Many people will have personal experience of struggling to get a GP appointment or support at home for relatives. When all avenues have been exhausted, they will have reluctantly gone to A&E or ended up in crisis. It feels like all roads lead to the hospital, and our hospitals are already full.
As argued in a major new report from The King’s Fund, the answer to the current pressure on hospitals is not more hospitals. This may sound counterintuitive, but in countries worldwide there is agreement that effective and sustainable health and care systems need to be rooted in meeting people’s needs as close to patients’ homes as possible. That means providing high-quality GP, pharmacy and other primary and community care services. It means diagnosing, treating and managing health conditions earlier, freeing up hospitals to treat the patients they are best placed to deal with.
Yet despite successive governments over many decades saying they are committed to this agenda, in England there is now a higher proportion of the NHS budget and staff going into hospital services and emergency care. At the same time, there has been a slow erosion of capacity and confidence in primary and community care. In this week’s Budget, the Chancellor committed an additional £6bn to the NHS, which includes £2.5bn for everyday spending and £3.4bn for digital transformation and improving productivity in the health service. There was little in the way of targeted support for primary care. It would not be an overstatement to say that the failure to grow and invest in primary and community health and care services is one of the most significant and long-running policy failures of the past 30 years.
The reasons for this are complex, but progress has been hampered in particular by an incorrect belief that moving care into the community will result in short-term cash savings. This is not the case – improving the flow of people through hospitals by preventing unnecessary admissions or helping provide ongoing support at home can only produce savings if hospital beds can be closed, and we do not believe that this is possible or desirable. England already has fewer hospital beds per capita than other developed nations. Bolstering out-of-hospital care might not bring short-term savings, but it would avoid having to build ever more expensive hospitals in the long-term.
The delivery of a primary- and community-focused health and care system has also been hampered by the fact that these services are not well understood and are less visible than hospitals. Data on this is hard to quantify and interpret, and senior NHS leaders primarily have experience in large teaching hospitals rather than in community services. The health and care workforce is becoming increasingly specialised into single disease areas. Urgent challenges such as A&E waiting times and planned-care backlogs become the priority for politicians who are tempted by quick fixes instead of fundamental improvement.
There is no simple answer to this, and a piecemeal approach of cherry-picking policies will not miraculously unlock change. What’s needed is a wholesale refocusing of the health and care system towards primary and community care. This includes a clear vision from any current or future government for strengthening these services, with all policies aligned to achieving that vision, and crucially the political will to stick to the vision over the long-term.
There needs to be a commitment to divert a higher proportion of any funding growth towards primary and community care. Achieving this shift will also mean incentivising people to work in community care through pay, status and career progression, improving buildings and equipment, and giving local areas more flexibility to meet their patients’ needs. It’s also clear that without reform of the ailing social care system, the ambition of “care closer to home” cannot be fully realised.
In an election year, it’s worth remembering that, ultimately, the health system looks upwards and will prioritise what politicians ask of it. It can’t do everything. So the way in which national political leaders talk about health and care and place their commitments will be the strongest sign for where the system should focus its energy.
Many politicians wrongly believe that voters just want more hospitals, but the evidence suggests otherwise. How many people do you know who want to go into hospital? Who would rather be there than cared for and supported at home? This anecdotal evidence is backed up by hard evidence, including from Healthwatch England, which reported that primary care is far and away the biggest issue that the public contact them about. To paraphrase one attendee at a recent event hosted by The King’s Fund, we will know this agenda has true political backing if we stop seeing politicians being photographed outside hospitals and start seeing them photographed outside GP practices and community health centres.
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