Paul Little is NIHR Senior Investigator and Professor of Primary Care Research at the University of Southampton in the United Kingdom
Primary Care in the United Kingdom
What do populations need?
Populations need equitable and efficient access to high-quality care, but such a statement reflects both cultural values and political context. The UK National Health Service (NHS) was launched in the early post-war years by the then minister of health, Mr. Aneurin Bevan, based on core principles: that it meet the needs of everyone; that it be free at the point of delivery; and that it be based on clinical need, not ability to pay. The NHS has been the centre of political debate since, and attempts to reform the NHS — particularly the market-based reforms starting in the 1990s — have been controversial.
How does the system provide for these needs?
Access to services is free at the point of consultation. Most patients are registered with general practitioners (GPs), but they can attend any general practice, emergency department or walk-in centre (see NHS structure). Copayments for prescriptions are free to key groups (e.g., children, full-time students, the elderly, people receiving benefits and patients with endocrine conditions). The National Institute for Clinical Excellence (NICE) — set up in large part as a response to perceptions about unfair post-code variations in care—provided explicit decision-making and nationwide guidance for care despite some difficulties (also see Civitas Health Briefing).
Who pays for the primary care system?
It is funded out of general taxation, but a thriving private sector — also accessed via the GP gatekeeper — is supported by private copayments, private insurance schemes and some occupational schemes.
What are the strengths?
The system provides easy access for most people, and the registered list provides a stable population and facilitates planning of both acute and chronic disease care and continuity of care. Patients are mostly satisfied with primary care, and doctors can act as patient advocates with relatively few conflicts of interest. Doctors are paid for managing patient populations with minimal incentives for inefficient care (e.g., over investigation, drugs for self-limiting illness), and although the Quality and Outcomes Framework, which pays doctors for achieving quality markers, does provide financial pressures, these are mainly evidence-based. The system is cost-effective, and NICE provides substantial advantages in explicit decision-making.
What are the weaknesses?
The system is arguably paternalistic with limited empowerment for patients, and no secondary care appointment can be made without a “gate-keeping” GP referral. NICE also provides control, and although guidance is mostly helpful, quality of guidance is variable — particularly where evidence is limited and “best practice” guidance suffices. Consumer aspects are sometimes poor (e.g., referral speed, choice of provider), provider contracts are generally conservative, and inefficiencies exist due to limited integration of care (e.g., bed occupancy, the coordination of social care). The Quality and Outcomes Framework, although providing important benefits in some areas, has failed in others, and can easily dominate consultations, providing real concern that relying on the measurable undermines the meaningful.
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