On 8 September 2022, the House of Lords is due to consider the following motion:

Lord Patel to move that this House takes note of (1) the role of primary and community care in improving patient outcomes, and (2) the need for reform.

1. What are primary and community care services?

NHS England defines primary care services as the “first point of contact in the healthcare system, acting as the ‘front door’ of the NHS”. Primary care includes general practice, pharmacy, dental and optometry services.

In contrast, community health services are mainly delivered in people’s homes, in addition to community hospitals, intermediate care facilities, clinics and schools. They cover a wide range of services and provide care for people from birth to end of life. This includes supporting people with complex health and care needs to live independently in their own home for as long as possible. Community health services also include health promotion services such as school health services and health visiting services. Many of these services involve partnership working across health and social care teams, including general practitioners, community nurses and social care workers.

2. What are patient outcomes and how are they measured?

The NHS outcomes framework is a set of national indicators developed by the Department of Health and Social Care (DHSC) that the secretary of state uses to monitor the health outcomes of adults and children in England. The framework also provides an overview of how the NHS is performing. Under the framework, indicators are grouped into five domains, which focus on improving health and reducing health inequalities:

  • domain one: preventing people from dying prematurely
  • domain two: enhancing quality of life for people with long-term conditions
  • domain three: helping people to recover from episodes of ill health or following injury
  • domain four: ensuring that people have a positive experience of care
  • domain five: treating and caring for people in a safe environment and protecting them from avoidable harm

However, the framework does not set out how the outcomes should be delivered. The NHS website states that it is for NHS England to determine “how best to deliver improvements by working with clinical commissioning groups to make use of the tools at their disposal”.

3. Have outcomes improved in recent years?

In March 2022, NHS Digital published data from its latest outcomes framework. It revealed mixed results for some of the data reported across the five domains. Below are some of the key findings on selected indicators from the data release. However, the full data release provides findings on all the indicators across the five domains, including figures showing changes over: the latest time period for which data is available; and the last five years.

3.1 Preventing people from dying prematurely

The data showed that life expectancy at age 75 for both males and females had fallen by 0.3 years since 2019 (from 11.8 to 11.5 for males and from 13.5 to 13.2 for females in 2020). Similarly, the framework reported that mortality rates for those aged under 75 from both cardiovascular and liver disease had “significantly deteriorated” since 2019. It revealed that deaths from cardiovascular disease per 100,000 people had risen from 68.8 in 2019 to 73.8 in 2020, whilst deaths from liver disease per 100,000 people had risen from 18.5 in 2019 to 20.6 in 2020.

However, there had also been some improvements. This included a reduction in the mortality rate for those aged under 75 and suffering from respiratory disease (from 33.7 people per 100,000 in 2019 to 29.4 per 100,000 in 2020).

3.2 Enhancing quality of life for people with long-term conditions

The admission rate for unplanned hospitalisation for chronic ambulatory care sensitive conditions—which are “conditions where effective community care and case management can help prevent the need for hospital admission”—for all ages saw a decrease of 199.9 admissions per 100,000 people between 2019–20 and 2020–21 (from 862.1 to 662.2).

3.3 Helping people to recover from episodes of ill health or following injury

The data revealed a “significant improvement” in cases of emergency admissions for acute conditions that should not usually require hospital admission, with the admissions rate falling from 1,409.4 per 100,000 people in 2019–20 to 849.9 in 2020–21. In contrast, there was a small increase in the number of emergency readmissions within 30 days of discharge from hospital from 14.4% in 2019–20 to 15.5% in 2020–21.

3.4 Ensuring that people have a positive experience of care

The data also revealed that people’s experiences of general practitioner (GP) services had improved, with 83.1% of patients from January to March 2021 scoring services either “very or fairly good” (up from 81.8% in 2019–20). However, people’s experiences of NHS dental services had “significantly deteriorated”, with 76.8% scoring them as “very or fairly good” from January to March 2021, compared to 84.2% between 2019–20 and 2020–21.

3.5 Treating and caring for people in a safe environment and protecting them from avoidable harm

The framework data revealed that deaths from venous thromboembolism—blood clots—related events within 90 days post discharge from hospital showed a significant increase of 39.0 deaths per 100,000 admissions from 60.4 in 2019–20 to 99.4 in 2020–21.

4. How has the government sought to improve patient outcomes?

In recent years, the government has sought to improve patient outcomes through the introduction of several policy measures. This includes publishing a plan to tackle the backlog of elective care resulting from the coronavirus pandemic and opening community diagnostic centres across England to reduce hospital waiting times.

