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Executive Summary

Healthcare in the United Kingdom (UK) is delivered mostly by the National Health Service (NHS).  The NHS is a model of healthcare owned by the state with the aim of delivering universal health coverage (UHC).  UHC is the concept of providing health services to all without suffering financial hardship as a result.

The UK is wealthy with the 5th largest gross domestic product in the world.  In 2017, it spent $2989 per capita on healthcare with a budget of £114b.  The private healthcare market in the UK is small and covers 10.5% of the population.

At the inception of the NHS, it was suggested that UHC would be affordable into the future due to improvements seen in the health of the nation, and consequent reduction in usage of state-funded health services.  In fact, the opposite has been true.    

Between 1990 and 2010, life expectancy in England increased by 4.2 years with improvements in reducing premature deaths from heart and circulatory diseases.  As such, people in the UK are living longer with more long-term conditions.  Over 15 million people in England now live with a long-term condition.  Most of this care is provided in the community by general practice.

For the UK to continue to provide UHC there are a number of challenges that need to be considered.

We need to move away from a national health service that treats illness toward a universal wellbeing service that favours the propagation of health.

Rumit

Dr R Shah

Chair

Dean_Eggitt_JHLancy-20170213112129158

Dr D Eggitt

CEO

A Universal Offer

1.1 The recognition of the importance of primary care is not new.  It is cited across the world as the foundation of a universal healthcare system, upon which, all else is supported.

1.2 Primary care is expected to be the first and main point of contact for most people within a healthcare system.

1.3 Primary care takes into account the whole person, is patient-focused, and recognises the physical, psychological, and social aspects of health and wellbeing.

1.4 As the first point of contact within a healthcare system, primary care teams advise patients on healthy lifestyles and behaviour, screen for illness, and manage chronic illness.  They are also uniquely positioned to promote wellness, provide education, and coordinate complex systems.

1.5 Strong primary care systems can improve health outcomes across socioeconomic levels, make health systems more people-centered, and improve health system efficiency (42).

1.6 Primary care encompasses the following characteristics:

1.6.1 Community orientated – it operates close to where people live and work and provides care that is focused on the needs of a geographical catchment.

1.6.2 Continuous – is the first, and often last, point of contact.  The people who use it identify it as their main source of care.

1.6.3 Comprehensive – it addresses a broad range of health problems, including prevention, cure, and rehabilitation.

1.6.4 Co-ordinated – it helps patients to navigate and communicate complex systems.

1.7 Access to good quality health services is vital for the improvement of health outcomes and may contribute several years to life expectancy (77).  Good access can be summarised as approachable, acceptable, available, affordable, and appropriate (76).

SR1 - Summary Recommendations

  • A UWS should offer
    • Equitable access
    • Wellbeing education
    • Assessment, diagnosis, and treatment of self-limiting illness
    • Assessment, diagnosis, and treatment of chronic illness
    • Coordination of health service navigation and communication
    • Evidence-based health screening
    • Contraceptive services
    • Palliative care
    • Rehabilitation
    • Occupational health

Workforce Supply and Demand

2.1 Demand for general practice services has risen as the population has increased, and aged.  Demand for GP consultations and prescriptions rose by 9% and 11.5% respectively between 2010 and 2018 (5).

2.2 There was a 38% growth in the number of General Practice consultations between 1995 and 2008 (43) and NHS Digital estimated a further 10% increase in consultations in the year ending in April 2019 (7).

2.3 General practice appointment bookings reached record highs over the winter of 2021. 

2.4 In March 2022, 30.1 million appointments were undertaken in general practice – 22% higher than two years prior (41).

2.5 There are now more patients who suffer from multiple chronic conditions.  In 2012, the Department of Health and Social Care estimated that people with long-term conditions accounted for 50% of general practice appointments (3).

2.6 At the same time, patients’ expectations of general practice have increased. 

2.7 Whilst the demand for GP services has increased over the years, the supply of GPs working in the NHS has fallen.  This has coincided with an increase in the supply of allied healthcare professionals delivering services in primary care.  GP numbers fell after 2015 whilst the number of other staff working in general practice continued to increase (44).

2.8 Continuity of care can reduce avoidable hospitalisations. The higher the number of primary health care physicians per thousand people, the lower the risk of avoidable hospitalisations (45, 46).

2.9 However, allied healthcare professionals are quicker and cheaper to train than GPs and have lower wages.  Due to the less rigorous academic demands of these roles, it is likely that they are also easier to recruit to training schemes.  This model of creating clinicians to supply the demands of the NHS affords quicker access to a larger, more diverse workforce that is cheaper to sustain in terms of wages.

