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Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 16 October 2008: NHS Alliance

Venue: International Conference Centre, Bournemouth

I’m pleased to be able to join your annual conference for the second year in succession.

I don’t normally stay in one government department for long enough do repeat performances but being able to come to this Conference is just one of the reasons I’m delighted to remain in this job following the re-shuffle.

Today, the Healthcare Commission published its annual health check of the NHS. It showed substantial improvements in performance, with 60 per cent of Trusts being rated good or excellent, whereas two years ago, 60 per cent were rated as fair or poor. I’d like congratulate all staff for their hard work and dedication in improving services.

Of course, there are elements of the report that show weaknesses that we will all address together, but that does not detract from the overall picture, which, as Ian Kennedy says, shows a real shift in performance.

As this is the year in which we celebrate the 60th anniversary of the NHS, I would like to begin by reflecting briefly on the importance of primary care in its genesis.

Access to primary care is what defines the NHS. On 5 July 1948, patients didn’t queue outside the doors of the newly nationalised hospitals – they queued patiently to be examined by a general practitioner. Today, primary care accounts for over 80 per cent of all interactions between patients and the NHS and is even more significant than it was in 1948.

We commemorated the 60th anniversary of the NHS with the publication of the Next Stage Review. It may have been written by a surgeon but it was not a manifesto for hospitals, because it is in primary care and the community that we can best address inequality and the lifestyle diseases that could overwhelm the NHS, if left unchecked.

The academic Barbara Starfield, shows that countries which invest more heavily in primary and community care are healthier, more equitable and spend less on secondary care as a result.

But primary care doesn’t always get the credit it deserves. David Haslam (President of Royal College of General Practitioners) wryly observed, with justification, that politicians who talk about education and health use the shorthand of “schools and hospitals,” - they say less about GP surgeries, children’s centres, the many community-based health services that help thousands of people every day.  

Primary care doesn’t have the same, prime time TV appeal as saving lives in an emergency room – while the stars of ER, House  and Gray’s Anatomy are pin-ups and role models, you can hardly say the same about Dr Finlay’s Casebook.

But as we all know, hospitals do not exist to prevent people from getting cancer or having heart attacks – their purpose is to deal with disease once it’s detected. The infinitely more complex business of promoting health and wellbeing, and tackling the causes of poor health lies in the capable hands of primary and community care professionals. 

A major part of this is inevitably about improving access. Earlier this week, we published figures showing that over 50 per cent of all practices are now offering appointments in the evenings or and at weekends – three months earlier than expected. I congratulate these practices, who will know this is not just a service that’s  popular with  busy commuters – it’s crucial for those who simply can’t afford to take time off work or caring duties to see their doctor.
But I’ve always been clear that improving access is about much more than extended opening hours.  GPs do not sit in their surgeries like shopkeepers, waiting for ill health to come through the door. At its best, primary care reaches far beyond the confines of the GP surgery, or dare I say, GP-led health centre – and works in partnership with community health and other local services to tackle health inequality.

But prevalence is important. Research shows that increasing the number of primary care professionals in areas of greatest need is one of the most effective ways of improving the health of that population.

Dr Julian Tudor-Hart unveiled his inverse care law theory in an article published in the Lancet in 1971: “In areas with the most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, and the availability of good medical care tends to vary inversely with the need of the population served.”  Nearly forty years on, the theory still applies albeit to a lesser degree. Despite increases in GP and practice nurse numbers, there are still twice as many primary care professionals in Cambridgeshire as there are in Manchester and residents of Cambridgeshire will on average live 6 years longer.

This is why we have provided new investment for over one hundred new practices in the most poorly served parts of England.  In addition to the 152 GP-led health centres – one in every primary care trust – which will also play a vital role in improving access to a range of health services and helping trusts to target local health issues more effectively. So North Yorkshire and York PCT, which has the highest rates of alcohol-related hospital admissions, is providing a range of drug and alcohol and mental health services in its Scarborough-based health centre. And the GP-led health centre in Hull, my own constituency, will provide dental and social care services.

It is important not to see primary and community care services just in terms of what GPs and practice nurses do. It is no coincidence that the PCTs who have the most success in improving health – particularly in more deprived areas –are those which invest in community health services and in the many allied health professional services such as physiotherapy, speech and language therapy, podiatry and occupational therapy, which play a vital role in addressing health inequalities.    

The improvements to the GP contract announced on Tuesday will underpin this focus on health inequalities. These changes do not override the principles of the 2004 contract, which has played a vital role in addressing the chronic shortages of GPs as well as increasing the amount of time they are able to spend with patients and enabling them to provide a greater range of services. 

But we’ve always been clear that the contract must drive continual improvement in primary care and keep pace with changing health needs. As we said in the primary and community care strategy, we will work with the profession to reduce the amount of money spent on historic income guarantees and channel more of those resources into fair payments - based on the number of patients a practice serves and the needs of those patients. We know that the practices who haven’t benefited as much from the Minimum Practice Income Guarantee are disproportionately more likely to serve poorer areas.

Similarly, the new agreement on the Quality and Outcomes framework (QOF) will ensure it better reflects the prevalence of illness amongst the population that GP practices serve. By April 2010, QOF payments will fully take into account whether GP practices are supporting high numbers of patients suffering from long-term conditions such as heart disease and diabetes – which are disproportionately more prevalent in poorer areas.

And we will consult shortly on new measures to make sure that QOF indicators are informed by a strong clinical evidence base and reflect the important role that GP practices play in prevention and the promotion of health and wellbeing. We shall be working with NICE and professional and patient groups to take these proposals forward.