4.1 Integration white paper

On 9 February 2022, the government published its white paper on health and social care integration. The aim of the white paper was to “draw on the resources and skills across the NHS and local government to better meet the needs of communities, reduce waiting lists and help level up healthcare across the country”. In the white paper, the government outlined several ways it sought to achieve this:

  • It would have a single person accountable for delivering shared outcomes at place level—which NHS England described as places with populations of approximately 250,000 to 500,000—by spring 2023.
  • It would work with partners and stakeholders to develop and introduce a framework with a “focused set of national outcomes”. These outcomes would focus on health services and the public’s health and adult social care. It would be expected to be implemented by April 2023.
  • In parallel, it would introduce accompanying oversight arrangements and regulatory structures that would have a “clear focus” on the planning and delivery of these shared outcomes.
  • It would also join up data and information, with a commitment that each integrated care system had a functional and single shared health and social care record for each person in the system by 2024.

In a statement to the House of Commons on the publication of the white paper, the then minister for health, Edward Argar, said the white paper would “make health and care systems fit for the future, boost the health of local communities and make it easier to access health and care services”.

Responding to the statement, Shadow Minister for Health and Social Care Karin Smyth criticised the white paper for a lack of detail:

There is little to explain how a joined-up system would be managed, how it would be accountable to the public, patients and service-users, how the funding will be allocated and shared or how performance would be assessed and weaknesses addressed. Nothing in the white paper addresses the key issue of balancing what is locally determined against national standards and national entitlements.

4.2 Plan for tackling the Covid-19 backlog of elective care

Elective care covers a broad range of non-urgent services, which are usually delivered in a hospital setting, ranging from diagnostic tests and scans, outpatient care, surgery and cancer treatment. In recent years, a backlog of elective care has largely been attributed to the coronavirus pandemic.

The British Medical Association has previously warned that the backlog of elective care is “adding to the pressure in primary care”, with patients having to be cared for by general practitioners whilst they wait for hospital treatment. Additionally, the Nuffield Trust, a thinktank focused on health, stated that during the coronavirus pandemic, many community services had to stop or partially stop to release capacity for other parts of the NHS. The thinktank argued that although some services had restored their activity, patients were having to wait longer to access community care. This included for community paediatric services, which had a waiting list of over 40,100 in August 2021.

In February 2022, the government and NHS published a plan to tackle the backlog for elective care. The plan made several commitments, including:

  • eliminating waits of longer than a year by March 2025 and ensuring no one is waiting more than two years by July 2022
  • making sure that 95% of patients needing a diagnostic test receive it within six weeks by March 2025
  • “continuing prioritisation” of cancer care, with the target of 75% of patients referred by GPs for suspected cancer given a definitive diagnosis within 28 days of referral by March 2024
  • making greater use of technology to transform models of care

Despite the commitments, the government and NHS conceded that the “ongoing uncertainties” relating to the pandemic and demand for hospital treatment made it “challenging” to predict how quickly the NHS would be able to recover elective services.

The plan was welcomed by several health bodies and thinktanks. The chief executive of the King’s Fund, Richard Murray, said that the plan “brings together a series of initiatives that, if successfully implemented, will improve access to services for the many patients anxiously waiting for care in pain and discomfort”. Similarly, the president of the Royal College of Physicians, Andrew Goddard, stated that “the focus this plan gives us for the next three years is welcome, as is its recognition that staff are central to successful elective recovery”. However, Mr Goddard warned that the plan would only be successful if it was implemented alongside “recovery of urgent and emergency care” as the two were “intimately entwined both with respect to workforce and estate”.

However, some health workers criticised the plan. Writing in the British Medical Journal, Jessamy Bagenal, a physician and senior medical editor at the Lancet, argued the plan had “gaps that will need to be rethought and developed”. In particular, she highlighted that the plan “does not include a clear path to expanding the workforce”.

4.3 Office for Health Improvement and Disparities

On 1 October 2021, the DHSC launched the Office for Health Improvement and Disparities (OHID). The DHSC said that the role of OHID would be to tackle health disparities across the UK “through a new approach to public health focused on stopping debilitating health conditions before they develop”. It would do this by working with the government, the NHS, local government and the wider public health system and industry to improve detection and prevention for people at risk of ill health. OHID would be jointly led by the deputy chief medical officer, Jeanelle de Gruchy, and the DHSC director general for OHID, Jonathan Marron.