2.10 The move toward expanding allied healthcare professional competencies and responsibilities whilst minimising the expansion of GP places has previously made fiscal sense.

2.11 Evidence shows a mismatch of skills and tasks within primary health care teams to population and patient needs (48) with three-quarters of doctors and nurses reporting being over skilled for some of the tasks they have to do in their day-to-day work. The mismatch of skills and tasks represents a waste in human capital.

2.12 The support role of nurses, community pharmacists, physiotherapists, counsellors, and other allied healthcare professionals has the potential to reduce the requirement for GPs without undermining the quality of care and patient satisfaction (47).

2.13 With the increasing demand for primary care services and diminutive resource allocation of around 7.1% of the total NHS budget, there is a need to gain further efficiencies in the delivery of primary care services or to restrict what is being offered. 

2.14 The debate over the quality of care provided by allied healthcare professionals and their long-term cost-effectiveness compared to GP is ongoing.

2.15 The roles of care coordinators, patient navigators, and social prescribers are progressively being introduced to focus on providing service integration and reducing inter-provider boundaries. These coordination functions include relationships with social services and non-traditional health and social care providers.

2.16 Patients with long-term relationships with their primary health care teams are more likely to communicate about changes in their medical conditions, allowing an opportunity for medical intervention and the chance to reduce the risk of deterioration.

2.17 Workforce shortages are particularly noticeable in deprived areas, resulting in inequity of access to healthcare (75).

2.18 A significant factor contributing to this is the early retirement of senior doctors, with a 3 fold increase over the last 13 years (82).

2.19 Whilst the determining factors in the retention of physicians are complex, they are known and understood (83), paving the way for the introduction of effective policies and strategies.

SR2 - Summary recommendations

  • A UWS should
    • have as its core multidisciplinary team
      • GP
      • Pharmacist
      • Pharmacy technician
      • Physiotherapist
      • Nurse
      • Community nurse
      • Child health nurse
      • Medical visiting professional
      • HCA
      • Care coordinator
      • Reception
        • Manager
      • Members of the MDT should be skilled in education
    • Incentivise working in deprived areas.
    • Incentivise attraction and retention of experienced workers

Premises

3.1 The most common model of primary healthcare relies on face-to-face consultations with a clinician who works in a practice located in the community they serve.

3.2 Primary care premises are often provider-owned and bespoke, reflecting the services provided for the population they serve.  However, this creates inconsistency in the quality, availability, and occupancy of premises.

3.3 There is the expectation that over time more providers will want to separate the decision to enter premises ownership from the operation of primary medical services.

3.4 Ending the current cost-reimbursement scheme of provider-owned premises in England allows for the adoption of a central owned and administered primary care estates system.

3.5 A centralised system of primary care estates ownership and management provides the opportunity to better understand available infrastructure and helps to identify where investment is needed to ensure premises remain utilised and fit for purpose.

3.6 Moving away from provider-owned premises provides commissioners with the opportunity to co-locate providers of health and social care, enabling them to better integrate and meet joint aims.

3.7 Better inclusion of allied healthcare professionals could increase the pool of patients that healthcare physicians oversee, while maintaining the quality of services provided (47).  Better integration of health and social care services could offer opportunities to better address social determinants of health and reduce the need for health care services.

3.8 In England, NHSEI plan to increase the provision of multi-use new build premises promoting the integration of services with multiple providers.

SR3 - Summary recommendations

  • A UWS should
    • Be located within the community it serves
    • Provide a designated hub for a locally designated population
    • Have a local transport service to pick up and drop off patients
    • Provide remote consultations to minimise travel
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Information technology

4.1 An electronic healthcare record (EHR) is a digital version of the patient’s medical history.  EHRs are secure, contemporaneous, updateable, and sharable, with functions to allow patient-level data access and provider-level decision support.

4.2 EHR systems allow users to diarise tasks to help coordinate and monitor care for patients with chronic diseases. 

4.3 EHR has been associated with improved workflow, policy, communication, and adoption of cultural practices (49).

4.4 EHRs provide a positive impact on patient safety and the overall quality of care by increasing clinician compliance with guidelines, lowering the number of medication errors, and reducing the risk of adverse drug effects (50, 51).

4.4.1 Telemedicine

Telemedicine is used to improve access to care for people living in remote and underserved areas.  In urban areas, telemedicine reduces the burden of commuting.  Telemedicine may include the use of telephone, webcam, email, or apps.