You’ll be well aware that plans to improve access  have not been without controversy. The campaign against us has insisted that by opening new surgeries, by giving every PCT the money to open a new health centre, accessible from 8am to 8pm every day, which can be used by patients whether they are registered or not, that somehow, this will damage services for patients.  They try to depict this debate as a choice between depersonalised, universal services on the one hand, and caring, cosy consultations on the other. This is of course total bunkum. New investment in areas where there are historic shortages of doctors is at least 40 years overdue. New health centres are not a threat to existing services – they will provide much needed extra capacity and far from having 25 GPs per centre as our opponents continue to claim, they will have around five.

As for the allegation that this heralds the privatisation of the NHS, over half of those being shortlisted for the contracts are GPs practices and consortia.

Accessibility is the foundation of good quality primary and community care, it is necessary but not insufficient. There are many more ways in which GPs, practice managers, nurses and community health service providers are working to respond more effectively to patient need and improved quality. Most primary care and community health professionals are not waiting for edicts from government ministers to improve services for patients. It is in primary care that some of the major innovations in how we deliver better healthcare originate.

Practices across the country are developing better ways of supporting patients on a daily basis. Such as surgeries that enable patients to monitor their own blood pressure at the surgery reception, where they can print off their results before they see their doctor. Or the surgery that provides its diabetes patients with all the results of their annual check-up a few weeks in advance of their annual review, so patients go to their doctor with that information already in their hands, and patient and practitioner can use that valuable consultation time more effectively. 

And increasingly, we are seeing primary care trusts listening more to patients and shaping their priorities according to their needs. Like Swindon PCT, which, following consultations with older people in the region, is going to work with the voluntary sector to improve access to podiatry services.

Longer opening hours, expanded services that are easily accessible to patients, more patients being able to manage their own conditions – these are essential developments that have been led by primary and community care professionals and it is these innovations in primary care that form the basis of the Next Stage Review.

Care plans for people with long term conditions, the patient prospectus, integrated care  - these are not abstract ideas cooked up in Richmond House. They draw extensively on the best in general practice and community health services, and it is the principles that these ideas embody, such as personalisation and empowering patients that we want to apply to the health service as a whole, as we remove from review to implementation.

Inextricably linked to all this is the drive to empower GPs and practice nurses to be the advocates of their patients.  GPs and practice nurses are involved in the majority of all contacts between patients and the NHS. They are also the chief referrers of patients – they have detailed knowledge of which services work for patients and whether they’re convenient for them.

Improving commissioning of health and social care services is a challenge that healthcare systems across the world are facing.  Although there are encouraging signs, we still have some way to go in improving how professionals commission services that meet patient needs and are of consistently good quality. Practice-based commissioning shouldn’t be something that a few practices do and the rest just talk about. We recognise that we haven’t done enough to support practice-based commissioning and that PCTs should do more to encourage practices to get involved.

For the first time, through world class commissioning assurance, PCTs will be held to account for how well they support practice-based commissioning. David Colin-Thomé is establishing a national improvement team, and through the practice-based commissioning capability development framework, which will be available by the end of November, we will be providing more training and resources to support practices who want to get more involved in commissioning.

We must address the barriers – both institutional and professional – that can prevent GPs from doing the best they can for patients with complex needs. The GP or district nurse who visits the elderly lady living on her own may well be able to treat her immediate health problem. But if he or she notices that the same elderly lady is at risk of a fall, because of a loose bit of carpet on the stairs, or a couple of light bulbs that need changing, or perhaps notice that she isn’t eating properly, it should be relatively straightforward for that GP to make one phone call and get the relevant professionals to go in and help her.

 It shouldn’t be a matter of going through 2 or 3 assessment processes, ten phone calls, juggling several different budgets, contacting 3 or 4 different decision makers. And if that sounds like a labyrinth for the professional, imagine what it’s like if you’re the patient or carer trying to navigate the system.

Integrated care – secondary care, primary care, community services and social care working together – should no longer be a novel idea. We have to overcome some of the practical barriers that prevent it being universal. Today, I am publishing the integrated care pilots prospectus. I want to see primary care professionals take the lead in how we develop integrated care and I hope many of you will get involved with the pilots.

Advances in medicine and public health have given us extraordinary powers to prevent disease and improve people’s quality of life.

The American journalist and poet, Franklin P Adams, who died in the same year as Nye Bevan, described good health as: “the thing that makes you feel that now is the best time of year.” The underlying principle of everything we are doing is that the NHS no longer sees good health as simply the absence of disease.

It is in primary and community care that this principle is uniquely understood, and it is here that doctors, nurses, community and allied health professionals can focus not just on eradicating sickness, but on actively promoting health and wellbeing.  

Enabling patients to take control of their own health, more personalised services, earlier intervention – these activities may not have the machismo and drama of saving lives in an emergency room, but in an age where the majority of our disease burden is preventable, they will save many more lives in the long term.

I suppose in essence, I am delivering this speech to the wrong audience because the Alliance is such a powerful force for progress. You not only know the route we ought to follow - you’ve helped to clear the undergrowth.

New investment to provide more GP practices and a GP-led health centre in every primary care trust, empowered professionals who can advocate and where necessary, agitate, for a better deal for their patients will be the foundation for a better health service. This is how in the 21st century, we will stay true to that fundamental principle of the NHS, established 60 years ago: the best of modern healthcare must be available to all, irrespective of wealth, ethnicity or social class.

Thank you for giving me the opportunity to join in your important deliberations.