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Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 5 March 2008: NHS Confederation Primary Care Network

It’s a pleasure to be here today. I really welcome this opportunity to talk about the future of primary care with you, and hopefully move the debate on from the often contentious issue of access, at what, I’m sure you will all agree is a quiet and tranquil time for us to discuss such pressing issues.

The discussion we have been having with the BMA about extended hours is important because better access to primary care is essential if we are to make the NHS more patient centred.  Patients tell us that access is a real issue - they want to see doctors’ surgeries opening at evenings and weekends and this is why we have taken action to get GPs to open their surgeries for longer. It is entirely wrong for the government’s position to be somehow characterised as seeking to punish the BMA and GPs for the contract introduced in 2004, and we would not be serving the public well if we weren’t prepared to push for the improvements to services that they want to see.

But extended hours is just one aspect of the primary care agenda and it’s now time to move forward and focus on the issues which the BMA rightly identify as joint priorities - how through primary care, we can do more to focus on prevention, improve the quality of care, and tackle health inequalities. 

Those who work in primary care – GPs, community and practice nurses, pharmacists, physios, speech therapists and many other professionals – are on the frontline in the battle for better health and wellbeing. If we want an NHS that can prevent as well as diagnose and treat, then this part of the system requires concentrated attention.

And we can only effectively develop our strategy on how we improve primary and community care in dialogue with the profession.

I have no wish to impose a fixed model of what primary care should look like or how it should be organised. This must be determined locally, in consultation with clinicians, by each primary care trust, based on what will work for their patients.  As Ara Darzi has said consistently since he began his Review, it is for local people and clinicians, not the Government, to decide what is best for their community. That may be a  small, traditional GP practice or it might be a larger, GP-run health centre. What is important is that what’s provided responds to the needs of local people and offers choice and flexibility. 

Importance of primary care

Access to primary care - ensuring that any citizen can see a local GP if they were sick or worried about their health, free of charge – is the underpinning principle of the NHS. The 1944 white paper, which set out formally the government’s ambition for a national health service, was explicit: “The first-line care of the health of everyone requires a personal doctor, or a family doctor, a general medical practitioner available for all problems of health and sickness.”

Sixty years on, the quality of primary care in the UK, as well as its universal and comprehensive coverage, can rightly be described as world class, and the relationship between GP and patient is its most powerful attribute.
 
The new GP contract, introduced in 2004, was a necessary step in supporting this relationship. We simply cannot return to a situation where GPs were effectively responsible for their patients 24 hours a day, 365 days a year, and it was not unusual for them to be called out at 4 o’clock in the morning, and be back in surgery at 7.30am to conduct appointments. No wonder a few years back, morale among GPs was at an all time low – with 82 per cent of GPs experiencing excessive levels of work-related stress, nearly half planning to retire early and over a quarter seriously thinking about leaving the profession altogether.

And we cannot leave patients in a situation where, because of GP shortages, they have to wait weeks, not days, to get an appointment, which are then sometimes little more than cursory except in the most chronic cases, because of excessive pressure on GPs.
 
Since the introduction of the new contract, there are 4000 more GPs and 3000 more practice nurses. Morale in the profession has improved dramatically, medical school places are being filled and more GPs say they are happy with their career choice.

Longer consultations, quicker appointments and being able to book ahead are improvements that have been appreciated by patients up and down the country. Patient satisfaction levels are up. And the new arrangements have enabled GPs to focus more on prevention as well as cure – identifying conditions and lifestyles that could lead to future ill health as well as treating the sick.

But we are all familiar with the new challenges that have emerged. Rising levels of obesity and an ageing population  make greater and more complex demands on the NHS. And we have not made enough progress on tackling health inequalities. The question is how we can better equip primary care providers to face these challenges.

Prevention

Earlier this week, we celebrated the 20th anniversary of the breast cancer screening programme. It was a timely reminder of just how powerful a tool early identification of diseases such as cancer can be. Breast cancer screening saves 1,400 lives and cervical cancer screening 4,500 lives.