4.4.2 ePrescriptions

Electronic prescriptions (ePrescriptions) allow prescribers to generate prescriptions from within the EHR.  ePrescriptions are retrieved electronically by connected pharmacies reducing the burden of travel on patients and the use of paper. 

ePrescriptions are not limited by the physical distance between a prescriber and their local pharmacy, allowing for the supply of remote treatment following remote assessment.

ePrescription programmes have been associated with a reduction in prescribing inappropriate medications (52) resulting in efficiency gains (53).

4.4.3 Algorithms and automations

Algorithms embedded within the EHR can collate patient data to predict disease risks guiding the creation of bespoke patient centered treatment plans (54, 55).

When used to review groups of patients, healthcare providers can identify cohorts of patients at risk of hospital admission allowing coordinated targeted preventive actions towards high-risk populations.

4.4.4 Remote monitoring

Remote monitoring includes the use of electronic patient portals and self-management applications. 

Through the utilisation of remote monitoring patients have a greater awareness of their condition and are better able to co-produce health-related decisions (56).

SR4 - Summary Recommendations

  • A UWS should
    • Utilise computerised EHRs
    • Maximise the use of remote consulting and monitoring
      • Telephone
      • Email
      • App
      • Digital photography
      • Webcams
    • Utilise electronic communications to engage with the community it serves
      • Websites
      • Social media
      • Texts
    • Prescribe electronically
    • Automate diary and recall functions
    • Utilise evidence-based clinical decision making tools

Integration

5.1 Many primary healthcare teams are not prepared to meet evolving complex health and social care needs without support.

5.2 On average, primary care clinicians have more than one clinical query about patient care for every two patients they encounter.  Nearly half of these questions are left unresolved (57).

5.3 There is currently an inconsistent offer for training and development, support, and integration of primary health care teams with specialist health and social care services.

5.4 Integration and coordination are important dimensions of patient-centered care that require the flow of information and consistency of decisions across health and social care settings (58)

5.5 When care is not coordinated, patients have to repeat processes, encounter conflicting information, and are subject to errors when transitioning between providers (59).

5.6 Co-location of providers and virtual team meetings are possible solutions.

5.7 Where virtual team working is optomised, outcomes can include reduced hospital outpatient attendances, reduced hospitalisation, and cost savings (68).

5.8 To ensure that providers work toward the same goal, it is important to ensure that barriers to integration are addressed, including payment mechanisms and alignment of expected outcomes (66, (67).

5.9 Integration is more likely when organisations view integration as part of their core business and there are high levels of trust (69).

5.10 Achieving a genuine partnership is challenging due to a range of structural, cultural and organisational differences. The persistence of organisational and professional protectionism has previously hindered attempts to achieve integrated working (70).

5.11 For a UWS to succeed in delivering meaningful change, integration and partnership working must extend beyond the traditional boundaries of health care.  Such new partners should include schools and employers.

5.12 For example, we know that adults with higher educational attainment have better health and lifespans compared to their less-educated peers, (78) and that socioeconomic status correlates significantly with morbidity and mortality outcomes (80).

5.13 The beneficial effects of childhood advantages translate into future outcomes (79).

5.14 We also know that whilst occupational engagement is on the whole beneficial, some occupations can have disproportionately negative effects on the health and wellbeing of workers (84).

5.15 The integration of occupational health into primary care is possible (85) and evidence of the effectiveness of programs such as Total Worker Health is building (86).

5.16 Recognising and responding to the influence of social factors on learning and health can catalyse individual and community-based solutions (72).

5.17 Previous attempts to integrate health and social care in England were in the form of Primary Care Trusts (PCTs). 

 

5.18 However, over their 13-year existence, PCTs largely failed to reduce variability in clinical outcomes, reduce growth in secondary care use, and build meaningful relationships with patients and clinicians (74).

 

5.19 For an integrated UWS to succeed there needs to be an alignment of sector and organisational goals with meaningful incentives to influence desire to attain these goals.

