The lack of primary care investment is ‘one of the most significant’ policy failures of the ‘past 30 years’, one of the country’s most influential health think-tanks has said.
The NHS in England ‘must be radically refocused’ to put primary care at its core, according to a new report by the King’s Fund.
NHS England and the Department of Health and Social Care (DHSC) should consider changes to the national contract approaches for primary care, ‘creating more flexibility for local commissioners to drive change based on local need’, the report said.
The financing model for primary care – general practice and community pharmacy through mainly national contracts – ‘does not allow easy flexibility or change’, or larger-scale local investment, the authors said.
They also pointed out that on average there are more than 876,164 GP appointments in the NHS every day – an increase of 34,219 appointments a day since 2018/19 – but that despite this rise in demand, the proportion of DHSC spending on primary care has fallen from 8.9% in 2015/16 to 8.1% in 2021/22.
The number of NHS consultants grew by 18% between 2016/17 and 2021/22, but the number of GPs increased by just 4% over the same period, while social care staff vacancies jumped from 110,000 in 2020/21 to 152,000 in 2022/23.
This is despite the NHS Long Term Workforce Plan identifying the need to grow the primary and community health and care workforce faster than the acute workforce, equivalent to 3,000 more GPs and 9,000 more community nurses by 2026/27.
The report said: ‘The failure to grow and invest in primary and community health and care services despite the often-avowed intention to do so must rank as one of the most significant and long-running failures of policy and implementation in the NHS and social care over the past 30 years.
‘Future growth in funding and staffing needs to be directed proportionately more to primary and community health and care services rather than to acute hospitals.
‘The Department of Health and Social Care and NHS England need to prioritise capital and revenue investment in technology and estates for primary and community health and care services.’
It also said that community services were seeing increasing numbers of specialist nurses being commissioned to provide services to people in their own homes rather than more generalist district nursing, and that national mechanisms of quality assurance were largely designed for hospitals and ‘poorly suited’ to primary care.
King’s Fund chief executive Sarah Woolnough said: ‘Many people across the country will have personal experience of struggling to get a GP appointment, trying to contact other services, and when all avenues have been exhausted, reluctantly going to A&E. It feels like all roads lead to the hospital, but our hospitals are already full.
‘To achieve an effective and sustainable health and care system, politicians and national leaders need to embark on a radical and wholesale refocusing of the health and care system towards primary and community services.
‘Doing so will free up hospitals to treat the patients they are best placed to treat, thanks to many more people being diagnosed and cared for in the community.’
NHS Providers’ deputy chief executive Saffron Cordery said: ‘As this report highlights, care provided in the community is too often overlooked when headlines and political priorities focus on a narrow set of acute-focused targets. But prevention is better than cure and with the right funding and workforce then community, primary and social care can play an essential role.
‘Community and primary care services help people to stay well, manage their conditions and live independently, which is better for patients and can help to ease pressure on the rest of the NHS.’
Royal College of Nursing (RCN) director for England, Patricia Marquis, said: ‘Care closer to home or in the home itself is both revolutionary and realistic.
‘However, it requires a workforce investment that we are not currently witnessing.’
She warned district nurses were carrying ‘an unsafe and unreasonable caseload of patients and struggle to spend respectful or even safe amounts of time with people who need to see them’.
And she said primary care staff ‘must be valued equally with nursing professionals in other sectors and specialties, getting at least the same pay, terms, and conditions as those employed by NHS hospitals’.
With a general election expected this year, she said that all parties needed to show they understood that the solution was not cutting vital hospital care, but ‘significantly levelling up investment in essential community and primary care services’.
Meanwhile, Dr Katie Bramall-Stainer, chair of General Practitioners Committee England at the British Medical Association (BMA), said that the GP appointment figures were ‘a massive underestimate’.
BMA data has estimated an average of 1.39 million appointments delivered by practices in England every day, including those provided by other general practice staff, such as nurses, she noted.
‘We have witnessed an exodus of GP numbers, with around 1,900 fewer fully qualified, full-time equivalent GPs since 2015, despite being promised the recruitment of more than 6,000 in that time. Coupled with rising costs, many practices are struggling to stay open without much needed help,’ said Dr Bramall-Stainer.
‘This should act as a wake-up call for the government. As the King’s Fund has outlined, there has to be a rethink on plans for general practice, otherwise services will simply continue to drop in quality.
‘Staff do the very best for their patients, but if there aren’t enough of the right sort of staff then patient satisfaction will continue to decline.’
A DHSC spokesperson said: ‘This government wants to end short-term thinking and we are taking the long-term decisions that will mean everyone can access high-quality care that enables choice, control and independence.
‘We commissioned the first ever NHS Long Term Workforce Plan to train, retain and reform the workforce, and put primary and community care on a sustainable footing.
‘Backed by more than £2.4 billion, the plan will increase the number of GP training places by 50 per cent by 2031.
‘We have also delivered our commitment to provide 50 million more GP appointments per year, rolled out the Pharmacy First service to reduce pressure on GPs, and made up to £8.6 billion available over this financial year and next to support the adult social care workforce and help people leave hospital on time.’
Last week, the Times Health Commission report suggested 10 reforms to the NHS and social care to create a ‘healthier Britain’ – including GP contract reform, and writing off student loans for nurses and midwives.
A version of this article was first published by our sister title Pulse
