of the regulation of the health professions have never been tackled, in spite of many promises.
The new Prime Minister said that the NHS will be a strong focus for her Administration. She will always find those who work in health and care committed, dedicated and willing to embrace change. What they ask for in return is honesty about the problems they face and recognition of their devoted service.
Lord Kakkar (CB)
My Lords, I join other noble Lords in thanking my noble friend Lord Patel for the very thoughtful way in which he introduced this important debate. In so doing, I remind noble Lords of my own interests. In particular, I am chairman of the King’s Fund and King’s Health Partners.
In opening this debate, my noble friend described—and many other noble Lords added to his description—the substantial challenges that the NHS faces in general and in particular in primary and community care. So far in the debate, there has been a consensus and recognition that failure to address those challenges will ultimately lead to the NHS, in general, becoming totally unsustainable. We see the manifestations of this every day in the crisis to ensure that patients in an acute situation can be delivered to hospital through the ambulance service; in the substantial waits and, quite frankly, clinically unsafe environment that now represents many accident and emergency departments; in the tremendous pressures demonstrated in the acute management of patients in medical, surgical and other disciplines in our hospitals; and, most importantly, in the failure to discharge patients from hospital back into the community. The result of all that is an NHS that is considered, regrettably, now to be failing in many aspects. That failure is attended by an increasing loss of confidence among our fellow citizens.
I strongly support my noble friend Lord Patel’s proposal to establish an ad hoc Select Committee of your Lordships’ House to examine in more detail the challenges and opportunities for reform in primary and community care. In proceeding along that line and in having identified the many challenges faced, the issue is to understand how we might address them. To do that, first, we must deal with a major problem, which is the discordant perception and expectation among some important groups, with regard to what should be delivered by primary and community care services in the NHS. The expectations are those of politicians, of the public, and of health and care professionals. Those expectations are starting to differ widely when we look at the reality of what can be provided through a model of primary and community care established at the birth of the NHS.
That model, having at its heart family doctors well versed with the needs of their patients in broadly small communities in small practice settings, was fine some 70 years ago, but the demographic changes in our country, and the nature of chronic diseases that now attend so many citizens, which have a profound impact on their quality of life and their need to avail themselves of health services, are quite different from 70 years ago.
In addition to that, advances in medical and clinical practice provide important opportunities to impact on many of these conditions, but those advances require changes in the way we deliver care, pathways of care and an important emerging recognition that the hospital cannot be the place where the majority of patients with chronic conditions are managed. They must be managed in the community. Indeed, many must be managed in their home. That requires a different approach to understanding how professionals in primary care and community care settings need to be trained and the skill sets required. It also requires a confidence in understanding that what clinicians might have done previously should be done by other professionals.
Therefore, a professional workforce must be developed, with a recognition that skill sets will have to be developed differentially and that those who might previously not have been involved in delivering direct care—more specialist nurses, community nurses and practitioners—will now need to be encouraged and developed to do so. It also requires the adoption of innovation and technology to ensure that this care can be delivered safely in the community. Patients and their relatives need to be confident that they can understand and have confidence in the digital and technological solutions provided in their own homes and in community hubs and community settings.
Regrettably, none of this seems to be being addressed cohesively, so we rightly welcomed the opportunity provided in the most recent Health and Care Bill for the development of more broadly integrated community care settings and integrated care partnerships and boards to supervise the delivery of that care and bring different elements of the healthcare system together. But we need to go far beyond that. The Minister will be aware that in the debates on that Bill, which he so ably took through your Lordships’ House, there were suggestions, which we have heard from other noble Lords, regarding ensuring that workforce planning, a better understanding of the methodology used in planning, and the parameters considered in terms of demographic change, emerging technologies, advances in our understanding of pathophysiology and the capacity to deliver care should be included in very sophisticated workforce planning that will help us understand not only the number of healthcare professionals required but their potential disposition by way of discipline and specialty, and the capacity, with emerging understanding, knowledge and technology, to train different groups of healthcare professionals so that, as we have heard, they can work more cohesively together as a team, delivering so much more of the care in the community and at home so that patients never need to come to the hospital.
Indeed, other European countries have been able to achieve these ambitions. They have much lower levels of bed occupancy in their acute hospitals. Therefore, they see no particular anxiety about times such as winter, when acute admissions will inevitably increase. We have failed to achieve that. This failure is now taking us to a place where the system will, as I said, become entirely unsustainable.
In closing, I urge Her Majesty’s Government to have the courage to start addressing the problems we face and to start establishing a narrative and communication to bring together professionals, politicians, the public and patients to help understand and develop a consensus around the very important, serious and far-reaching decisions that now need to be taken to ensure that we strengthen primary and community care with new models; to ensure that those models are properly co-ordinated with the changes that need to occur in secondary and tertiary care; and, attending all that, to ensure that we have appropriate workforce planning across those different environments and care settings, attended by a proper review of the regulatory framework in which those professionals will deliver care and a better understanding of how we will ensure proper adoption of innovation through funding innovation streams beyond the recurrent funding for day-to-day delivery of care.
Lord Farmer (Con)
My Lords, it is a pleasure to follow the informative and thoughtful speech of the noble Lord, Lord Kakkar. I too thank the noble Lord, Lord Patel, for securing what is a very timely debate, given the new Health Secretary’s pledge to put patients first, and the opportunity to talk about how community-based care can improve patient outcomes.
I declare my interest as director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. Family hubs are well-placed to deliver a broad range of paediatric physical and mental health services that are more accessible for families. The noble Lord, Lord Hunt of Kings Heath, mentioned accessibility. That accessibility, and the integration of health with other family support in a non-stigmatising and parent-educating environment, has the potential to transform outcomes. Paediatric health needs that are psychosocial and practical require a whole-family approach. Moreover, delivering them in hospital settings a couple of bus rides away from where people live makes it far less likely that children will attend.
Watson and Forshaw’s study found that a third of all paediatric hospital appointments were missed over a six-month period. Even more concerningly, a third of those children who were “not brought in” by their parents were known to social services and therefore likely to come from families already struggling greatly with the basics of child-rearing. Distance from home contributes to the social gradient in health and perpetuates the inverse care law that those with the greatest healthcare needs have the poorest access to that care.
Accessibility matters greatly if services are to be delivered for the convenience of hard-pressed parents and their children, rather than the system. I welcome family hubs’ inclusion in the statutory guidance for the preparation of integrated care strategies. These are described as
“a way of joining up locally and bringing existing family services together to improve access, connections between families, professionals, services, and providers, and putting relationships at the heart of family support. The Family hub model brings together services for families with children of all ages (0-19) or up to 25 with special educational needs and disabilities … with a ‘Start for Life offer’ at its core.”
Otherwise, access was not prioritised in this guidance, but it should be.
A provider of healthcare services in one county, contracted to provide similar services in two integrated care systems and in two very different ways, told me:
“In one ICS, our contract to deliver children’s community health provision gives us the autonomy to deliver in the community and close to people’s homes. Where we can, we deliver this in Family Hubs so we can provide education for the parents, early help and appropriate expertise. We provide allergy, continence, perinatal mental health, speech and language and other support, all of which prevents unnecessary attendances in GP practices and A&E. However, in another ICS where we are sub-contracted by an acute hospital, we are required to deliver the same services from a hospital setting. The parent and patient experience differs significantly from one that is educated, empowered and supported to one that is the recipient of a treatment.”
Moving on to how health is described in the DfE’s Family Hubs and Start for Life Programme Guide, the lens always seems to be the very early years. Reference is made, for instance, to
“a clinical setting such as a maternity hub”,
mental health is couched in terms of helping families receive appropriate support for their parent-infant relationship and the specific conditions mentioned, such as neonatal necrotising enterocolitis, infer babies’ health needs. This is an important start, and the Department of Health and Social Care is, at this point, mainly interested in family hubs as the place where start for life services can be delivered, but their potential is so much greater than that, as my earlier example made clear.