The Centers for Disease Control and Prevention (CDC) uses a four-level social-ecological model to describe “the complex interplay” of factors that influence the likelihood of negative health outcomes (73)

(1) individuals (biological and personal history factors),

(2) relationships (close peers, family members),

(3) community (settings such as neighbourhoods, schools, after-school locations), and

(4) societal factors (cultural norms, policies related to health and education, or inequalities between groups in societies)

SR5 - Summary Recommendations

  • A UWS should
    • Align primary and secondary care aspirations and incentives
    • Co-locate providers
      • Primary care
      • Community nursing
      • Child health
      • Local authority
      • Medical visiting service
    • Assign primary care hubs to named specialist support units
    • Assign primary care hubs to named schools
    • Assign primary care hubs to social support units
    • Assign primary care hubs to large local employers
    • Ensure access to secondary care is via primary care
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Quality

6.1 Ambulatory care sensitive conditions (ACSCs) are conditions for which primary care can prevent the need for hospitalisation, or for which early intervention can reduce the risk of complications or prevent more severe diseases developing (60).

6.2 Diabetes, chronic obstructive pulmonary disease (COPD), asthma, hypertension, and congestive heart failure (CHF) are ACSCs with evidence to show that much of the treatment can be delivered in primary care.

6.3 Treated early and appropriately, deterioration in people with these conditions can result in avoidance of hospital admissions.   Consequently, hospitalisations due to ACSCs are defined as “avoidable hospitalisations” (61, 62).

6.4 As the costs for treating patients in primary health care are lower than those observed in urgent care settings and hospitals, health systems with strong primary health care can attain higher levels of cost-effectiveness.

6.5 Avoidable hospital visits and admissions should be considered indicators of misallocation of resources across health and social care (63).

6.6 Appropriate prescribing is also a good marker of primary health care quality and efficiency, because it indicates inappropriate use of resources.

6.7 Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilisation (71).

6.8 In 2001, the OECD initiated the Health Care Quality Indicators Project.  The aim was to develop and report indicators for international comparisons of health care quality.  Over the following 20 years, this evolved to become the Health Care Quality and Outcomes Programme which uses 64 indicators to allow for international comparison across 40 countries.

6.9 The OECD defines health care quality as a core dimension of health system performance.

Quality in health care means that the care provided is:

      • Effective: achieving desirable outcomes, given the correct provision of evidence-based healthcare services to all who could benefit, but not to those who would not benefit
      • Safe: reducing harm caused in the delivery of health care processes
      • Patient-centred: placing the patient/user at the centre of its delivery of healthcare

SR6 - Summary Recommendations

A UWS should be assessed upon collection of data on key topics

  • Smoking
  • Obesity
  • COPD
  • Asthma
  • Hypertension
  • Heart Failure
  • Diabetes
  • CKD
  • Access
  • Prescribing (antibiotics and opiate use)
  • Patient experience
  • Integration
  • Education
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Payment

7.1 The NHS is funded through three means: general taxation, national insurance contributions, and private fees for a small number of services.  Where income has dropped in the form of national insurance contributions and private fees, general taxation is used to ensure the NHS receives its budget.  In 2018/19 the budget for the NHS was £114b (64).  General taxation accounts for around 80% of the budget (1).

7.2 Utilising general taxation as the major source of funding is equitable due to the large-scale pooling of financial and health risks (1).  The use of this means is efficient with low administrative costs when compared to implementing dual or multiple systems and affords the state legitimate control over the healthcare agenda.

7.3 However, healthcare runs the risk of causing a financial burden to the government.  By definition, a tax-funded healthcare system depends upon a well-performing economy.  In such an instance where economic weakness could result in a reduced healthcare budget due to reduced tax revenue, a plurality of financial income streams may be advantageous.

7.4 Currently, private fees provide a small contribution to the UK healthcare budget.  The benefit of this is to limit the exposure of patients to a market where eligibility is based upon risk selection and ability to pay.  Minimisation of this market also limits resource wastage in the form of excess management and administrative costs. 

7.5 The minimisation of resource wastage reduces this barrier to the provision of universal healthcare.

7.6 Whilst there is no formula to address the funding needs of universal healthcare, a plurality of income streams with majority funding by social means appears preferable. 

7.7 With limited practical means to increase revenue with which to increase the NHS budget, effective resource allocation and usage is of paramount importance.  It seems sensible to ensure that the NHS continues to provide essential care with limited resources whilst the private healthcare market services those patients with the means to purchase non-essential care.

7.8 NICE has the mandate to assess the evidence base of the cost-effectiveness of an intervention, service or programme, with the aim of helping decision-makers to maximise gains from limited resources.  In doing so, NICE undertakes analyses of the existing evidence to estimate the impact of resource utilisation in relation to the benefits and harms of current alternative courses of action.  NICE uses a range of economic analysis methods to scrutinise resource impacts in terms of the additional cost or saving above that of current practice. 

