When our parents and grandparents survived WW2, they were determined not to go back to the unfairness of pre-war society. Influenced also by their recent experience of social solidarity, they committed to a national health service based on the generous principle that illness is neither a crime for which people should be punished, nor an indulgence for which they should pay but a misfortune, the cost of which should be paid for by the community. Aneurin Bevan’s book In Place of Fear captured the initial purpose of the NHS precisely.
The NHS still serves us well. In an independent review of eleven rich countries in 2012 by the Commonwealth Foundation in New York (nothing to do with the British Commonwealth), the NHS ranked first on almost every quality indicator, with the US coming last. Yet the NHS spent the second least on health care per head, while the US spent most, by a country mile. We could spend more on the NHS without being exorbitant or wasteful in international terms.
The gatekeeping role of general practice has been the main explanation of the efficiency of the NHS, by keeping most care in the community. What keeps patients in the community is satisfaction with the care they receive, and the avoidance of complications from the conditions they have. The NHS neglects this function at its peril, but that is what it has done. Politicians, NHS managers and civil servants, while claiming that ‘the NHS is safe with us’, have nevertheless presided over some calamitous trends.
The general practice share of the NHS budget has fallen by a sixth in the ten years from 2006. During the same period, workload increased substantially due to the ageing population, increased patient expectations and transfer of work from secondary care. Many GPs have gone part-time, recuperating from 11-12 hour days. Older GPs are retiring early. Training posts lie vacant. Two thirds of the younger GP workforce is female, but the average age of female GPs leaving the profession is in their mid-40s. GP recruitment and retention have had to become government priorities. For the next decade, the GP landscape will be pitted with sink holes, as practices cannot fill vacancies and implode.
The consequences are already apparent. Patient care becomes less coordinated and complications occur earlier. Patients ‘spill over’ into unscheduled care, including out of hours, A&E and emergency admissions, often for problems which could be dealt with in primary care but also for more serious problems which could have been prevented or delayed. The solution to this problem is not more A&E or hospital investment.
A parallel trend has been a decade of preferential NHS investment in specialist services, in both hospital and community care, with the community health services budget (for mental health, alcohol misuse, addiction services etc) increasing by 42% and the hospital consultant establishment by 60%.
Specialist services have strict referral criteria, waiting lists to control demand and evidence-based protocols and targets to deliver, followed by discharge to general practice when they are done. They work to high standards, but leave a lot for general practice to do, helping patients who do not fit the criteria, who are not good at accessing services, who have other conditions at the same time (multi-morbidity) or who are not made better by specialist treatment.
Most professional people see their GP occasionally, usually for a single condition. Most are oblivious to the real work and value of general practice within the NHS, which is to provide unconditional, personalised continuity of care for patients with complex multi-morbidity, whatever combination of conditions they have. About a sixth of patients account for about a half of the work of general practice. The 10% of Scottish patients with four or more conditions account for a third of all emergency hospital admissions and a half of potentially preventable hospital admissions.
Such patients may need specialist care on occasion, but they mostly need a continuing relationship with a clinical generalist who can work through their problems, building knowledge and confidence in living with their conditions and making best use of services. The ‘worried well’ present their own demands and expectations but what the ‘unworried unwell’ need, at least to begin with, is a worried doctor, staying with the patient, steering the course, facilitating access and anticipating hazards. By definition, specialist services cannot do this and are an expensive way of dealing with only part of the problem. Nurses, pharmacists and link workers can help but are not an alternative to the generalist clinical role.
Over-investment in specialist services, with their associated management and backroom staffs, has robbed front line services of resource and threatened to capsize the NHS in the process (a la a ‘machine that does the work of two people, but needs three people to work it’). And, it has also made life difficult for patients with multi-morbidity, especially patients in very deprived areas where multi-morbidity, typically combining physical, psychological and social problems, begins 10-15 years earlier.
People assume that because the NHS deals with emergencies in an equitable way, based on need and no other consideration, the same approach applies in all areas of the service. But that is not the case in two important respects – specialist treatment, which affluent groups are better at accessing, and general practice.
Although premature mortality and complex multi-morbidity both more than double in prevalence across the social spectrum, from most affluent to most deprived, the distribution of GP funding per Scottish patient is almost flat. The arrangement provides everyone with access to a doctor (horizontal equity), but not access to needs-based care (vertical equity). The consequences for patients in very deprived areas include shorter GP consultations despite higher levels of complex illness, lower expectations, poorer outcomes, greater GP stress and increased pressure on hospitals.
First described in 1971, the ‘inverse care law’ states that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’. It is not that medical care in deprived areas is bad. Quality indicators, such as the recently jettisoned Quality and Outcomes Framework, showed little difference between practices in affluent and deprived areas. A better understanding of the problem is the difference between what practices in deprived areas can do for their patients and what they could do if they were better resourced.
Neither the inverse care law nor inequalities in health are marginal issues affecting small numbers of people at the edge of Scottish society. They are a major feature of contemporary Scotland, mostly affecting, on a pro-rata basis, the most deprived 40% of the population. The most affected constituencies all have SNP MSPs.
Compared with 1948, there is now a collective of tools and resources of effective NHS interventions capable of improving not only individual patient health but also, via mass delivery, the health of the public. The corollary is that if health care is delivered inequitably, with some social groups benefitting more than others, the NHS itself becomes a cause of widening health inequality. Almost every recent official Scottish report and policy on health inequalities has turned a blind eye to this new, important, social determinant of health.
Why don’t people see the inverse care law as a problem requiring urgent attention? First, because it doesn’t produce noise, from patients who have learned not to expect more (the Chief Medical Officer’s call for ‘Realistic Medicine’ doesn’t address this issue), professional bodies serving other interests, or politicians supposedly representing affected communities. Second, because despite much bluster and conceit to the contrary, we are a conservative society, most comfortable in how things are. Third, many people do not know or cannot imagine how general practice makes a difference.
The intrinsic features of general practice – patient contact, population coverage, continuity, flexibility, long term relationships and trust – make general practice the natural hub of local health systems. Cumulative knowledge of patients is the starting point for integrated care. No other part of public service has these characteristics in such large degree but although essential these features are not sufficient. Closer links (i.e. local, familiar, quick and flexible) are needed to a host of other resources and services.
The NHS will continue to provide emergency care and access to specialists, while striving to give more children a better start in life and everyone a dignified end, but increasingly its task is to support people with multi-morbidity to live long and well in the community. General practice in its current plight needs to be rescued and supported so that it can lift its head and lead the building programme that is required, based not on bricks and mortar but on relationships, building strong patient narratives, on the one hand, and better relationships with local colleagues and services, on the other. This can only be done at a local level.
The health professions often call for politics to be kept out of the NHS but, as George Orwell observed, that is itself a political position. With no hands on the wheel, the NHS does not sail a straight course towards equity, but a crooked course reflecting the interests of the most powerful groups.
We need political involvement more than ever, not to micro-manage the NHS with targets, but to set and scrutinise the direction of travel, beginning by correcting the imbalances which have developed between backroom and frontline staff, between clinical generalists and specialists, and between care received by different social groups. Chiselled above the entrance to the Scottish Government Health Department and every Health Board HQ in Scotland should be the mantra: ‘If the NHS is not at its best where it is needed most, inequalities will widen’.
Professor Graham Watt is Emeritus Professor of General Practice and Primary Care at the University of Glasgow
Deep End Report 30: A role for members of the Scottish parliament in addressing inequalities in health care in Scotland (see www.gla.ac.uk/deepend)