In January, the Prime Minister also announced our intention to launch a vascular screening programme that will enable doctors and other clinicians to identify more people at risk of heart disease, diabetes, stroke or kidney disease – conditions that affect over 6 million people. And by offering men over 65 a simple ultrasound test to detect early abdominal aortic aneurysms, we will be able to save more than 1600 lives each year.

But in the frontline battle against lifestyle epidemics, prevention goes wider than detecting illness – it’s principally about promoting health and wellbeing. This is not a new idea. The1944 white paper stated: “Much of present custom and habit still centres on the idea that the doctor and the hospital and the clinic are the means of mending ill health rather than the increasing of good health.” It’s relatively easy to recognise in a doctor’s surgery if someone is overweight or obese, and therefore, at higher risk of diabetes or heart disease. What is more difficult is identifying those who are at risk of becoming obese or severely overweight and taking steps to prevent it. 

Doctors and practice nurses can’t prescribe a change in lifestyle. But as the best doctors and primary care clinicians know, by working with a whole range of professionals, community groups, other public services and even employers, it is possible to enable more people to take charge of their own health and manage these risks themselves.

And the potential gains are enormous. 42,000 lives could be saved each year if people ate enough fruit and vegetables every day. 20,000 lives saved if people ate less salt. The World Health Organisation estimates that 3 per cent of the world’s disease burden is caused by physical inactivity. If every adult were to do the recommended amount of exercise each week, we could save tens of thousands of lives, not to mention billions of pounds.  

Health inequalities

Prevention is about everybody’s health, but it’s particularly vital in tackling health inequalities.

I know that you will be only too aware of the stark correlations between where people live, how much they earn and their life expectancy. The same correlation applies as to whether they access potentially life-saving services such as screening.

A man living in a deprived area of Kingston-upon-Hull will be in poorer health for seven years longer and die four years earlier than an affluent male in Kingston-upon-Thames.

Leaving affluence aside doesn’t remove the disparities. People with severe mental illness have substantially lower survival rates for stroke, heart disease, diabetes and cancer.

Only 19 per cent of disabled women are screened for cervical cancer, compared to 77 per cent of the population as a whole. And black women are likely to have more advanced cancer at the time of diagnosis than white women.

Primary and community care strategy

The NHS next stage review will present a vision for primary care that we want to develop in partnership. Involving those who work in primary care and their patients is essential to this whole project – as is the continued involvement of the BMA, the Royal College of General Practitioners and other professional representative bodies.

Some of the specific things we want to consider as part of the primary and community care strategy are:

• How do we strengthen the focus in primary care on promoting health?
• What changes are needed to tackle health inequalities?
• How do we ensure that care is more personalised and integrated?
• What do we do to improve the quality of primary care across the board?
• And how do we support all this through better commissioning? 

On promoting health, we need to make sure that more patients can access information about staying healthy, with the wider primary care team supporting them to lead healthier lifestyles.

This builds on what many successful primary care trusts are already doing, in partnership with local authorities and the community. Sheffield, for example, has had significant success in reducing health inequalities (in particular in life expectancy) by empowering local communities to develop and deliver activities that promote health and wellbeing. Their approach also encompasses local developments in housing and transport.

The Next Stage Review Interim report sets out a number of proposals to improve access to primary care for the poorest communities, including £250 million for the most deprived primary care trusts to procure over 100 new GP practices and to enable every primary care trust in the country to develop a GP-led health centre.

But we also need to think about how through primary and community care, we reach out to people who may be at risk but aren’t likely to trouble the new GP surgery or health centre.  There’s some exciting best practice that we can build on - Birmingham’s heart health teams are expanding the reach of their screening programmes by offering screening in high profile community venues such as football clubs. And by providing health services and advice through children’s centres, many PCTs are finding they can improve access to health services for both children and their parents.