4.4 Community diagnostic centres

Also in October 2021, the DHSC announced that 40 community diagnostic centres would open across England in settings ranging from local shopping centres to football stadiums. Describing these centres as “new one-stop-shops for checks, scans and tests”, DHSC said that the centres would help to achieve:

  • earlier diagnoses for patients through easier, faster, and more direct access to the full range of diagnostic tests needed to understand patients’ symptoms including breathlessness, cancer and ophthalmology
  • a reduction in hospital visits, which would help to reduce the risk of Covid-19 transmission
  • a reduction in waiting times by diverting patients away from hospitals, allowing them to treat urgent patients, whilst the community diagnostic centres “focus on tackling the backlog”
  • a contribution to the NHS’s net zero ambitions by providing multiple tests at one visit, which would reduce the number of patient journeys and help cut carbon emissions and air pollution

DHSC stated that centres would be supported by a £350 million investment from the government and would be fully operational by March 2022. In April 2022, the government reported that 73 centres had already opened and had delivered over 700,000 additional CT, MRI, ultrasound, endoscopy, and ultrasound tests. The government also stated that health and social care funding would help to deliver up to 160 centres by 2025.

4.5 Health and Care Act 2022

The Health and Care Bill 2021–22 was introduced by the government in the House of Commons on 6 July 2021. The bill enacted several policies set out as part of NHS England’s recommendations for legislative reform in its long term plan (published in 2019) and in the government’s integration and innovation white paper (published in 2021).

The bill’s provisions placed existing integrated care systems (ICSs) onto a statutory footing. The role of ICSs would be to bring together NHS trusts and foundation trusts, primary care, local authorities, and voluntary sector partners, with the aim of “remov[ing] barriers between organisations to deliver better, more joined up care for local communities and ultimately to improve population health”. Within each ICS is an integrated care board (ICB). Under the bill, clinical commissioning groups (CCGs) would be abolished, with ICBs taking on their functions. CCGs were previously responsible for commissioning healthcare including mental health services, urgent and emergency care, elective hospital services, and community care. The bill gained royal assent in April 2022 to become the Health and Care Act 2022.

Although some aspects of the bill were welcomed by the Labour Party, such as provisions on childhood obesity and advertising, it stated that it could not support the bill overall. At third reading of the bill in the House of Commons on 23 November 2021, the then shadow secretary of state for health and social care, Jonathan Ashworth, argued that the bill was “an extensive reorganisation of the national health service at a time when we are still in a pandemic and when NHS staff are exhausted and facing burnout”. Mr Ashworth stated the government should be tackling “the monumental waiting lists, the huge referrals for mental health treatment, the crisis in A and E, and the huge pressures on ambulance services and general practice” instead.

4.6 Health and social care levy

In a statement in the House of Commons in September 2021, Prime Minister Boris Johnson announced the government’s plans to increase funding for health and social care from 2022/23 to 2024/25 through a new tax, the health and social care levy. He explained that the levy would be based on an increase of 1.25 percentage points in the main classes of national insurance contributions (NICs). It would be introduced in the 2023/24 tax year, after temporary transitional arrangements to increase NICs rates by the same amount in 2022/23 to allow for systems to be updated. Legislation to create the levy, the Health and Social Care Levy Bill 2021–22, was fast-tracked through Parliament from September to October 2021. The government argued that the bill needed to be fast-tracked because the levy was required to be in place for the 2022/23 tax year, which begun in April 2022. However, in August 2022, Liz Truss—who is standing to be leader of the Conservative Party and replace Boris Johnson as prime minister—stated that she would reverse the rise within days of becoming prime minister, should she win.

Opposition parties criticised the government’s decision to base the levy on NICs. Leader of the Opposition Keir Starmer argued that the levy broke a pledge in the Conservative Party’s 2019 general election manifesto not to raise rates:

This is a tax rise that breaks a promise that the prime minister made at the last election, a promise that all Conservative members made—every single one of them. It is a tax rise on young people, supermarket workers and nurses; a tax rise that means that a landlord renting out dozens of properties will not pay a penny more, but the tenants working in full-time jobs will; and a tax rise that places another burden on businesses just as they are trying to get back on their feet.

Similarly, the Scottish National Party’s leader at Westminster, Ian Blackford, stated that:

The scandal of the tax hike is that it will fall hardest on the young and the lowest paid—the two groups that have suffered the worst economic consequences of the pandemic.