Can my noble friend the Minister let me know what encouragement DHSC is giving to the wider provision of health in family hubs? I ask because, at present, the Family Hubs Network and others have found a distinct lack of awareness of their potential to ease the load on health providers. Health professionals tell us that paediatricians at local hospitals still do not know about family hubs, but need to. They often see families with well-established problems, such as obesity and incontinence, which are best treated closer to home with regular contact with early-help practitioners in family hubs. Social prescribers and therefore local GPs, even in areas where there are flagship family hubs, are similarly unaware.
Hubs are also a better place to take on the non-health problems which consume so much of GPs time. In 2015, Citizens Advice’s report, A Very General Practice, itemised how much time GPs spend on various non-health issues and found, unsurprisingly, that 80% of GPs said that such demands cut into their time for meeting patients’ health needs. Citizens Advice called for non-health demands to be met in ways that free up GPs to focus on patients’ health, particularly where they require specialist knowledge. The top three non-health issues that patients raise during consultations could and should be part of the family hub offering: 92% of patients mentioned personal relationship problems, 77% problems with housing and 76% problems with work or unemployment. Only one-third of GPs felt they were advising patients adequately.
Family hubs already join up services, including housing and employment coaching, from a wide range of government departments. DWP runs reducing parental conflict programmes in family hubs, where it is easier and less stigmatising to access relationship support, particularly for low-income families. Similarly, the MoJ’s pilot family hub in Bournemouth links with the family court and enables separating parents to get help earlier, and avoid costly and adversarial court processes.
Last week, the Children’s Commissioner’s Family Review said that every government department should bring forward family-strengthening policies, led strongly from the top. Family hubs should be the key delivery sites for them and expand their remit, for example, to include better support when parents make child maintenance claims, measures to tackle rural loneliness and disadvantage and intergenerational opportunities. A Cabinet-level Minister needs to co-ordinate these across government, backed by the new Prime Minister. Liz Truss pioneered this in government when she commissioned my review into the importance of prisoners’ family ties to prevent re-offending and intergenerational crime. She has also promised to look at family taxation, so I am expecting great things from her.
The Children’s Commissioner also said how important family stability is for children and parents. Profound mental and physical health ramifications flow from family breakdown. In a major study of more than 43,000 children, clinicians said that family relationships problems are the most common reason children and young people access mental health services. Resolving them often requires a whole-family integrated approach that it would be better for the health service to deliver in family hubs rather than secondary or primary care settings, which necessarily individualise conditions. Reform to make this a mainstream, default approach, where appropriate, is urgently needed for better patient outcomes, but it requires leadership from government to divert the NHS away from its well-worn tracks. Will the Minister kindly arrange a meeting for us to discuss this further with his new boss?
Baroness Finlay of Llandaff (CB)
My Lords, like others I congratulate the noble Lord, Lord Patel, on raising this crucial debate. I declare that I am a fellow of the Royal College of General Practitioners as a GP—indeed, a medically qualified Dr Finlay—and got my fellowship before moving to hospice work. I am also a patron of the Louise Tebboth Foundation to prevent GP suicides and am president of the Chartered Society of Physiotherapy. I will focus on family medicine specialists—GPs—but we must not forget the major impact that physios and others have on conditions through direct access.
I chaired the Independent Commission on Medical Generalism for the Royal College of General Practitioners and the Health Foundation. Our 2011 report concluded that the generalist approach is essential across healthcare and that if it did not already exist it would have to be invented, while work by Barbara Starfield showed that the health of a nation depended on the quality of its primary care services. I do not believe that that has been dented by Covid.
Patients are the raison d’être of healthcare delivery. People become ill at all times of the day and night, presenting with undifferentiated conditions. Some conditions progress rapidly, in others the course is fluctuating or resolves. In our communities, many people live, work and contribute to society with a broad range of chronic long-term multiple co-morbidities. Some have rare conditions. Differentiating abnormal from the normal requires diagnostic skills and risk-assessment experience. Good primary care training is essential, providing adequate experience in paediatrics, women’s health, acute and early presentations of serious illnesses and the complexities of medicine in the elderly—and now the workload of GPs has become increasingly linked to social problems in society and mental health.
However, the problem we have is that GPs are leaving practice faster than they can be recruited. The 27,500 whole-time equivalents GPs are made up of a workforce with a headcount of around 40,000. As the noble Lord, Lord Hunt of Kings Health, pointed out, there are now 2.5% fewer GPs than in 2019 and 5% fewer than in 2015, but the average GP is responsible for 16% more patients than 10 years ago. More patients need to be seen than there are 10-minute appointments in a day, let alone time for home visits.
Seeing 40 to 60 patients a day, many of whom have complex medical and social problems, for five days a week is unsustainable. GPs become burnt out and leave. They seek work in other areas in medicine, but often in much more administrative or peripheral roles. Many GPs develop an extended role, developing expertise in some branch of medicine, such as women’s health, diabetes or hospice work, or in emergency medicine departments as part of a portfolio of clinical work. They need to carry on working but feel burnt out with the workload of routine general practice.
The GP is the first point of contact for undifferentiated complex problems. They can provide a holistic and comprehensive service for the long-term and acute care of the population they serve in their communities. An integrated approach must address the whole person: the physical, psychological, spiritual and emotional aspects which have led to the condition that has presented. Importantly, there is good evidence that, where continuity of care is in place, there are better clinical outcomes at lower cost, with greater patient satisfaction. We desperately need more GPs—incoming newly qualified GPs—but also to find ways to retain our experienced, highly skilled doctors who are leaving the profession in large numbers.
These doctors are trained family medicine specialists, and they need parity of esteem with consultant specialists in secondary or tertiary care. From that position, some will need to be able to pursue particular special interests, which will support other services such as mental health—thereby combining the family medicine specialist’s interest with some days in community practice—where integration with social care provision is essential.
There have been efforts to increase the numbers of allied health professionals in primary care to help with the shortage of GPs. But there is increasing evidence that, unless these professionals are carefully integrated into the primary care team, they cannot replace the experience and value of a GP. They need support and nurturing. The incoming chair of the council of the Royal College of General Practitioners, Professor Kamila Hawthorne, wants to create associate membership of the college for those allied health professionals who contribute to the primary care team to ensure better integration and understanding between the different disciplines in proper team working. In GP clusters that work well, all disciplines coming together has been shown to improve clinical outcomes and decrease the burden on secondary care. Change will be embraced if those delivering care can lead it and funding issues cannot be ignored in terms of the way that people are paid and reimbursed for their services.
There are other disciplines and services in the community. Hospice home care teams and Marie Curie nurses can be an essential supplement to primary care provision, but they need to be involved early. As many GPs have an interest in palliative care, I hope that the specialty will reopen to those with MRCGP, rather than allowing entry to consultant level training only to those with RCP membership, because their mature clinical experience in the community is invaluable, especially for hospice at home.
We must recognise that the diagnostic, management and risk-assessment skills of the trained GP are essential for our communities and the NHS. Community work is not easy, but it can be very fulfilling if allowed to work properly. The employment of family medicine specialists, with parity of esteem with the hospital consultant body, would allow those who wish for a much more flexible career approach to develop their special interest roles while retaining a firm foothold in family medicine in the community, with all its complexities. Working with their communities, with their own patient population and with all aspects of social care, they can be community leaders.
In the pandemic, around 30,000 doctors were granted temporary emergency registration and over 9,500 have remained licensed to practice until now. At the end of the month, they must apply to restore their registration and for their licence to practise to remain. To date, around 8,000 have not acted despite a streamlined process being in place. Will the Government request NHS trust responsible officers to be available to doctors in their area who wish to relicense?
I have not focused on pensions, but it has aggravated the problem of the loss of GPs from practising. As judges have been given an exemption from the pension cap, will the Government review the pension cap for clinicians? It would be far more cost effective than gaps being filled by expensive locums or leaving services with gaps unfilled and a population without the healthcare it needs.
