Paying the price for quality in primary care

Abstract

It was only later that I realised the full import of what he'd said. We'd been sharing views about the state of general practice in the UK and the impact of the new contract. As one of the British Medical Association's (BMA) negotiators of the contract, he'd had an inside track on the negotiations, and was now a beneficiary of the outcome. Like many general practitioners I'd met, he was pleased with the new contract, although a little embarrassed at the size of the pay rise that had resulted. Talking through how this had been achieved, he volunteered that the BMA's negotiators had privately set a target of achieving a 50% increase in income for a 50% reduction in working hours. His embarrassment reflected their success in coming close to achieving that outcome.The skill of the BMA's negotiators suggests that when it comes to contracts and pay, primary care really is in the driver's seat. The same cannot be said of resource allocation and priority setting in the UK's National Health Service (NHS), which remains dominated by acute hospitals and specialist care. The Government's recent white paper on care outside hospitals aspires to achieve a shift in resources towards primary care, but it is doubtful that the means exist to achieve this objective.One of the messages of Primary Care in the Driver's Seat? is that the UK is not alone in recognising the importance of primary care while struggling to realise its full potential. As a study by the Organisation for Economic Co-operation and Development (OECD) cited in the book concluded, only a few countries have been able to improve essential features of primary care since the 1970s. And while primary care has evolved over time in most countries, the extent of change should not be overestimated.As some of the contributors to this book point out, despite evidence that primary care contributes to the achievement of goals such as equity and good health, it has proved difficult to avoid even more resources being drawn into acute hospital services. In part this reflects the distribution of power in the medical profession, with specialists having higher status than general practitioners, and in part it reflects the much greater use of expensive technology in hospitals. With the public and politicians often equating health care with hospitals, it is not surprising that budgets are biased in favour of secondary and tertiary care.The reason this has to change can be found in the shifting burden of disease in developed countries. If the main health challenges in the first half of the 20th century arose from infectious diseases, and in the second half of the 20th century from acute illnesses, then in the new millennium the rising tide of chronic diseases constitutes the most important challenge. Hospitals may have been the most appropriate focus for the treatment of acute illnesses that required a rapid response from relevant specialists, but they seem increasingly anachronistic as chronic diseases become more prevalent.The nature of chronic diseases means that they cannot be fixed through episodic treatment in an acute hospital. To be sure, the expertise of specialists has an essential contribution to make to the effective management of chronic diseases, but this has to be harnessed in support of the care provided by primary care teams. It is these teams that will be the first port of call for most people with a chronic condition and that will then provide the continuity of care for conditions that can neither be cured nor are life threatening. Moreover, people with chronic diseases also have a major part to play in managing their conditions. Understanding that the main primary care providers are people with chronic diseases, rather than health professionals, is the first step on the road to reshaping health services so that they are appropriate for societies that live in the time of chronic diseases. From this simple but profound insight, three important implications follow.The first is that much more needs to be done to enable people to become effective primary care providers. Compared with the massive investment of resources in the training of health-care professionals, paltry sums are spent supporting patients to be expert in their own care. The NHS exemplifies this neglect with the much lauded Expert Patient Programme that aspires to support 100 000 patients by 2012. In the context of an estimated 17 million people in the UK living with a chronic disease, the Expert Patient Programme is a drop in the ocean, and testifies to the chasm that has to be bridged to make supported self-care a reality.The second implication is that people with chronic diseases need care that is integrated rather than fragmented. In the course of their illness, this may entail continuing contact with a trusted primary care physician able to call on nursing and other expertise within the immediate team. In turn, the primary care team will need to have rapid and easy access to specialist advice when additional expertise is required. Support from social care and other professionals must be part of this approach.It follows that health-care systems and health professionals need to shift the focus to integrated care, learning from the experience of those organisations that have begun to realise its potential. Paradoxically, many of these organisations are to be found in the USA, the country where health care is arguably most fragmented in the developed world, and yet which has spawned organisations like Kaiser Permanente, Group Health Co-operative, and Health Partners that achieve much closer integration of care for their populations than the supposedly integrated systems of western Europe, which are so comprehensively reviewed in this book.The third implication is that the way in which health care is funded needs to reward good quality care for people with chronic diseases while also ensuring continuity of care over time. By linking pay to the quality of care offered to patients with defined chronic diseases, the new contract for general practitioners holds out the promise of ensuring that their work is directed at meeting the needs of these patients. On the other hand, by enabling doctors to choose to work fewer hours, the contract makes continuity of care more difficult to achieve, and risks further fragmenting services at precisely the moment when closer integration is needed.My conversation with the BMA negotiator concluded with us reflecting on how much more could have been achieved for patients if the strength and resolve of the team of which he was a part had been matched on the other side. The push back the BMA had anticipated from the Department of Health and the NHS never came, with the result that general practitioners achieved most of their objectives. The consequence is that general practitioners in the UK are now among the most highly paid family doctors in the world, and they have also succeeded in reducing their working hours. People with chronic diseases ought to experience care of a higher quality, but this gain has been bought at a huge price and with the real risk that continuity of care and service integration will