Table Of ContentMaking Sense of a Primary
Care-Led Health Service
Making Sense of a Primary
Care-Led Health Service
Edited by
PETER LITTLEJOHNS
Director of the Health Care Evaluation Unit
St George's Hospital Medical School
and
CHRISTINA VICTOR
Senior Lecturer in Health Services Research
St George's Hospital Medical School
Foreword by
ROGER JONES
Wolfson Professor of General Practice
UMDS (Guy's and St Thomas')
| 2\ CRC Press
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First published 1996 by RadclifFe Publishing
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© 1996 Peter Littlejohns and Christina Victor
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Contents
List of contributors vi
Foreword viii
1 Introduction I
Peter Littlejohns
2 What is a primary care-led health policy? 10
Andrew Harris
3 Information for a primary care-led health service - 30
health needs assessment
John Shanks and Tim Crayford
4 Information for a primary care-led health service - 44
monitoring performance and quality
Azeem Majeed
5 Stimulus for change - the evolution of fundholding 55
Howard Freeman
6 Commissioning - the best for all 67
Andrew Willis
7 Maintaining quality - the role of audit and education 76
Ralph Burton
8 Hospital - a primary secondary care interface 87
Christina Victor
9 Role of the new health authorities 97
Sian Griffiths and Jonathan McWilliam
Index 109
List of contributors
Dr Ralph Burton
Senior Lecturer in General Practice
St George's Hospital Medical School
Cranmer Terrace
Tooting
London SW17 ORE
Dr Tim Crayford
Lecturer in Public Health
King's College Hospital and Dental School
Bessemer Road
London SE5 9PJ
Dr Howard Freeman
General Practitioner
12 Durham Road
West Wimbledon
London SW20 OTW
Dr Sian Griffiths
Director of Public Health and Health Policy
Oxfordshire Health Authority
Old Road
Headington
Oxford OX3 7LG
Dr Andrew Harris
Honorary Lecturer in General Practice, King's College Hospital Medical School
Senior Registrar in Public Health
Bancroft Unit
Tower Hamlets Health Care Trust
London El 4DG
Contributors
Dr Peter Littlejohns
Director of the Health Care Evaluation Unit
St George's Hospital Medical School
Cranmer Terrace
Tooting
London SW17 ORE
Dr Azeem Majeed
Lecturer in Public Health Medicine
Department of Public Health Sciences
St George's Hospital Medical School
Cranmer Terrace
Tooting
London SW 17 ORE
Dr Jonathan McWilliam
Consultant in Public Health
Oxfordshire Health Authority
Old Road
Headington
Oxford OX3 7LG
Drjohn Shanks
Consultant in Public Health Medicine
Lambeth, Southwark and Lewisham Health Authority
I Lower Marsh
London SEI 7NT
Dr Christina Victor
Senior Lecturer in Health Services Research
Department of Public Health Sciences
St George's Hospital Medical School
Cranmer Terrace
Tooting
London SW 17 ORE
Dr Andrew Willis
Chairman
The National Association of Commissioning General Practitioners
19 Thorburn Road
Northampton
NN3 3DA
Foreword
The central research and development committee of the NHS R&D programme
recognized the importance of the interface between primary and secondary care
four years ago and commissioned an extensive programme of research on a
number of priority topics. Many of these topics are reflected in the subjects and
themes of this timely book, which deals with a number of important questions for
policy management and research in the health service. The editors and authors
have provided valuable landmarks in a key area of change that is still being mapped.
Re-appraisal and re-configuration of health services is taking place across the
world and shifts in the interface between primary and secondary care are par-
ticularly apparent in North America and North Eastern Europe. They are based at
least partly on the recognition of the value of a strong primary care service, a belief
reflected in the structures of emerging health care systems in many non-European
countries. Whilst the imperatives of national economies and health care policies are
powerful forces for change, it is also important to recognize the equally potent
effects on the interface of changes in medical practice, advances in information
technology, drug therapy, near-patient diagnostics and, not least, a growing sense of
confidence and maturity in general practice, which long predated the creation of
the internal market and EL(94)79.
We are now spectators of a fascinating range of natural experiments in health
policy taking place around the globe, in relation to registration and capitation
systems, health maintenance organizations, changes in traditional roles, the mix of
skills required for health care delivery and innovations in funding arrangements for
health care. One experiment being watched with a high degree of interest is, of
course, the purchaser-provider arrangements developed within the NHS, and the
increasing role played by primary care professionals in commissioning services.
As the interface shifts and becomes blurred, so the nature and shape of primary
care itself also alters and the roles and responsibilities of those working in it change.
Challenging and exciting times lie ahead, but we also face considerable problems
in primary care, not least those of low morale and difficulties in recruiting high-
quality graduates and registrars to general practice. Despite their best intentions,
many general practitioners can find no slack in the system and are concerned that
the demands being placed on primary care are not underpinned by a commen-
surate shift of resources. Indeed, moving the focus of care from the hospital to the
Foreword ix
community may not necessarily be cheaper and the systematic care of chronic
disease may turn out to be more expensive than unstructured, sporadic care.
These shifts in the focus of clinical care are mirrored by changing perceptions of
the community as an appropriate setting for teaching and research. The Winyard
Report emphasized the importance of creating a mechanism to provide adequate
funding for general practitioners involved in undergraduate education, while the
Culyer Report similarly emphasized the need to identify a funding stream to pro-
vide a research and development infrastructure for research in primary care and
community settings. This is also echoed in the work of the NHS R&D strategy and
strategic thinking in the Medical Research Council.
The creation of an evaluative culture in general practice, with a strengthened
research and development infrastructure linked to enhanced academic training
opportunities, the promotion of evidence-based practice and the creation of strong
new alliances between clinical and academic general practice should contribute to
the provision of the new skills, confidence and resources required to deliver a first
class primary care service in the UK. The editors and authors of this book have
done a superb job in charting the way ahead.
Roger Jones
Wolfson Professor of General Practice
UMDS (Guy's and St Thomas')
April 1996