More medical school places, greater flexibility around revalidation and an ability to have flexible career paths could help supply and retention. However, the problems leading to attrition must be addressed, and the scenario from dentistry is the flashing warning light in front of our eyes.
Lord Baker of Dorking (Con)
Before the noble Baroness sits down, I thank her for a very interesting, well-informed speech. She identified the pressures placed upon GPs, which are not going to be relieved easily. Would she welcome what happens in a country such as France, where many—
Baroness Bloomfield of Hinton Waldrist (Con)
I am very sorry, but the noble Lord is not on the speakers’ list.
Baroness Bloomfield of Hinton Waldrist (Con)
No, not in a time-limited debate with a provided speaking time.
Baroness McIntosh of Pickering (Con)
I add my congratulations to the noble Lord, Lord Patel, for calling such a timely debate. It is rather curious to hold a debate without any general practitioners being present to contribute. I understand that in your Lordships’ House there are no general practitioners. I declare my interest as advising the board of the Dispensing Doctors’ Association, which represents over 4,000 general practitioners in over 1,000 dispensing practices, accounting for 15% of all practitioners.
What lies at the heart of this debate and what I would like to focus on is how health services are delivered in rural areas. There are twin challenges which lie at the heart of this debate; there is a rural and urban aspect to health policies, which is often overlooked. We often have a metropolitan elite running the Civil Service at the highest possible level. There is also the challenge of the conflict between primary and secondary healthcare. It is a flawed approach to seek reform to primary care without looking at the bigger picture. I entirely endorse what the noble Lord, Lord Kakkar, said about needing a cohesive and holistic approach to any possible reform.
I put on record that there were 365 million GP consultations in 2021, which equate to about 6.5 consultations per patient. Excluding Covid vaccinations, that equates to over 311.5 million consultations—the same number delivered in 2019. There were 179 million face-to-face appointments in 2020-21, according to NHS Digital. It is also important to state that GP pay peaked in 2005-6 and has fallen every year to 2013-14. It is still not back to the pay between 2004-8, without taking inflation into account. The source for that, again, is NHS Digital.
My concern is the lack of joined-up government in delivering healthcare across the piece. Neither the Department of Health and Social Care nor NHS England rural-proof policy. That flouts the detailed proposals set out by the noble Lord, Lord Cameron of Dillington, in 2015, when our current Prime Minister was the Defra Secretary. Whenever rural-proofing is raised with officials, we are told it is a Defra issue. I hope that it is something my noble friend the Health Minister will take a personal interest in. Perhaps this could be addressed by a House of Lords committee, such as the one sought by the noble Lord, Lord Patel.
The expression “delivering at scale” fills me with alarm and anxiety. Policy which delivers at scale must recognise the challenges of delivering health policy in all its settings, particularly rural ones. For example, do officials understand the lead times to run a vaccination campaign and how this affects a GP workload? GP practices need to order vaccines in November and by January by the latest to run an autumn schedule. There has been much vacillation and incoherent messaging to contractors about the flu and Covid booster campaigns this year. I think that has added to uncertainty in GP practices and to their lack of preparation time.
The preference for large vaccination centres run directly by the NHS does not work in rural areas. Indeed, the National Audit Office reported:
“In terms of delivery costs, dedicated vaccination centres have been the most expensive method at £34 per dose compared with £24 for GPs and community pharmacies. GPs and community pharmacies were the most popular delivery model for all priority groups”.
There has clearly been wastage of valuable medicines in the big centres, which I see as an example of delivering at scale. I argue that it simply does not work in rural settings, where it is extremely difficult for patients living in a rural area to access such a big out- of-town urban centre.
Dispensing in rural areas is often the best choice for those with chronic conditions, and often rural practices dispense because there is no viable pharmacy. This dates back to Lloyd George and national insurance when it was first set up. Dispensing practices receive a disproportionate number of outstanding inspections from CQC, for some bizarre reason. They are often the last public service left in many communities and are highly valued by their patients.
I applaud the work done by successive Ministers for Health, not least my noble friend Lord Bethell, succeeded by my noble friend Lord Kamall, but the digitalisation of the health service in a health rural setting has not been a huge success. There are huge problems of rural connectivity. Poor broadband and mobile signals hamper delivery of the service and make remote consultations almost impossible. There is no electronic prescription service available for dispensing patients. Recruitment of GPs is difficult but, where they train in rural practices, they tend to stay and become partners.
I argue that the system of drug reimbursement needs to be overhauled to remove perverse incentives so that what is good for patients is also good for the NHS and contractors. I add that the closure of community hospitals in rural areas has put increasing pressure on acute hospitals and, indeed, community nurses. That has exacerbated the situation, as others have set out in this debate.
We need to assess the impact of Covid and the delays in diagnosis and treatment. We need to consider the impact on the morale of front-line medical and nursing staff. I applaud the fact that the Government are looking at the pension cap, which has been addressed by others today. We need to look at models such as that agreed by senior judges, which I think would be acceptable to all parties; that seems a good model to use.
In the briefing preparing for today, I noticed that one concern is that the need for regulatory reform has been extended at the moment only to regulating physicians and anaesthetists. When will that be extended and in what timeframe to, for example, general practitioners and all doctors generally? That goes to the heart of having a positive, cohesive approach.
I have a question for the Minister. Bearing in mind that some 15% of the population live in an area served by dispensing doctors—in rural, isolated, sparsely populated areas—how do the Government intend to deliver healthcare in those settings on the same basis as in urban settings?
I conclude with parity of esteem. My father was appointed as one of the first ever general practitioners in 1948. His brother eventually became a general consultant. He referred to my father rather affectionately as a panel doctor. Until then we end this contest and conflict between hospital consultants and senior GPs, I do not believe we will achieve the parity of esteem that best serves patients and the health service.
Baroness Meacher (CB)
My Lords, I too applaud my noble friend Lord Patel for tabling this important debate. As he and many others have said, the NHS is broken; I really do not think that is any exaggeration. The fact is that the demand for GP services has increased over the years, as we know and as others have mentioned. It is incredible when you think about it that between 1990 and 2010 life expectancy increased by 4.2 years. People are living longer with more long-term and complex conditions. Remarkably, over 15 million people now live with at least one long-term condition. Where do these people go? To their general practitioner, so it is no surprise that they are in trouble. The effects of the pandemic are going to be with us for years. Where do all these tens of thousands of people waiting for treatments, assessments and so on go? They go to their GP, who cannot really help them, but they are desperate.
The impact of all this on GPs is colossal, made worse by the falling number of GPs, as the noble Baroness, Lady Finlay, referred to. We now have a downward spiral in primary care as GPs suffer ever greater pressure of work, ever longer days, burnout and the sense that they cannot deliver the quality of service that they wish to for their patients. A growing number are leaving the service or planning to do so—terrifying numbers of GPs are now actively engaged in the business of how and when exactly they will leave the service.
A family member is cutting their hours, as are many others, so, when we talk about the number of GPs, are we talking about full-time equivalents or are we merely talking about heads, many of whom will be working part-time? A family member GP works at a practice with 13 GPs but only three are now working full-time—he himself has cut his hours to six sessions—yet about 10 years ago I believe that all of them were working full-time. Of course, those who are working full-time are working 12 hours a day so they are literally burned out, and I watch that happen.
A common response is that GPs must employ more pharmacists and nurses. That is right, of course, but this has been happening for years and the main problem is that these people are also very hard to recruit. There are not enough of them. The big issue, raised by the noble Lord, Lord Hunt, is of course the inadequate level of prevention and preventive work within general practice even today. I must say that I feel that every general practice should have a dietician to take on the vast numbers of people in this country suffering from obesity, many of whom take up large amounts of a GP’s time. Frankly, they need to go to a dietician and get things sorted out. Perhaps that is rather a tough view but it is mine. Another specialism that I feel could take on a lot of work in a preventative capacity is psychological therapy. How many people go to their GP because they are basically a bit depressed, unhappy or whatever it is? Again, if a GP could really make sure that people’s distress was being handled, I think that would make an enormous difference.
