NHS scores well on access, out of hours care, and patient engagement but not on outcomes, conference hears

BMJ 2013; 346 doi: (Published 14 March 2013) Cite this as: BMJ 2013;346:f1694
  1. Nigel Hawkes
  1. 1London

The paradox of a service that seems to do all the right things but does not always deliver the right results was never quite resolved at a conference in London on primary care on 11 March.

Ara Darzi, the former Labour health minister and now co-director of the Centre for Health Policy at Imperial College London, organised the conference with the aim of harnessing international experience to raise the quality of primary care in the NHS.

He called primary care the “rock” of the NHS. David Nicholson, chief executive of the NHS in England, added that it was its cornerstone. And the conference watched a slide presentation by Robin Osborn, vice president of the New York based Commonwealth Fund, who extolled the NHS as the exemplar of what a health service should be.

On almost every slide Osborn showed (except the one on outcomes) the NHS came out best or nearly best in an international comparison of 11 advanced countries: on access, out of hours care, patient engagement, shared care plans, electronic medical records, and patients’ and doctors’ opinions.

She ended her presentation by expressing the hope that healthcare in the United States would change dramatically in the next 10 years, “inspired by the example the NHS sets.”

However, on the measure of mortality amenable to healthcare the United Kingdom performed worst in 1997-8 and second worst in 2006-07 of the seven countries Osborn compared for this (France, Australia, the Netherlands, Germany, New Zealand, the UK, and the US).

So the UK enjoys a great health service but not great health, a puzzle that the conference participants never fully tackled. One who tried was Liam Donaldson, the former chief medical officer. “I think it strains credibility to say we have a world class service,” he said in response to Osborn’s presentation. “I don’t think it is.”

Donaldson made two recommendations. One was to model primary care on a general practice in Tower Hamlets, east London, run by Sam Everington, another of the day’s speakers. His practice provides a partnership between medicine, education, and the local authority in improving the health of local people, a rare set-up, Donaldson said.

He also believed that hospital outpatient care should be largely transferred to primary care. Darzi agreed, saying that it was time to “repatriate” many activities that were once done in primary care but had migrated into the secondary sector.

Among overseas examples of primary care, the US MinuteClinic model offers something different: a retail model of primary care that is delivered in nurse led clinics, open seven days a week and offering affordable advice that is based on protocols and backed up by access to clinicians.

There are now 640 clinics in 25 states, said Andy Sussman, president of MinuteClinic, 200 of them established since 2011, and a total of 1500 are planned by 2017. Half of the patients who attend the clinics have no primary care doctor, and 85% use insurance coverage to pay for care that he claimed costs 40% less than in other clinics, without sacrificing quality.

There was evidence that MinuteClinic users were less likely to attend emergency departments or to need to visit doctors. Although the chain of clinics had started by treating minor conditions such as sore throats, it was now moving into chronic care—something increasingly needed in the US, where every day 10 000 people turn 65.

Andy Haines of the London School of Hygiene and Tropical Medicine argued that middle income countries also had lessons to teach, citing the remarkable progress made in Brazil. There primary care teams, comprising a doctor, a nurse, and four to six community health workers who are the eyes and ears of the team, visit families on their list at regular intervals to check on vaccination status, adherence to drug treatment, the possible effects of violence, and general lifestyle issues.

The policy had had remarkable effects, Haines said, reducing infant mortality, numbers of hospital admissions, and inequality in access to care. In a Rio de Janeiro slum that he had visited, the effects on community life had been dramatic. Critics argued that in the UK such a system would represent the “dumbing down” of primary care, but he preferred to see it as an add-on.

Tom Kibasi, a partner at the consultancy firm McKinsey & Co, argued that primary care in the NHS was locked in a 1946 model, a straitjacket stitched together in the negotiations that set up the NHS two years later. Different patients’ needs varied hugely, but primary care provided a 10 minute slot for each patient regardless of actual need.

“The model is stretched to the limit because patients with very different needs get the same healthcare,” he said. Innovation should begin by reducing this mismatch.

Some conditions were best managed outside recognised patterns altogether, argued Rachel Carrell of Dr Thom, an online provider of sexual healthcare. The convenience of online access meant that some women preferred to pay £30 (€35; $45) a month to Dr Thom for contraceptive pills that they could, in principle, get free through their GPs.

“Lots of patients are willing to pay,” she said, because of the time they saved by not needing to arrange and attend appointments, although she conceded that this worked only because Dr Thom’s services covered a narrow range of conditions that didn’t require a physical examination and were aimed at low risk patients.


Cite this as: BMJ 2013;346:f1694