Editorials

"Schools and hospitals" for "education and health"

General practice, not hospital care, accounts for most of the health service

The phrase "schools and hospitals" is repeated almost every week. Whether it is in a speech to the Labour party conference, or this week in a speech to the party faithful in north London, the British prime minister's shorthand phrase for "education and health" is always "schools and hospitals." Perhaps this isn't entirely surprising. After all, about 80% of any healthcare budget goes into secondary care, and the potential for dramatic glory as well as disaster is often concentrated within hospitals.

However, secondary care is not the health service. Far from it. In the United Kingdom about 90% of the work of the health service is carried out in primary care. In one recent year 268 million consultations with general practitioners were made,^w1 and satisfaction rates with general practitioners are high91% according to a survey organised by the Cabinet Office.^w2 Despite the complexity, importance, and emotional context of consultations with general practitioners, only one formal complaint is made for every 70 000 consultations.^w3

This undervaluing of primary care is puzzling. In the 10 years from 1991 to 2001 the number of hospital doctors in the United Kingdom increased by 60%,^w4 whereas the number of general practitioners was almost static.^w5 However, hospital death rates are even more closely related to the number of general practitioners than to the number of hospital doctors, according to a major study that showed that, to reduce deaths in hospital by 5000 per year, the NHS would need either 9000 more hospital doctors or 2300 more general practitioners,¹ which makes the current workforce figures all the more worrying.

Why should general practice have such a major effect on the national health? There can be little doubt that keeping patients away from hospital, except when it is essential, is generally good for them. General practitioners not only see huge numbers of patients but they also absorb huge levels of risk and uncertainty. Every computer contains a device known as a heat sink. The heat sink seems to do little other than absorb the heat in the system. It doesn't compute, calculate, or display. But if you take it away, the system crashes.

General practice is the heat sink of the NHS, absorbing both risk and workload. Generally, referral rates are low. On average, only five patients are referred to secondary care services for every 100 consultations, equivalent to 12 referrals per 100 registered patients per year.² An experienced general practitioner is likely to know when a headache needs an urgent investigation, and when it is a result of "dis-ease" or unhappiness in the patient's life. No doctor will always get this right every time, but the high rates of satisfaction and the low rates of complaints point to a high level of skill.

General practitioners working in emergency units are less likely to investigate or admit patients compared with junior hospital doctors.³ In a study in the United States, men aged 55 and older were randomised to primary care, with or without continuity of provider. Among the men who were randomised to continuity of provider fewer emergency admissions to hospital were noted, as were shorter hospitalisations and greater satisfaction.⁴ In addition, the seminal work of Barbara Starfield on international comparisons of health care has shown that the more orientation to primary care a healthcare system has the higher the patient satisfaction with the system, the lower the overall expenditure on health care, the better the population health indicators, and the fewer prescribed drugs taken per head of population.^5-8

Part of the traditional success of general practice has come from the long term relationship that is formed between patient and doctor. Continuity of care is perceived by many patients to be deeply important and is associated with the development of trust by patients.⁹ Doctors who know their patients are less likely to admit or investigate them,¹⁰ and, of course, the therapeutic relationship between general practitioners and their patients entails a great deal more than simply the avoidance of risk. The current accent on the importance of rapid access to primary health care will hopefully not dilute continuityalthough the risk is that the increase in part time working by doctors, and more flexible patterns of working in society as a whole, may make this inevitable.

Morale for many general practitioners is poor. ^{11 12} Low morale is both a cause and a result of increased stress. In any organism, person, organisation, or even country stress leads to paranoia. Paranoia leads to defensive behaviour, and the chief result of defensive behaviour in doctors is an inevitable increase in investigation and referral.

The delivery of the NHS Plan depends absolutely on referral patterns of general practitioners remaining the same, or falling. Undervaluing the skills of general practitioners, assuming that most apparently simple consultations can be carried out by other primary care team members, and moving more secondary care procedures into primary care may have exactly the opposite outcome. The choice of which member of the team is consulted must be the patient's, not the system's. With adequate resources, it is entirely logical for primary care teams to take on much more of the work of the NHS, perhaps ending some of the duplication and tribalism that has resulted from the divide between primary and secondary care. But without adequate resources, time, and teams the opposite will occur. An increase in referrals will show just what an effective risk sink British general practice has been for many years. But, like the heat sink, you will only notice it when it fails.

David Haslam, chairman of council. 

Royal College of General Practitioners, London SW7 1PU

Footnotes

Competing interests: None declared.

Additional references appear on bmj.com