I want to address a further point. I regard the Pulse proposal to end GP contracts and bring the vast majority of GPs into trusts as salaried doctors as foolish and potentially costly and dangerous. Too often, Governments seek to resolve the problems of the NHS through reorganisation, but this distracts all the managers from top to bottom into worrying about their own jobs, their colleagues’ jobs and so on instead of focusing on patients, and the patient focus gets lost. Personally, I would warn against revolution and say that, really, we need to deal with all these things through evolution. As I have said, a lot could be done by bringing in preventive personnel who could alleviate a lot of the problems of GPs. Employ more medical and pharmaceutical staff, psychological therapists, dieticians and nursing staff—definitely, yes.
Also, as the noble Baroness, Lady Finlay, mentioned, the Government need to sort out the pensions crisis rapidly and urgently. I hope that the Minister can give us an update today on what exactly the Government plan to do on this, because very senior and valuable doctors are leaving the NHS every day because of this problem. We cannot afford for this to be delayed at all, so please could the Minister give us some help on that one?
As a Dutch GP who came to work in the UK said recently, GPs are not the problem:
“They are knowledgeable, driven and hard working.”
He said that the NHS structure, secondary care and the media are the problem. I do not know what to make of all of that, but we need to value our GPs—that is what I take from that. We need a serious review and urgent support to ensure the sustainability of the primary care services that we value so highly. I strongly support the proposal of my noble friend Lord Patel to establish a special committee in this House to take on this work.
Baroness Hodgson of Abinger (Con)
It is a great pleasure to follow the noble Baroness, Lady Meacher. Like others, I thank the noble Lord, Lord Patel, for securing this debate and introducing it with his usual thorough and considered approach. It is particularly timely, given the recent Health and Social Care Committee report’s conclusion that healthcare providers in England are facing
“the greatest workforce crisis in their history.”
We have heard this from many speakers today. A cancer specialist wrote last weekend in the Daily Telegraph that NHS general practice had reached the “point of no return” and was “irrevocably broken”, citing that, since 2013, 474 practices had closed permanently, affecting 1.5 million patients.
We hear consistently about the crisis of patients not being able to access doctors, with only 56% of patients reporting that they had had a good experience in making an appointment and 53% saying that they found it easy to get through to the practice on the phone. Most worryingly, the survey also found that 55% of people—up by over 13% over the past year—said that they had avoided making a GP appointment, with the major reason being that it was too difficult.
Many GP practices have taken on the system of triaging patients. Although I understand that this can have some benefits for doctors, it can also be very intimidating. I have had an experience of a very aggressive triaging doctor shouting at me when I was asking for a doctor to come to my very sick elderly mother. It was extremely upsetting, especially because it was followed by a refusal to attend. People who are stressed or unwell are unable to deal with being treated like that, and it creates a barrier to people receiving the care that they should.
As the noble Baroness, Lady Pitkeathley, mentioned, the result of this can be that people give up trying to see their GP and go straight to A&E instead, causing increased overcrowding there, with the knock-on effect of ambulances being unable to discharge patients and then unable to attend other urgent cases. Although we are being urged to stay away from A&E, if patients cannot access their doctor, it may be their only option to get care. There is an enormous loss of faith in GP services. A British Social Attitudes survey found that, since 2019, the proportion of patients who were satisfied with their GP services has plummeted from 68% to 38%, the lowest level on record.
It is clear that GPs are also feeling hugely under pressure. A report published by the Health Foundation charity paints a picture of high stress and low satisfaction with workload among UK GPs. Just one in four UK GPs are satisfied with the time that they are able to spend with patients—appointment times are among the shortest of the 11 countries surveyed. As we heard, only one in four GPs in England is now working full time, and most GPs work three days a week or fewer.
Although I am sure that the pandemic has exacerbated this situation, the cracks were there before. One of major things that has gone wrong is that many doctors now do not know their patients. There is enormous benefit in knowing your GP, especially for the elderly, those with small children or those with serious and ongoing health issues, and it makes it much easier for GPs to treat them. I accept that that is not always the case for younger and healthier people, who may need to see their GP very infrequently.
Last year, a Norwegian study published in the British Journal of General Practice demonstrated this. It showed that those who had the same doctor for between two and three years were about 13% less likely to need out-of-hours care, 12% less likely to be admitted to hospital and 8% less likely to die that year, rising to 30%, 28% and 25% respectively after they had had the same doctor for 15 years. Meirion Thomas, whom I referred to earlier, highlights that continuity of care is crucial in early cancer diagnosis. Survival rates in the UK lag behind almost all comparable high-income countries. Recent research has shown that 37% of patients with cancer in the UK present in A&E with acute symptoms and with advanced disease associated with a poor prognosis.
The Norwegian report stated:
“It can be lifesaving to be treated by a doctor who knows you”.
Smaller practices delivered this—yet, in the UK, the trend has been for GP practices to become bigger and pool their patients, thus eroding the relationship between doctors and patients. Although patients over 75 in the UK are given a named doctor, some doctors interpret this as just having to look at the patient’s records. Although I understand that patients who wish to be seen urgently cannot always see their GP that day, it is impossible for a doctor to be responsible and deliver appropriate care for a sick elderly patient without ever meeting them. Older GPs say their job satisfaction came from knowing patients, often whole families, and caring for them through the years. Yet so many doctors training as GPs then leave or work as locums because the pay is much better and there is less form filling.
The job has changed in other ways too. The head of the Royal College of General Practitioners recently said that family doctors were working at an intensity that was “unsustainable”, leading to many cutting their hours or taking early retirement—other speakers have referred to this. I gather that, on average, a doctor is asked to deal with 40 patients in a day, with some GPs being asked to see closer to 50. Apparently, GPs feel that the right number is probably around 30. This overload is leading to burnout and early retirement, as we have already heard. The Royal College of General Practitioners has said that 65% of GPs say patient safety is being compromised due to appointments being too short.
What can we do to improve all this? We had much better primary care 20 years ago; the damage started in 2004 with the change in the GP contract. We urgently need a system that works both for patients and doctors, but a health system needs to be patient-focused. As the noble Lord, Lord Patel, said, this is about caring for people. Training more GPs is perhaps an easy answer, but people also need to be encouraged to look after their own health so that they have fewer visits to a doctor and are healthier for longer—prevention is absolutely key. Health checks are very important. We should also include mobility checks. People who cannot exercise well can tend to put on weight, leading to diabetes and heart problems, and checks would also help the prevention of hip and knee problems.
I welcome the new women’s health strategy for England, which will tackle the gender health gap and improve the health and well-being of women and girls. We must make it advantageous for doctors to work in a practice rather than being a locum. We need to cut down on the number of patients they are asked to see daily, and make the job more enjoyable and satisfactory for them—less stress might encourage more to work full-time. We also need to encourage doctors to know their patients again; the system works best when doctors know their patients and patients have faith in their doctors. This will lead to better outcomes and help ease pressure on the whole system. If that is the case, Zoom appointments and phone calls—which can cut down on time—can be beneficial, but if a doctor does not know their patient, it is much harder to treat them satisfactorily in this way.
The NHS app is excellent for things such repeat prescriptions. Could modern technology do more to remove some of the bureaucratic functions and form filling? Practice nurses should be able to deal with more conditions, while qualified pharmacists could give a wider selection of medication without a prescription. Community nurses are a huge asset, and we need to ensure that doctors work closely with them. Mental health takes up more and more time: are there better ways of dealing with this, rather than endless medication? In addition, we should encourage people with certain conditions not to go first to their GP—for example, those with back pain should go to a physiotherapist, osteopath or sports therapist, and people should go elsewhere for sight and hearing checks.
It is urgent that primary healthcare works better for patients, as well as being a job that is once again enjoyed by doctors. Bold steps need to be taken. I absolutely support the suggestion by the noble Lord, Lord Patel, of setting up a Select Committee to look at this. If we can once again restore primary healthcare, it will greatly ease the whole health system and deliver better outcomes.
