The big shake-up in primary care announced by the Department of Health last week is designed to be a further step towards a patient-led NHS.
Unfortunately, it is unlikely to make much difference to most patients.
Primary care trusts are an unloved part of the health service, for good reason. They have not delivered on their promise to improve the way that the NHS provides primary care. Although they have sizeable budgets, they have had almost no impact on the way that money is spent. Nor have they succeeded in tackling one of the biggest problems in primary care - shortages of GPs.
The reforms are welcome, as far as they go. They are designed to produce efficiency savings of around £250m a year. They also mean that PCTs will be unlikely to provide services directly. Instead, they will buy in services from other providers, public and private. The changes will also speed up the introduction of GP practice-based commissioning, transferring responsibility for this from the PCTs.
It makes sense for GPs to be responsible for commissioning services - they are closer to their patients, and should have a better understanding of their needs. The problem is that in the relationship between patient and GP, the doctor is firmly in the driving seat. There are precious few incentives in the system for GPs to listen closely to the needs of their patients. While the best will do this anyway, many do not. If the government is serious about making primary care patient-led, it needs to change this relationship.
Giving patients greater control over their primary care is important for two reasons. First, the vast majority of patients’ interactions with the health service are with their GP. Second, their relationship with the doctor is the point of continuity in the health care system.
Bringing this about does not mean the kind of wholesale changes that have been introduced in other parts of the health service. In theory, patients have the right to choose their GP already. In reality, however, 14% of the population live in areas where lists are closed and, in many other cases, patients have only one option when it comes to registering with a GP. So, if they are unhappy with the way they are treated, or with the services on offer, they do not have the ability to decide to go elsewhere. This needs to change.
On the most straightforward level, they should have the option of registering with a GP they can visit without having to take time off work. This might sound like a trivial problem to those with the luxury of a job that allows some flexibility about when you work. But it can be a real barrier to obtaining health care for those at the bottom end of the job market, where not turning up to work can mean losing income or even their job. These patients should be able to register with a surgery that opens early in the morning or in the evening, or be allowed to use one near their place of work, rather than their home.
Patients with chronic or serious conditions might want to choose a GP based on other criteria. They might want to be able to register with a practice with particular services, or with specialist expertise.
Two main changes are needed to improve incentives for GPs to provide services more closely tailored to the needs of their patients. First, the concept of closed lists should be abolished and, second, PCTs must take seriously their role in meeting capacity problems within primary care.
Getting rid of the concept of closed lists would mean that no patient could be turned away from a GP’s surgery they wanted to register with. Popular GPs, with the support of their PCT, would then be expected to respond to meet that demand. This would place the onus on the PCT to take a more active role in developing capacity where it was most needed.
It might also be that, on occasion, a patient would want to be treated by a GP other than their usual one. This, too, should be possible, once the introduction of electronic patient records allows other doctors to access medical records.
However, this does not mean that we should lose the principle of registration. Each patient will still need to have a primary relationship with a GP who has an overview of their health needs and who takes responsibility for screening and preventative health.
Creating a primary care system that is patient-led does not need major structural change, or even a change in the balance of responsibilities between different parts of the NHS. It does require taking seriously the notion of empowering patients by putting them in control of the patient-GP relationship. Let us hope that the white paper has more to say on this than recent announcements by the Department of Health.