remain distant goals. It was only later that I realised the full import of what he'd said. We'd been sharing views about the state of general practice in the UK and the impact of the new contract. As one of the British Medical Association's (BMA) negotiators of the contract, he'd had an inside track on the negotiations, and was now a beneficiary of the outcome. Like many general practitioners I'd met, he was pleased with the new contract, although a little embarrassed at the size of the pay rise that had resulted. Talking through how this had been achieved, he volunteered that the BMA's negotiators had privately set a target of achieving a 50% increase in income for a 50% reduction in working hours. His embarrassment reflected their success in coming close to achieving that outcome. The skill of the BMA's negotiators suggests that when it comes to contracts and pay, primary care really is in the driver's seat. The same cannot be said of resource allocation and priority setting in the UK's National Health Service (NHS), which remains dominated by acute hospitals and specialist care. The Government's recent white paper on care outside hospitals aspires to achieve a shift in resources towards primary care, but it is doubtful that the means exist to achieve this objective. One of the messages of Primary Care in the Driver's Seat? is that the UK is not alone in recognising the importance of primary care while struggling to realise its full potential. As a study by the Organisation for Economic Co-operation and Development (OECD) cited in the book concluded, only a few countries have been able to improve essential features of primary care since the 1970s. And while primary care has evolved over time in most countries, the extent of change should not be overestimated. As some of the contributors to this book point out, despite evidence that primary care contributes to the achievement of goals such as equity and good health, it has proved difficult to avoid even more resources being drawn into acute hospital services. In part this reflects the distribution of power in the medical profession, with specialists having higher status than general practitioners, and in part it reflects the much greater use of expensive technology in hospitals. With the public and politicians often equating health care with hospitals, it is not surprising that budgets are biased in favour of secondary and tertiary care. The reason this has to change can be found in the shifting burden of disease in developed countries. If the main health challenges in the first half of the 20th century arose from infectious diseases, and in the second half of the 20th century from acute illnesses, then in the new millennium the rising tide of chronic diseases constitutes the most important challenge. Hospitals may have been the most appropriate focus for the treatment of acute illnesses that required a rapid response from relevant specialists, but they seem increasingly anachronistic as chronic diseases become more prevalent. The nature of chronic diseases means that they cannot be fixed through episodic treatment in an acute hospital. To be sure, the expertise of specialists has an essential contribution to make to the effective management of chronic diseases, but this has to be harnessed in support of the care provided by primary care teams. It is these teams that will be the first port of call for most people with a chronic condition and that will then provide the continuity of care for conditions that can neither be cured nor are life threatening. Moreover, people with chronic diseases also have a major part to play in managing their conditions. Understanding that the main primary care providers are people with chronic diseases, rather than health professionals, is the first step on the road to reshaping health services so that they are appropriate for societies that live in the time of chronic diseases. From this simple but profound insight, three important implications follow. The first is that much more needs to be done to enable people to become effective primary care providers. Compared with the massive investment of resources in the training of health-care professionals, paltry sums are spent supporting patients to be expert in their own care. The NHS exemplifies this neglect with the much lauded Expert Patient Programme that aspires to support 100 000 patients by 2012. In the context of an estimated 17 million people in the UK living with a chronic disease, the Expert Patient Programme is a drop in the ocean, and testifies to the chasm that has to be bridged to make supported self-care a reality. The second implication is that people with chronic diseases need care that is integrated rather than fragmented. In the course of their illness, this may entail continuing contact with a trusted primary care physician able to call on nursing and other expertise within the immediate team. In turn, the primary care team will need to have rapid and easy access to specialist advice when additional expertise is required. Support from social care and other professionals must be part of this approach. It follows that health-care systems and health professionals need to shift the focus to integrated care, learning from the experience of those organisations that have begun to realise its potential. Paradoxically, many of these organisations are to be found in the USA, the country where health care is arguably most fragmented in the developed world, and yet which has spawned organisations like Kaiser Permanente, Group Health Co-operative, and Health Partners that achieve much closer integration of care for their populations than the supposedly integrated systems of western Europe, which are so comprehensively reviewed in this book. The third implication is that the way in which health care is funded needs to reward good quality care for people with chronic diseases while also ensuring continuity of care over time. By linking pay to the quality of care offered to patients with defined chronic diseases, the new contract for general practitioners holds out the promise of ensuring that their work is directed at meeting the needs of these patients. On the other hand, by enabling doctors to choose to work fewer hours, the contract makes continuity of care more difficult to achieve, and risks further fragmenting services at precisely the moment when closer integration is needed. My conversation with the BMA negotiator concluded with us reflecting on how much more could have been achieved for patients if the strength and resolve of the team of which he was a part had been matched on the other side. The push back the BMA had anticipated from the Department of Health and the NHS never came, with the result that general practitioners achieved most of their objectives. The consequence is that general practitioners in the UK are now among the most highly paid family doctors in the world, and they have also succeeded in reducing their working hours. People with chronic diseases ought to experience care of a higher quality, but this gain has been bought at a huge price and with the real risk that continuity of care and service integration will remain distant goals.