Baroness Watkins of Tavistock (CB)
My Lords, it is a pleasure to follow the noble Baroness. I congratulate my noble friend Lord Patel on securing time for this important debate and support his proposal for a special committee. I declare my interests as a registered nurse and as president of the Florence Nightingale Foundation.
Other noble Lords have spoken about the medical workforce—in particular, general practitioners—and the need to invest in dentistry services. I will focus on the multidisciplinary teamwork in general practice and community care, with a particular emphasis on nurses, midwives and health visitors. In England, the primary care networks have enabled some community nurses and GP practices to work closely together at a local place level. This is building on a successful neighbourhood model that has been in existence for many decades. However, as briefing from the Queen’s Nursing Institute reminds us, a one-size-fits-all model does not apply because of the variety of geographical neighbourhoods—including rural and urban communities —and the different needs within those communities.
The Fuller stocktake report referred to by other noble Lords gives good examples of where services work closely together, successfully emphasising that the focus in both community and primary care should be on good outcomes for patients, not a one-size-fits-all approach for the sake of administrative uniformity. It is for that reason that the local integrated care boards should ensure that local practitioners, in partnership with the people they serve, are closely involved in determining the shape of local community services. It is widely recognised in government that there is a significant workforce shortage in the NHS, including in primary and community care. Yet everything points to the need for more care to be delivered in patients’ homes and in community settings, and this must be considered in workforce planning.
It is particularly vital that we educate more qualified specialist district nurses to lead and manage teams in the community. This in turn links to patient safety and quality outcomes. Similar investments are necessary in the mental health and learning disability community nursing services. Our extremely esteemed colleague my noble friend Lord Kakkar, who is a surgeon, defined this very accurately in his speech, so it is a pleasure to agree with him. There is significant untapped potential in the nursing workforce and many other healthcare professions including, for example, physiotherapy and occupational therapy. All healthcare professionals should be encouraged to use the skills and knowledge they have to the highest level of practice for which they have been educated. Instead, many feel frustrated that they are not enabled to work to their maximum potential. We need to be clear about career development for healthcare professionals working in community settings. This would aid retention and develop more independent and professional practice, meaning that many patients with long-term conditions would need to be seen by GPs only when their healthcare status changed significantly.
It is argued that the first 1,001 days from pregnancy to the age of two are a period of unique rapid development which lays the foundations for a child’s lifelong mental and physical health. Midwives, who lead interventions, including support with breastfeeding, smoking cessation and parental emotional well-being, have a positive and far-reaching impact on a child’s subsequent health development and life chances. The reverse is also true, and it is often during pregnancy that families get locked into the intergenerational cycles of inequality. For example, babies born to families on lower incomes are significantly more likely to be born underweight, have higher risks of mortality and experience of developmental problems.
The latest NHS workforce figures for England show that there were 541 fewer midwives in June 2022 compared with 12 months earlier. The drop in numbers was particularly pronounced in the north of England—evidence of the need to level up. The most recent Office for National Statistics figures show that 11,000 more babies were born in 2021 than in the previous year, so we have fewer midwives yet more births. The Institute of Health Visiting estimates that there is a shortfall of 5,000 full-time equivalents in England—a loss of over a third since 2015. It is worth noting that there were 536 child serious harm events in 2020-21 including, sadly, some child deaths. This was an increase of nearly 20% on 2019-20.
The health visitor performance matrices from August 2022 show that the lowest-performing local authorities had 4.2% of new birth visits within 14 days and 5% of two to two-and-a-half-year reviews, against the highest-performing local authorities, where the figures were 99.3% and 100% respectively. This means that, in some parts of the country, almost all children receive a two to two-and-a-half-year review whereas, in others, fewer than one in 10 children is assessed by health visitors for what are deemed to be mandated contacts. This kind of postcode lottery should be of significant concern to us all. Health visitors make a difference through improved identification of children with developmental delay and vulnerabilities by supporting families through early intervention and thus improving outcomes.
Does the Minister agree that it would be helpful to harness the skills and experience of all clinicians in the delivery of public health and to locate health and care services in easily accessible and prominent community facilities? This would enable healthcare teams to work closely together and make preventive care easily accessible to all. Early intervention is not only crucial to the health and well-being of families and children but good for community cohesion and economic productivity, as well as leading to savings in the cost of unemployment, crime and mental illness.
Finally, I turn to information from the Royal College of Nursing. In June this year, it reported that over half of nurse respondents in primary care said that there were insufficient nursing staff to safely meet the needs of their patients, and two-thirds said that the skill mix was not appropriate to meet the needs and dependencies of the service users and patients effectively. With advanced skills, registered nurses in primary and community care should be able to lead care for patients who have received accurate diagnosis and treatment plans from GPs and/or hospital consultants. Safely delivering high-quality care improves patients’ outcome and reduces readmission to hospital.
Key to patient outcomes are the structure and processes of health and social care services—and, I would add, housing. Investment is urgently needed to improve the digitalisation of patient records and test results in primary care. Patients want effective healthcare delivered by compassionate, professional, trained staff and to understand their treatment, which assists them in adhering to their own personal care plans. The latest idea in general practice is to be told, “You’ve had this blood taken, but if you don’t hear from us then everything is fine.” None of us trusts it, to be honest.
Local integrated care boards should be involved in planning the most appropriate structures and processes of services to meet their local need, but must also be mindful of ensuring uniformity of access to NHS-funded services in England; I recognise that not all services have to be delivered directly by the NHS. Access to community-based physical and mental health services is as important as the right to an operation or emergency care following an accident. Can the Minister assure the House that this aim will be supported by the Government to improve patient outcomes and reduce the disparity of access to primary and community services in England?
Baroness Brinton (LD)
My Lords, it is a pleasure to follow the noble Baroness, Lady Watkins, and to hear the voice of the nurse talking about their important role within primary and community care. I also congratulate the noble Lord, Lord Patel, on securing this vital debate: I cannot think of a better champion to talk about reform of medical services—I will not use the word “NHS” because I think “medical services” is what we are discussing here today. I thank all the organisations that have sent us briefings.
Like the noble Baroness, Lady McIntosh, I want to go back to 1947-48. My husband’s grandfather was a general surgeon at Huddersfield Royal Infirmary, as well as being a GP and a qualified pharmacist. He had to make the choice in 1948 and he chose the hospital. It was right for him. An amusing side note is that after his death, when we were clearing his house, his entire pharmacy was in the attic, in those glorious 19th century-type glass bottles. He took his joint role very seriously. One thing that has happened to general practice over the last 10 to 15 years has been the beginning of general practice specialisation, which is almost inevitable because of the specialisations of hospital doctors as well. I think that, although I have not heard much discussion of it, we should focus on that as well.
Primary care is the bedrock the NHS but, Cinderella-like, is often out of the limelight while providing that first point of essential contact for a patient, be it with their GP, the practice nurse or the healthcare assistant. But what is primary care? Always, the public will tell you that it is the GP, but we have heard in this debate today that it is so much more. It is community nurses; it is physiotherapists; it is occupational therapists; dentists; end-of-life care practitioners; health visitors; school nurses; and those who provide support to people with long-term conditions. And, of course, it is the invisible support staff who back them all up.
But primary care is broken and too many of those working in it are at breaking point too. The noble Baroness, Lady Finlay, helpfully laid out the real problems in her contribution. The noble Baroness, Lady Hodgson referred to some research. Unfortunately, research by GP Online, published in January this year, showed that GPs were completing 46 patient contacts a day, and the corresponding admin work that goes with it, which is 84% more than the 25 daily contacts recommended as a safe limit. Ministers have complained frequently, including during the recent leadership campaign, about too many part-time GPs, but that research also showed that, because of the 30% increase in paperwork over the last five years, most GPs are working 12 to 14 hours a day: that is one to three hours extra at the end of the day on admin alone, as routine, as well as being on call. One GP, responding to a publication of this survey, said, “It’s awful, it’s unbearable, there is too much to do to get it all done safely and if you try to be efficient, patients complain. I’m shattered and there is just no stopping the demand.” The noble Baroness, Lady Meacher, spoke movingly about the increasing number of GPs leaving. This is why.
