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Remember Barbara Starfield: primary care is the health system’s bedrock

BMJ 2013; 347 doi: (Published 30 July 2013) Cite this as: BMJ 2013;347:f4627
  1. Michael Caley, specialty registrar in general practice and public health, Public Health Warwickshire, Warwick CV34 4TH, UK
  1. mikecaley{at}

Barbara Starfield’s research showed that investing in primary healthcare is the way to a successful health system. So why are these lessons not being heeded, asks Michael Caley, and will general practice commissioning help?

The UK government’s Health and Social Care Information Centre published data in March showing changes in the medical workforce of the NHS in England between 2002 and 2012.1 The number of consultants rose 49%, from 27 070 to 40 394, whereas the number of general practitioners rose by only 19%, from 30 312 to 36 105. The proportion of all doctors working in general practice has fallen steadily, from 42% to 37% of the total medical workforce.

So what has driven this disproportionate increase in consultants compared with general practitioners? The answer may be more financial than ideological. The introduction of payment by results for secondary care since 2003-04 enables hospitals to increase revenue, and hence workforce, by increasing activity and from the general increase in demand for NHS services. An analysis by the think tank the Nuffield Trust showed that between 2003-04 and 2011-12 spending on hospital care increased in real terms by 40%, compared with only 22% for primary care.2 In contrast, general practice contracts are paid on an annual cost per patient basis, which can be capped regardless of increases in demand for services; this occurred in the most recent negotiation of general practice contracts.3

Over more than 20 years, Barbara Starfield, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore, who died in 2011,4 consistently showed that increasing the supply of primary care physicians, even after correction for socioeconomic factors, results in lower all cause mortality5 6; lower mortality from cancer, heart disease, and stroke7; increased life expectancy and better self reported health6; lower rates of admission to hospital8; lower infant mortality9; reduced health inequalities10 11; and reduced costs.12 Furthermore, she showed that relatively more medical specialists compared to primary care physicians resulted in greater costs and a trend towards an increase or neutral effect on overall mortality.5 10

Improvements in these outcomes are broadly identical to the objectives of the NHS in England now and in the previous decade. However, looking at the changing distribution of finances and workforce throughout the NHS, it is clear that her lessons have been either forgotten or ignored. Instead, investment in secondary rather than primary care has been prioritised, and the most deprived areas of the country with the worst health outcomes continue to have the fewest general practitioners.13 Some of the strongest and most consistent evidence for the improvement of health and the reduction of health inequalities has been ignored in favour of the expansion of hospital or specialist care.

The faster growth in hospital spending and workforce relative to primary care raises questions about whether the NHS has the right balance for the future. If we consider the preliminary findings of the Department of Health commissioned report on general practice workforce, there is some hope that the trend of the past decade may be corrected. The report suggests a 41% rise in the number of general practitioners will be required to meet demand by 2030. This increase is hoped to be achieved by an already planned expansion of training places for general practitioners.13 This workforce planning needs to be matched with financial investment in primary care by NHS England to allow structured expansion of capacity, skills, and infrastructure.

So what does this mean in the new NHS in England? To achieve the required investment in primary care, the patchwork of newly created organisations with separate but interdependent budgets and responsibilities must work in a fully integrated way. However, even the most charitable review of the history of NHS organisations would conclude that only a handful of trailblazers will succeed. The likelihood of clinical commissioning groups transferring savings made in secondary care to NHS England to commission additional primary care services seems remote. Even general practice leaders in clinical commissioning groups who are successful in making savings may be prevented from investing in primary care because of perceived conflicts of interest—despite this investment being in the best interests of their patients and the population.

Starfield consistently reminded us that sufficient, consistent, and high quality primary care is the bedrock of a high performing health system. Let us hope that the new organisational and financial system of the NHS does not make us forget her lessons once again.


Cite this as: BMJ 2013;347:f4627


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.


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