To ensure that primary care is more personalised and more integrated, it must be built around the needs of patients, not around what’s convenient for professionals, or by sticking to the old routine

For patients with multiple needs, it matters not a jot whether someone providing them with care or health advice is employed by the local authority or a primary care trust – what matters is whether they can access the care and support they need in a way that works for them.

Greater flexibility is vital in helping patients to manage their own health. Many surgeries now provide telephone consultations or a GP “ring-back” service for patients who want to speak to their GP but can’t get an appointment at a convenient time. Consulting with your own GP over the phone is another way of ensuring patients get faster and more convenient access to care.

The forthcoming pharmacy white paper will also explore how we can expand the role of the local pharmacy - making it a healthy living centre, with readily available expertise on treating minor aliments, screening, routine testing, advice on taking medicine and support for patients with long term conditions such as asthma.

We also want to see a relentless focus on improving the quality of primary care. Access is part of this debate. We know that where there is greater access to primary care, patient satisfaction levels are higher, expenditure on healthcare is lower and fewer drugs are prescribed.

But if the relationship between patient and GP is one of the most powerful attributes of the NHS, then it’s the overall quality of the experience which really counts. 

Throughout general practice, doctors and other health professionals take a justifiable pride in the service they provide to patients. But there are significant variations in the quality of primary care and we want to support the profession’s efforts to maintain high standards of care for all patients everywhere. 

This is why we welcome the work of the Royal College of General Practitioners to develop a professionally led accreditation scheme for GP practices. The scheme will be piloted in forty practices across England. We hope that, when rolled out, it will both recognise and celebrate excellent practice and encourage all surgeries to develop and improve the quality of services they provide to their patients. Improving quality is at the heart of the government's strategies for the NHS and we are working with the College and the BMA to explore a variety of approaches - including accreditation schemes – as we develop further proposals on primary and community care.

But this is not the only lever to improve quality. We also need better commissioning. Primary care trusts do not simply administer primary care contracts - commissioning is also a lever to improve quality. 

A publicly funded health system must offer excellent care to all patients -  and that means PCTs working with GPs and other providers of primary care services and the public, to improve quality. There’s already more flexibility and stronger emphasis on quality in the GP contracts.  But where there is poor quality, we want to see primary care trusts taking active steps to tackle it – if necessary by removing contracts.

It also means, where there are gaps in primary care services, PCTs must commission the best providers available. This does not mean that there should be an automatic preference for new, private sector organisations over existing GP contractors. But there does need to be an element of competition and there must be local accountability. This is about locating the providers who can offer the best possible care to patients, in accordance with local need – whether they are a social enterprise, an existing GMS or PMS practice, or from the voluntary or independent sector.

For the same reasons, it’s also important that, where there’s local agreement, we can unbundle aspects of the national tariff. If a GP has a patient who needs an x-ray, and it’s more convenient for them to have this in the community, then there should be flexibility for the GP to arrange this, along with any follow-up treatment that might be needed at the local hospital.

I recognise that the Department of Health has a role to play in supporting PCTs to become world class commissioners. By providing access to independent, accredited experts in commissioning services, the Framework for External Support for Commissioners (FESC) can help PCTs to develop their capacity and skills to commission more effectively. We have been piloting FESC in a small number of trusts. Many PCTs involved in FESC are discovering that there are real benefits to bringing in external expertise  - in particular, they can improve the skills of those involved in commissioning who work for the Trust.  And I am pleased to announce today that I am now opening up FESC to all primary care trusts that need it.

Conclusion

This year, having improved access to primary care, we want to work with the profession, patients and the public to improve commissioning, tackle health inequalities, implement better accreditation and advance the cause of prevention.

This is a huge agenda that recognises the key role of primary care over the last sixty years and the even greater role that GPs, and everyone involved in primary care must play in the years to come. 

Thank you