I come back to the more general strategic issue, outlined so well by the noble Lord, Lord Kakkar, who gave us an overview of the crisis facing us. The service has changed; the funding has changed. Twenty years ago, when Governments of all colours started to reduce the number of hospital beds on the grounds that people did not need to stay so long in hospital, which is absolutely right—although demography needs to be taken into account, and they have gone beyond that point—what failed to happen was an understanding that recovery time and support is needed in the community, and there was no corresponding increase in support, finance and reframing of primary care services. That is one reason we have the problem that we do.
The noble Baroness, Lady Masham, raised the issue of sick notes, and perhaps reforms are needed there. I make the point that that is one of those admin jobs that has increased and grown. It may be that we have to review how sick notes are dealt with.
The noble Viscount, Lord Eccles, talked about his experience of community care and said he was given no explanation of why it happened. I have to say, from a recent discussion with a person awaiting an assessment of care adaptations that would be needed to their home as their long-term condition was worsening, that no explanation was given other than that they would have this appointment. That individual was terrified that their house was going to be changed out of all recognition for things they did not want to happen. When they actually had the assessment, their life was transformed, but the difficulty was that for the three weeks between being told that someone was going to come and make changes to their home to the point at which that happened, the communication was not good enough. But I suspect that that is because the pressure on the service as a whole means that in a five-minute appointment, you cannot explain.
The noble Baroness, Lady Pitkeathley, was absolutely right to focus on carers, whether paid or familial. Yet again, communication to patients is vital. I agree too that social care is not fixed: it may be that the money coming in is now being paid from a different source, but where is it going to go? How are we going to improve the workforce in social care and the support? Familial carers are currently having to pick up extra burdens, such as the increase in virtual wards at home that we were discussing in an Oral Question just a day or two ago. In all the discussions, there has been no mention either of the extra support for familial carers of virtual wards or of primary care support, which must inevitably grow. So I ask the Minister: will there be support for primary care with the increase in virtual wards?
The noble Lord, Lord Farmer, spoke of family hubs and the inverse care law: I think that was very powerful. I hope—as the noble Baroness, Lady Pitkeathley, said—the “not invented here” syndrome and not learning from excellent practice elsewhere will change within the NHS.
The problems in dentistry absolutely speak to the issues that GPs are beginning to face. Net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. Over 40 million NHS dental appointments have been lost since the start of the pandemic, and 91% of NHS dental practices were not able to accept new adult patients, mainly because of the problems with the contract. That is a real issue because—as with primary care, particularly rural primary care—when there are inequalities, it is much harder to access those services.
The noble Baroness, Lady Hodgson, spoke of the effective triage systems that are needed, and also how it can happen very poorly. She spoke powerfully about the need for patients to know their GPs. I absolutely agree with that, which is why I am concerned. The noble Lord, Lord Bethell, said it: we do not need a certain number of GPs; what we need if we are reframing services is the right number of GPs to be able to support the population. It is all about the needs of patients and what we are expecting GPs to do, while accepting that technology is going to play a part and that support staff and other healthcare professionals will have an increasing role. If we start the discussion about reforms by saying we can manage with fewer GPs, we are deluding ourselves.
I do not think I have heard anyone mention the role of expert patients. I am lucky to be such an expert patient. I have a long-term condition; I have done the course—tick. I have to say that that has transformed my relationship with my GP and other staff. Hospitals often do not understand it: I was told once by a consultant when I had a temperature and had gone in that I knew too much about my disease. My specialist soon put him right, I have to say. But my GP surgery completely understood.
So we do need reform. We need to start afresh. Let us accept new technology and other roles, but the key issue must be that primary care remains free at the point of access, available as needed, with signposting and education for the public. The post-pandemic period is a good time for this, because the public have accepted changes. But we must have real investment in doctor training, campaigns to encourage GPs to come forward and, above all, we must get to grips with the current crisis so that we do not lose more of our really valuable primary care staff.
Baroness Merron (Lab)
My Lords, I also congratulate the noble Lord, Lord Patel, and thank him for bringing this debate before your Lordships’ House, which he did with his customary attention to detail, but also searing analysis of what is before us today. This has indeed been a very sobering debate, and I hope it will be of use to the Minister and also to the new Secretary of State, who of course we wish well in her endeavours.
The noble Lord, Lord Patel, spoke of primary and community care as the bedrock of the health and social care services, and indeed it is the door through which most of us enter when we are seeking to access health and community care. However, our access to it and its suitability are deeply affected by the lack of co-ordination, resources, staffing and planning, as we have heard during the debate.
Dissatisfaction is running at an all-time high. This is not only a bad thing in itself but it affects confidence in the system. It is of increasing concern that those who should be making contact with their local GP are simply put off from doing so because they cannot access the service they require, not least because getting an appointment is beyond them, or so delayed, or difficult. This is not how it should be.
My noble friend Lady Pitkeathley hit the nail on the head when she reminded your Lordships’ House that people do not know or care who provides services; they just want the right service, at the right time, in the right way. People need to be seen as whole people and not only according to the bit of the system that is seeking to treat them. I think there is a very strong message for the Minister about the organisation of health and care services being around individuals and all that comes with them, rather than the other way round.
There are critical backlogs in both the sectors we are considering. There are some 1 million people waiting for care services within the community. The backlogs are a key factor in the dire ambulance delays that we are seeing, and they are added to by the number of patients who are in hospital beds when they should be in their own beds, either in their own homes or in a care setting—something about which the noble Baroness, Lady Masham, spoke so clearly.
The Community Network, which is comprised of organisations including NHS Providers and the NHS Confederation, has called for the Government to treat waits in the community sector on an equal footing to backlogs in the acute hospital sector, including through the development of a plan to address these delays as well as accelerating work to improve the quality of national data collections in community care. Could the Minister confirm whether the department has explored this option, because it would be a helpful way forward?
The noble Lord, Lord Kakkar, was right to put down a challenge to how systems are organised and about whether hospitals are the right place—the best place—for dealing with chronic conditions when there is so much opportunity to deal so much better with a number of these closer to home. I hope the Minister will reflect on this.
It is the case, as we have discussed so many times, that the issue of the workforce comes up time and again. We know that there is an increasing volume and complexity of demand, a rapidly aging population and, with that, huge workforce shortages. I must repeat the call for a long-term workforce plan to address what is a stark situation. Failure to address this will only exacerbate the backlogs and health inequalities still further.
The response so far has been disappointing, as we saw in the passage of the Health and Care Bill. This is not just about numbers, important though they are. It is also about what staff do, and whether we have the assessment available to make a judgment as to whether we have the right range of staff, as the noble Baroness, Lady Watkins, referred to, to make sure that they can be available to meet peoples’ needs.
Although it is welcome that there are, as we have heard, additional roles to be developed and additional staff to be made available to work in primary care networks—including pharmacists, physiotherapists and link workers—and it is welcome that there is to be recruitment, there is a gap: how will general practices implement a multidisciplinary model of care, either within or across practices, which will embrace these roles? This is lacking, as we have seen from the King’s Fund investigation into this issue, and it is leaving staff isolated and demoralised. How will this be dealt with beyond recruitment? How will these additional and new roles come into play?
How will the fact that appointments are getting ever more difficult for people to get be dealt with? A GP Patient Survey found that only 56% have reported having a good experience of making an appointment, and there are early signs that the pressure on GPs is affecting patients’ experience of their appointment even when they actually do get one. Similarly, the British Social Attitudes survey showed that satisfaction with GP services fell to 38% last year, which is the lowest level ever recorded. What will be done to address this problem?
