Primary Care and Public Health in England: What does the

future look like?

Professor Azeem Majeed, Department of Primary Care and Public Health, Imperial College London, UK

What challenges does the NHS face?

• England’s National Health Service (NHS) faces major challenges

• The NHS has improved substantially in the last 15 years and needs to continue to improve

• Population of England is ageing• Greater support is needed for frail, older patients• Prevalence of many chronic diseases – such as diabetes – is

increasing• Greater focus in prevention and healthy living needed• Quality of care can vary between different family practices, NHS

Trusts and geographical areas• Considerable financial pressures on government spending

Expected rise in LTCs in England 2010-2040

Annual growth in NHS spending 1998-2012

Recent changes in NHS spending on primary care

Spending on primary care as a percentage of NHS budget

International comparisons on healthcare spending

NHS Trust End-of-Year Finances

NHS Five Year Forward View

• Published in 2015• What forms of integration are being proposed?• Family practitioner led integration• Hospital led integration

Family practitioner led integration

• Traditionally, family practitioners (general practitioners) in the UK have worked in group practices with other doctors, nurses and administrative staff

• Family practitioners come together to form federations of larger groups: ‘primary care at scale’

• These federations can then apply to become Multispecialty Community Providers

• Multispecialty Community Providers can employ other professionals such as nurses, specialists, and allied health professionals

• They could also potentially have their own hospital beds• Take over much of the work currently done by hospitals, e.g.

outpatient clinics

Hospital led integration

• Hospitals will also be allowed to develop integrated services• This will include the option to employ family practitioners and

form Accountable Care Organisation structures• Larger hospitals will also be able to form partnerships with other

hospitals including smaller hospitals and specialist hospitals

Integration of urgent and out of hours care

• Currently, there are many different providers of emergency care• Family practitioners, emergency departments, urgent care

centres, ambulance and paramedic services, rapid response teams

• Can be confusing and difficult to navigate for patients• Integration of these services is now planned through the

development of urgent and emergency care networks

Other linked initiatives

• Much greater emphasis on prevention and promoting healthy lifestyles to address problems such as obesity

• Greater emphasis on person-centred care• More care delivered in people’s homes• Community engagement• Promoting health in the workplace• Use of new technology, such as remote monitoring and tele-

consultations• Give patients access to their electronic family practitioner

records

Expansion of GP training numbers

• Increasing recognition that the NHS needs more generalists (family practitioners) to deliver these changes

• Support for greater investment in primary care• Give clinical commissioning groups greater control over the

development of local primary care services• Expand the number of general practitioners in training with a

target of 50% of UK medical graduates to work in primary care• New roles for general practitioners: GPSIs, urgent care, elderly

care, child health – in additional to traditional roles• Will the NHS be able to train, recruit & retain more GPs?• Other models of primary care need to be considered• Look at skill-mix in primary care & gatekeeping role of GPs

GP Five Year Forward View

• Published in April 2016• Recognition at a senior level that primary care is struggling• Increase NHS spending on primary care by £2.4 billion per year by

2020-21, around 10.7% of the NHS budget• Recruit 5,000 GPs, 3,000 mental health workers and 1,500 clinical

pharmacists• Measures to support struggling practices, boost premises investment,

cut bureaucracy and GP workload• Funding for ‘7-day’ working (but not compulsory for practices)• Promote online and video consultations• £6m for training practice managers and £45m for reception and clerical

staff. £15m for practice nurse development.

Some potential limitations of GP Five Year Forward

• The new funding money is not being put into core funding for practices. It is largely attached to schemes and initiatives NHS England is keen to push and develop. Some of these will potentially benefit all practices, others will only help those practices embracing the government’s plan to deliver general practice ‘at scale’.

• Not ‘new’ money from the Treasury, it is money from the overall £8.4 billion uplift in funding for the NHS announced in the Autumn. Other areas of the health service will be receive proportionally less and is predicated on large (£22 billion) efficiency savings.

• Other Department of Health budgets (e.g. HEE) are being cut• Bringing general practice funding up to 10% of the NHS budget is

taking it back up to the proportion it received a decade ago.

What about public health?

An example from Lambeth Council

• We are keen to hear your views on how we can run great services on less money. All residents, stakeholders and service providers in Lambeth are welcome to give views. Your feedback and suggestions will help us reshape services in the borough in view of our reduced resources

• Since 2013, Lambeth council has been responsible for Public Health (when it was transferred to us from the NHS). As with other councils, Lambeth receives a specific Public Health grant from the government which is used to fund a range of services to improve the health and well-being of local residents. These include:• Sexual health (testing, treatment and contraception)• Drug and alcohol treatment programmes• Services to promote health improvement (eg: health visitors, NHS Health

Checks, stop smoking services, diet and weight management services, and physical activity services).

An example from Lambeth Council

• We have been working closely with partners in the NHS, with patients, with service providers, with Public Health specialists and a range of other stakeholders to improve and transform these services.

• This work will continue this year but, unfortunately, the government has now announced that it is reducing funding for these services and this requires us to pause our improvement work to address the immediate funding shortfall.

• The government cut means we have a shortfall of around £3million this year and we will have further cuts to our Public Health grant each year between now and 2020.

• In the last financial year, the council covered the £1.9m cut to its Public Health grant from its reserves, but the government is giving less money to the council to run services. We cannot keep using council reserves. As a result, we have to look for ways to spend less on Public Health while maintaining a good level of service and continuing to try to improve our residents’ health.

How will new developments be evaluated

• Important to evaluate new developments in the NHS• Quality of care and health outcomes• Health care efficiency• Patient experience including patient reported outcomes and

quality of life• Experience of health care providers• Impact of public health cuts on the NHS and health outcomes?

Conclusions

• Some new NHS investment – but investment is very low by historical standards

• Will the new models of healthcare delivery deliver the £22 billion efficiency savings the Treasury expects?

• What impact will contractual changes have? Junior doctors, consultants, GPs, public health consultants

• Can primary care attract and retain enough doctors?• What impact will cuts in public health budgets have on careers

in the specialty?