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All healthcare eyes look upon us with envy

Lynn Young
Primary Healthcare Advier for the RCN

Spring is here and with it a renewed NHS drive to implement the white paper Our Health, Our Care, Our Say and achieve the magical 18-week wait.(1) The optimists among us will wish to shut the door on our year of ghastly deficits, develop a spirit of  hope that most of the NHS books are in a happy state of financial balance, and look forward to emerging new community health services.

This is the dream for many community nurses, who for several years now have believed that, given the right resources, far more patients could receive spectacular services closer to home.

But research can be a wonderful thing as it often blasts away commonly held views, perceptions and assumptions. For as long as I have been a devotee of primary care, the mantra "develop more primary care and we can diminish the demands put upon hospitals" has prevailed. It feels right, doesn't it? In many ways, this is the driving force of current UK health reforms and that of most of the developed world. All healthcare eyes look upon the UK with its well-developed general practice system and community services with envy and a heartfelt desire to grow their own in their particular countries.

However, health and healthcare is a complex business, and to support this rhetoric recent research asked the question: "Can primary care reform reduce demand on hospital outpatient departments?"(2)

With this particular study the researchers identified a number of promising interventions, but also some ineffective and even potentially harmful strategies. This being so means that a rapid rethink is required on some current trends in service development and the funding that has been allocated for such services.

Given the fact that future healthcare must concentrate on the excellent management of long-term conditions, it is heartwarming to be told by the researchers that one effective strategy is for primary care to manage chronic disease - the bread and butter of many a practice and district nurse - and for outpatient follow- up appointments to end.

The jury is still out on the value of the GP with Special Interest (GPwSI) initiative and the research indicated that the quality of minor surgery might be compromised within general practice.
The new PCT and practice-based commissioning agenda is the vehicle for ensuring that local people have access to redesigned services - once again, in line with "care closer to home" aspirations. The health outcomes for individuals as a result of healthcare interventions should underpin commissioning decisions, and this is tough work considering the lack of evidence available on many nursing activities. Yes, plenty of examples of best practice and patient satisfaction, but little hardcore clinical evidence.

However, this research demonstrated that primary care clinics for chronic disease showed just as good  health outcomes as those in the hospital setting, while at the same time improving access to services. More detail on the GPwSI role reveals that although such GPs provide high-quality care with good health outcomes, the lack of a national system for both providing and monitoring care means that current research findings are limited in their value.

Interestingly, the cost of GPwSI services is more than that of those provided by specialist consultants, which, along with the occasional attack of hostility from the odd consultant, might render some treatments unsafe.

This study comments on a number of well-worn and popular assumptions, so very briefly the conclusions reached are as follows:

  • It may not be as safe to carry out minor surgery in general practice as in the hospital, and GPwSI services may not be as safe as those of the specialists.
  • Care in the community is not cheaper than that provided by the hospital.
  • Improved community services might well increase both demand and referral patterns.
  • Although community care is popular with patients, it may not survive loss of quality and efficiency.
  • The moral of this column is that while it is easy and fun to make assumptions on change, quality and cost, it is important to take heed of research before entering the world of total redesign and so-called modernisation.

References:

  1. Department of Health. Our health, our care, our say. London: DH; 2006.
  2. Martin R, et al, on  behalf of the NHS Service Delivery and Organisation Research and Development Programme (SDO). Can primary care reform reduce demand on hospital outpatient departments? Manchester: National Primary Care Research and Development Centre, University of Manchester; 2007.