On GP numbers, my noble friend Lord Hunt again raised the important question about the reduction in GP training places. What is the thinking on this reduction? How does this square with the expectation that we need, and are told that there will be, greater numbers of GPs?
Improving access will require actions from across the health and care system, and it is critical that integrated care systems and their partners consider how they will provide support to general practice to improve access in the short term. How will this manifest itself within the new integrated care boards?
As we know, and as the noble Lord, Lord Bethell, referred to, the pandemic accelerated new ways of working, including a rapid uptake of existing digital tools to deliver patient care. While this has benefits for patients and staff, there is a proportion of the country who are digitally excluded or who have needs that make digital access less appropriate for them. How will this be addressed so that nobody is left behind?
Finally, I refer to the proposal from the noble Lord, Lord Patel, for a special Select Committee to take forward how we can address the lack of co-ordination in the primary care sector. I hope that the new Secretary of State will consider this worthy of consideration, because there is no doubt that the debate today has shone a very clear light on the fact that we need to step back, make the change and build the system around the needs of the patient, and not the other way around.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, before I begin the response to the noble Lord, Lord Patel, and other noble Lords, I am sure that all noble Lords will be concerned by the news from Buckingham Palace about concerns over the health of Her Majesty. I am sure that the thoughts of all noble Lords are with Her Majesty and her family at this time.
I begin by thanking once again the noble Lord, Lord Patel, not only for introducing this debate but for our many conversations and his advice. In fact, he has given me so much advice, I sometimes think about calling him “uncle”. It has all been part of my learning—understanding the processes and the whole range of our health service, as well as some of the challenges. That was very well demonstrated in the noble Lord’s opening remarks and in some of the issues he has raised with me over time.
What has been interesting in this debate is that lots of people have different views on answers. We agree that there are problems and that they have to be fixed, and we want to see better integration. Some say that we need a revolution; others say that it should not be a revolution but evolution; and others would criticise evolution as piecemeal. We have to be very careful about that. Some say GPs are central to primary care; others say that it should be not only GPs but a range of workers. In fact, a number of GPs complain that they spend far too much time on things that could be done by other professionals in their practice.
The noble Baroness, Lady Watkins, rightly said that we should be careful about a one-size-fits-all approach and trying to suggest or impose one model that would work everywhere. It has to be community led, in many ways. In answering, it is really important to address these issues. I suppose the final debate we had was of some saying that we need a clear distinction between primary and secondary care, and others saying that we do not, as the lines are blurry and what is important is that patients are able to access the health and care services they need. All of that is part of this whole debate, which I found fascinating.
The noble Baroness, Lady Pitkeathley, reminded us that we are now talking about an integrated health and social care system. It is absolutely right that we look to make sure that its social care aspect has parity with the rest of health. I pay tribute to the noble Baroness for consistently reminding me and the Government about that.
We all agree that primary and community care are essential services. As a Government, we recognise that they are under significant pressure, as do noble Lords. My noble friend Lord Eccles asked why this is. There are a number of reasons. At the moment, we have more doctors and nurses than ever before but, as many noble Lords reminded me, demand is outstripping supply. Think about our awareness. During the passage of the Health and Care Bill, we spoke about the importance of mental health and about it having parity. Think about how seriously we took mental health only 30 years ago: many syndromes—post-traumatic stress disorder, for example, and others—were not even recognised until the 1980s. Before then, people were just told to pull themselves together or have a stiff upper lip. Now we recognise how important it is to tackle people’s mental well-being.
Some noble Lords will remember a debate I took part in recently on neurological disorders. When I asked my team for a briefing, I asked them to list all the neurological disorders so that I could understand this. They said, “Minister, do you realise that there are 600 of them?” Imagine that awareness of 600 disorders and how many people are needed right across the country. That shows the challenge we face in demand outstripping supply. It also highlights one of the points behind the question from the noble Lord, Lord Patel: given that all this demand is outstripping supply, is it really appropriate to continue with a model from 70-odd years ago, as the noble Lord, Lord Kakkar, rightly said? The debate we are having is on whether it should be revolution or evolution, and how we ensure it is patient centred.
Another important point mentioned by a number of noble Lords was prevention. It should not be about waiting for people to get ill and then, hopefully, curing them; it should be about prevention in the first place. Individuals, bodies and organisations can all play a key role in that. As the noble Baroness, Lady Brinton, said, it is right that the voice of patients is heard. No one should ever say again to the noble Baroness—I would not dare to—that patients know too much. We want patients to have a partnership with their health and care professionals, so that they understand the issues and so the patient feels valued and understood—a number of noble Lords mentioned this when it comes to named GPs, for example.
It is critical that we look at prevention. That shows that it does not always have to be the GP. I am sure that if the noble Lord, Lord Mawson, had been here, he would have talked about the Bromley by Bow Centre and how there are a range of skills and individuals there. It is not about only the GP but about making sure people have healthier lifestyles. I think the website of the Bromley by Bow Centre and others is about creating health. In his book, Turning the World Upside Down, the noble Lord, Lord Crisp, says that we have to shift away from cures to prevention, not just curing people but creating health. We have seen a lot of progress in the thinking about how we get that into the system.
I will respond to some of the general points that a number of noble Lords made. To draw again on the noble Lord, Lord Crisp, he said that we should also look to other countries. We have this view—not just the United Kingdom but the whole western world— that the rest of the world can learn from us. However, as he said, if you go to some of these countries which have challenges such as resource challenges, they have some very innovative solutions. Some of them have defined completely new roles which would not be recognised here. These people are trained for shorter times and are more specialised, and although the doctors’ lobbies in those countries have railed against them, he said that it gives you effective outcomes. Perhaps we have to look at some of the traditional roles, such as doctors and nurses—we are seeing physicians’ assistants, for example, and specialists. I hope that the rest of the medical profession will be open to completely new hybrid roles, which are not the same as those of 70 years ago.
My noble friends Lady Hodgson and Lord Eccles talked about the right to see a named GP. We understand that, but not every patient will want a named GP. We have to get the balance, because the technology gives us a better service but it is not just about that; it is about people’s first interface. They want to speak to someone who understands their condition. Clearly, however, in other cases it will be important to see a named GP. At the moment, all practices are required to assign their registered patients to an accountable GP but, as my noble friend Lady Hodgson reminded us when we debated the Health and Care Act, that does not mean that the individual always responds. In theory, they should be responding, so one thing we want to look at in more detail is why that is not happening in many places.
A number of noble Lords, including the noble Baroness, Lady Finlay, talked about how we are growing the GP workforce. There are concerns. One of the things I promised in previous debates—I have not had the answer yet; I hope I get it before I leave office, whether that is this week or whenever—is on this cap on training numbers. Yes, we are training more GPs, but at the same time we are losing an awful number of them. Programmes on retention are in place, and the issue of pensions is clearly important. Sadly, I am not able to update the noble Baroness, Lady Meacher, on this; I have asked the question but, let us put it this way: discussions are taking place with another government department. When I worked in other areas of commerce and elsewhere, quite often people reminded me that the price of acquisition is often more expensive than the cost of retention., so we should be investing in the retention of people who still want to work. However, we do not want any of these artificial retirement dates; people are all living healthier lives. We are increasing the number of trainees but we also have to look at morale and retention. A number of proposals are there, but how do we make sure that they get out?
The GP business model is changing—it should not be one size fits all. I talked about the Bromley by Bow Centre; I speak to some GPs who are concerned that their practice is seen as too small. They say, “I am under pressure to go into a practice, but I give a personalised service and I worry about the service we are getting.” At the other end, you get these large health centres that are taking on some functions which were previously secondary care. I understand that challenge, therefore we agree that the primary care entry point should be about multidisciplinary teams. It should be making use of the best capacity we have and looking at alternative sources of expertise, such as dieticians, a physiotherapist or social prescribing, which a number of noble Lords mentioned during the passage of the Health and Care Act.