4.7 Future proposals for reform?

In a speech to the Royal College of Physicians in March 2022, the then secretary of state for health and social care, Sajid Javid, discussed healthcare reform. Mr Javid said that the NHS was facing several long-term challenges, including how to:

  • keep the NHS focused on delivery while futureproofing it for changing demographics and disease
  • meet rising patient expectations and address the injustices of widespread disparities
  • deal with an unsustainable financial trajectory whilst backing the people who work in health and care

During his speech, Mr Javid also noted that the NHS long term plan had made “great strides forward”. However, he stated that it was “designed in a pre-pandemic world” and “won’t be sufficient to meet the challenges we face after the pandemic”.

Therefore, Mr Javid made several proposals and targets for reforming primary and community health services. This included:

  • four million people benefitting from personalised care by March 2024, which would cover everything from social prescribing to support plans
  • a ‘right to choose’ model to reduce waiting times, whereby patients waiting long times to be seen would be proactively contacted to discuss an offer of alternative provisions
  • the publication of the government’s first digital health and care plan in spring 2022, as it wanted a “digital future for the NHS that works for everyone”
  • electronic records to be rolled out to 90% of trusts by December 2023, and 80% of social care providers by March 2024

5. Proposals from third parties to reform primary and community care services

Parliamentary committees, health organisations and stakeholders have previously proposed reforms to primary and community care services.

5.1 Parliamentary inquiry

In September 2021, the House of Commons Health and Social Care Committee launched an inquiry examining whether changes to the organisation and delivery of NHS services would be required to manage the backlog of cases caused by the coronavirus pandemic. In January 2022, the committee published its report, which concluded that tackling the wider backlog presented a major, “if unquantifiable”, challenge. The committee made several recommendations including calling on the DHSC and NHS England to work together to produce a “broader” national health and care recovery plan by April 2022, which would focus on emergency care, mental health, primary care, community care and social care.

In May 2022, the government published its response to the committee’s report. The government rejected calls for a new plan, arguing that its delivery plan for tackling the Covid-19 backlog of elective care “builds on initiatives that were already taking place and puts workforce at the heart of the government’s plans to improve the NHS and recover services”.

5.2 Organisations and stakeholders

In June 2022, the Royal College of General Practitioners (RCGP) published an article warning that general practice was facing a “mass exodus” of general practitioners within the next five years. Detailing the results of a survey on GP career progression answered by 1,262 of its members that were either GPs or trainees, the RCGP found that 42% of respondents said they were likely to quit the profession within five years. With a workforce of more than 45,000, this would be the equivalent of 18,950 GPs and trainees in total. The RCGP noted that 60% of respondents not planning to retire had cited stress, working hours and a lack of job satisfaction as their reasons for wanting to quit.

In response to the findings, the RCGP announced that it was launching a new plan, Fit for the Future, setting out “urgent actions” for the government to take to “tackle the workforce and workload crisis in general practice, and support GPs and their teams to meet the healthcare challenges of the 21st century”. The plan included calling on the government to:

  • publish a new recruitment and retention strategy that went beyond the 2019 target of delivering 6,000 more GPs by 2024
  • launch an NHS-wide campaign to “free up” GPs to spend more time with patients by “cutting unnecessary workload and bureaucracy”
  • invest in new technology products and support for practices, which would improve patients’ experience of accessing care
  • return funding for general practice to 11% of total health spend, including £1 billion of additional investment in GP premises

Writing for the Nuffield Trust website in May 2022, Rebecca Rosen, a policy fellow at the thinktank and a general practitioner, discussed her proposals for reforming general practice. Warning that general practice was “on the brink”, Ms Rosen stated that any reform should incorporate seven components. They included:

  • ensuring that arrangements for contacting a practice must allow all patients to access care on an equal footing
  • embedding non-medical clinicians—such as pharmacists and dieticians—into general practice teams, supervised by general practitioners
  • improving the use of digital technologies, for example, for clinical encounters and providing long-term condition monitoring

Also in May 2022, Policy Exchange published a report detailing its proposal to reform general practice. Describing the current model of general practice as “neither adequately staffed, nor optimally planned”, the thinktank proposed that general practice moved away from its existing partnership model whereby partnerships own or lease their premises and manage their own workforces. Instead, the report recommended that general practitioners should be offered “predominantly salaried and contracted” employment by scaled providers, such as trusts or large-scale primary care operators. In the report, Policy Exchange also called on the government and NHS to “make better use” of technology to tackle general practitioner shortages in deprived areas. This included through remote consultation, which Policy Exchange argued was “unconstrained by geography” and a “viable tool for expanding access rapidly”.

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