‘Cycle of invisibility’ for primary care

4 minute read

England’s King’s Fund says the focus on tertiary care is a profound, decades-long failure in the NHS.

A healthy health care system needs an aligned focus on primary care, differential funding throughout the system, increased generalism and a focus on local needs, says The King’s Fund.

The King’s Fund is an independent charity set up in 1897 to improve health care in England.

This month, The King’s Fund published a report outlining the importance of refocusing health and care on primary and community services, moving away from tertiary care, in order to build an “effective” and “sustainable” health care system.

While the paper focused on England’s health care system, which differs in many ways from Australia’s, the sentiments are widely applicable.

Over many years, successive governments have said the right things about prioritising community-focused health care over hospitals, but “that vision is very far from being achieved”, the authors say.

“The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years.

“If this shift in focus does not happen, more expensive hospitals will need to be built to manage people with acute needs that could have been prevented or better managed.”

The group interviewed patients and health care professions from across the sector, reviewed international research from the past 30 years and analysed national data.

Despite the accepted importance of a focus on primary care, growth in the hospital sector continues to outweigh primary sector growth.

The reasons are extensive, said the authors.

There remains a lack of clear understanding around the need for a shift to primary-focused care and a “cycle of invisibility” for primary care services that are easy to overlook, the authors found.

“Hierarchies of care mean that urgent problems take priority over longer-term issues, for example treatments for urgent medical problems take priority over services that prevent the development of problems,” added the authors.

There was also found to be inadequacies in the organisation of the sector, meaning that short-term approaches were prioritised and the workforce was not set up to deal with the complexity of patient needs.

And the solutions are as complex as the problems, the authors note.

“We found that to achieve the vision [of primary-focused care], political and other national leaders will need to completely shift their focus away from hospitals towards primary and community health and care – and all policies and strategies must align to that focus,” they write.

Leaders will need to be clear about the reason for the changes: “to deliver improved care and improved outcomes, and to ensure the health and care system is sustainable for the future, rather than to deliver cost savings in the short term”.

Funding would need to be assigned differentially across the system: “In a cash-limited system, and to avoid destabilising services, the solution is likely to be differential growth for each part of the health and care system, and a longer-term strategy for investing growth monies into primary and community health and care services.”

Of course, a suitably trained workforce is a must-have.

“The system needs to increase generalism and multidisciplinary integrated teamworking, with practitioners able to hold risk and to enable people to live healthily in their communities,” the paper says.

“This will require pay and reward systems, workforce planning, education and training, and regulatory bodies to reflect the nature of this work.”

Flexibility is also needed to allow local communities to build health systems that reflect their local needs.

The group warns against partial implementation of a shift to primary care, unnecessarily restructuring the health system and expectations of short-term savings.

“This report is not about closing hospitals or moving existing services from one location to another, although the latter option may sometimes be appropriate,” noted the paper.

“Rather, it is about a wholesale shift in the focus towards primary and community health and care across the domains of leadership, culture and implementation.

“This will free up every sector to provide the care that it is best equipped to deliver.”

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