We made an announcement in July about reforms to dentistry. These are not the complete reforms; there are still conversations around the UDA, for example, and what is felt to be fair remuneration, but we have at least made some progress in those conversations and now have a collaborative discussion. For some people, that is not enough and we have to speed up; I completely understand that, but at least we are making some progress. Up to now they have just been at loggerheads, and we have had others saying, “You’ve got to look at the UDA, which is the source of all these problems.” We are now looking at that, and I pay tribute to the BDA and others for those collaborative conversations.
My noble friend Lady McIntosh of Pickering always raises the issue of rural practices—and rightly so; it is critical that we are reminded of it. We recognise that there are issues with retention in certain areas, and one thing we have been doing with the new medical schools is understanding that people are more likely to stay where, or close to where, they are trained. That is why we have been looking to open some schools in those areas. That will not solve everything. My noble friend also talked about rural connectivity. That issue is widely recognised at the top of the NHS, which is looking at connectivity to be managed locally and the availability of networks. I had a meeting earlier this week with a number of different suppliers on telecare. The meeting was about the switch from analogue to digital, but an issue that came up was the poor provision in many rural communities. One conversation we must have is with the broadband suppliers. Fortunately, technology will fill in a lot of this—we are seeing the cost of satellite coverage dropping and more support for fill-in systems—so I hope we will be able to improve on that. We want to recruit more people in rural areas.
Let me just make sure that I have tackled all the points raised. The noble Baroness, Lady Masham, talked about the steps to discharge patients. It is the Government’s priority to make sure that people are safely discharged. The moment the previous Secretary of State came into office just before the summer, he got together the heads of the various parts of the NHS and spoke to particular trusts and said, “What can we do to clear the pipeline to make sure that people can leave quickly to the community, and what challenges are there?” I know that my new boss, my right honourable friend the Secretary of State for Health, will look at that.
A number of noble Lords raised the issue of seeing a GP in person, and technology. One challenge we have had is that sometimes there is too much technology. We want the NHS app to be the gateway. The noble Lord, Lord Patel, referred to the recent report by Policy Exchange, and I thank Policy Exchange and the other experts who sent us all notes to help us with this debate. When you go on the NHS app, you can, in theory, book an appointment—but you cannot. Then I go to my GP’s website, which says, “You can book an appointment”, but when I go to book one, it says, “You can’t book that appointment; you have to phone us up.” Then we get back to the problem of 8 o’clock in the morning—and not just Monday, but all the way through the week.
One very sensible question is why you have to phone that day for the appointment. Can we look at a way to ensure that you can book today for up to, say, seven days in advance? We have gone backwards. When I was ill as a child, my mother could pick up the phone, phone the local GP and if they could not see you that day, if it was not that urgent, they would say, “How about next Tuesday?” How do we get back to that situation? We are still trying to understand those challenges and why that cannot be done. It says on the website that you can book an appointment, but when you press it, you cannot do so.
We are trying to make the NHS app the gateway. If I get an appointment at my local hospital, I think, “Oh great, I will just look at the appointment on my NHS app.” It does not appear there. I then get a text from that hospital that says, “Please go on to our portal.” So I have the NHS app, my GP website and my hospital website. This is the challenge. They have all said, “Yes, we want technology”, but it is about the processes behind that. On top of that, we all have to know how to make sure it works and to plug the gaps. I was asked to go to have an ECG at a primary care centre. I thought, “That’s very clever. Good, that works much better”, and was told that the consultant would phone me a week later for a conversation. I am quite relaxed about having a phone consultation, but when the consultant phoned me a week later and started talking, I asked, “Sorry, did you see my ECG from last week?” He said, “What ECG?” Then I said, “I tell you what, I can tell you the exact time and date, you can get it and then we can have the conversation.” He said, “Oh, don’t worry about that, I will make a new appointment for you.” We can have all the technology in place, but how do we ensure that the people processes are in place too?
This shows that we all have a role to play in this. The noble Baroness, Lady Merron, often brings up, rightly, the amendment on workforce planning. We talked about this during the debate. There is local-level workforce planning in the ICS. Individual practices and centres have their workforce planning. Many noble Lords will know that regarding the long-term, the department commissioned Health Education England to look at and report on those drivers. We have also commissioned NHS England to develop the long-term workforce plan for the next 15 years, including long-term supply projections. Also, under the Health and Care Act 2022, the Secretary of State has a duty to report every five years at minimum describing the NHS workforce planning and supply system. A lot is being done on workforce planning. One reason we did not accept the amendment at the time was the timeframes, and whether they would change between one report and another. We wanted to look at it in the long term, and for it to come from the NHS and to be from the bottom up.
I have gone on for far too long, but I really hope that this debate has shown everyone not only that all political parties are committed to reform but that at the same time, we must ask ourselves some very big questions. In some ways, it is a valid criticism that we are tinkering with a system that was designed 70 years ago. We must evolve a system rather than tinker with a system. We must tackle the supply of workforce, and we must look at the roles as defined today and whether there are newer roles. Can we learn from overseas, from some of the new roles that are defined elsewhere? Is everyone ready for change? Sometimes, I am not entirely convinced that every player in this system is ready for change. I have had GPs say, “I can take on more patients in my area, but the problem is that the system does not incentivise me to take on a patient elsewhere. They must deregister then re-register with me.” I hope that some of the primary care network initiatives we have will help that, but we all must accept that the current system has just been tinkered with for the last 70 years.
I am not necessarily concerned about the distinction between primary and secondary. It is important that the patient speaks to the right person when they need to, whether in person or remotely, and that they get the right follow-up care. I have had conversations about the model with the noble Lord, Lord Patel. As it is, if you can see a GP, you get five to 10 minutes. Noble Lords rightly expressed the pressures of that. You then hope for a referral. There must be a better way. Some patients are voting with their feet and getting direct referrals to consultants, and others are not. We do not want that two-tier service. We want everyone to have the same access.
The Government must do more. We clearly understand that. Maybe we are not doing it quickly enough, but we must look at the whole system and the roles as defined, while ensuring that it is not “one size fits all”. What is appropriate for one area and one population is not the same as what is appropriate for others. One of the really interesting things that the noble Lord, Lord Crisp, said, when talking about community workers, was that these are people who know about 120 people in their location. They know the families, they are trusted, they go out and knock on the doors of families to ensure that they are all right and help them with their diets and lifestyle. That is being tried in a couple of wards in London. We look forward to the results, but it might be revolutionary in terms of prevention.
I thank the noble Lord, Lord Patel, and all noble Lords. There were more specific questions that I did not answer. I will read the Official Report and write to noble Lords in response to those questions that I have been unable to answer today.
Lord Patel (CB)
My Lords, at the outset, I respectfully associate myself with the Minister’s comments and wish Her Majesty the Queen well.
I thank all noble Lords who spoke, and the Minister in particular for taking the debate and answering at length. Your Lordships spoke not just with passion but with real research behind it in finding out what the problems are with primary and community care. I hope the Minister got the information he needed, as was highlighted by everybody.
It was striking that in this debate, unlike others, no speaker tried to get at the government policies. There were no combative speeches; they all tried to help resolve the problem we now face in primary and community care, which must urgently be fixed. There is one message I suggest the Minister takes back to his ministerial colleagues—by the way, it is a good idea that they and their advisers all get a copy of today’s debate. In his meetings with his colleagues, the Minister should highlight the important issues that were raised today. I still say that primary and community care are in intensive care; if we do not rescue them soon, they will die. The problem will not be worse any more, because it will not be there.
I could summarise every speech, but I will not do that. They all made very important points. I say to the noble Viscount, Lord Eccles, please keep coming back; as the noble Baroness, Lady Hodgson, said, you are not past your sell-by date.
I ask the Minister to take this matter seriously. We hope the new Secretary of State recognises that primary and community care need fixing. I appreciate all the support I had for my proposal for a special Select Committee and hope the Liaison Committee listened very carefully. I thank noble Lords for today’s debate and for contributing; I appreciate it very much.