7.9 In meeting the ideals of UHC, NICE factors into their considerations access to healthcare provision and the financial consequences of not providing an intervention, service, or programme.  However, financial protection is not considered at an individual level by NICE and so healthcare market failure could go unnoticed unless the problem is endemic.

7.10 Providers of primary medical services receive financial resources via a core budget paid prospectively based upon a weighted practice level capitation. This allows an element of predictability of income to ensure that services can operate without interruptions.

7.11 As the dominant purchaser of care in the UK, market failure is a risk to the state when taxation can no longer support stability in the healthcare market.  This has become increasingly evident in the last decade with reduced availability of some clinical procedures which some regard as a cost saving exercise.

7.12 Despite fairly low inequalities in access to a GP, people with a lower income consistently have lower utilisation rates of preventive services (65).

7.13 For cervical, breast and colorectal cancers, the probability that those in the target population and in the lowest-income quintile will have undergone screening in the recommended period are significantly lower than that of people in the highest-income quintile.

7.14 Therefore, primary health care may not be currently succeeding in delivering recommended preventive care across different socioeconomic levels.

7.15 Large employers who disproportionately contribute to worsening healthcare outcomes should contribute to the costs of the provision of a UWS

SR7 - Summary Recommendations

A UWS should

  • Receive a capitation-based maintenance payment
    • Socioeconomic weighting
    • Incentive-based payment based upon achievement
    • Pool budgets to align provider outcomes
  • Be part-funded by taxation of large employers

Incentives

8.1 Payment for performance (P4P) programmes and related to quality and performance targets should focus on outcomes that matter the most to patients, such as improving quality of life and daily life activities through better management of chronic conditions, and on patient-centred care processes, such as care coordination.

8.2 P4P programmes, and value-based payments, need to be designed and blended with other payment schemes to ensure consistent basic income to reduce the risk of market failure.

8.3 Whilst P4P programmes are widely and increasingly being used, there is inconsistency in their design, leading to significant challenges in defining what methodology is effective.

8.4 In England, the quality and outcomes framework (QoF) and network-based impact and investment fund are the quality incentive schemes in primary care that define expected outcomes and result in payments if thresholds are met. 

8.5 QoF is paid prospectively based upon predicted performance, and a reconciled figure at the year-end based upon actual performance.  If the provider is inefficient, there is a possibility that the organisation results in a year-end financial deficit.

8.6 Commissioning for Quality and Innovation (CQUIN) is the tool used to incentivise outcome and performance of secondary care providers in England.

8.7 The use of P4P programmes strikes a balance between provider stability and encouragement toward achieving designated outcomes and provides financial controls to help meet challenges in budget allocations.

8.8 Appropriate information systems are required to monitor and follow up on process and outcome indicators.

8.9 Complex P4P systems can encourage gaming.

8.10 P4P systems can disincentivise altruistic practice.

8.11 Negotiation of P4P programmes between commissioners and providers can dampen the effect of the scheme.

SR8 - Summary Recommendatons

A UWS should

  • Be incentivised to engage in
    • National P4P schemes
    • Local P4P schemes
  • Have incentive schemes that align primary, secondary care, and social goals
  • Collate accurate data relating to incentive schemes via the HER
  • Align incentive schemes to internationally recognised standards

Regulation

9.1 Primary medical services in England are mostly delivered by self-employed contractors to the NHS.

9.2 Contractors provide services under three different types of contracts: the General Medical Services Contract (GMS), the Personal Medical Services Contract (PMS), or the Alternative Provider of Medical Services (APMS) Contract. 

9.3 GMS and PMS contracts are granted in perpetuity to contractors who must be general practitioners or in the case of the latter, employees within the NHS. 

9.4 APMS contracts are time-limited and can be granted to anyone with the means of fulfilling the requirements of the contract.

9.5 In 2018/19, 2% of practices held an APMS contract. 

9.6 The terms of the GMS contract are defined nationally by NHSEI following annual negotiation with the General Practitioners Committee (GPC) of the British Medical Association (BMA). 

9.7 The agenda for contractual negotiations is set by the Department of Health and Social Care (DoHSC) and the BMA GPC after consultation with relevant stakeholders. 

9.8 PMS contracts are varied annually, mirroring the terms of the GMS contract as a minimum, although additional features can be locally agreed upon. 

9.9 APMS contracts are designed based on local needs and are usually varied 5 yearly.

9.10 The quality of care provided by contractors to the NHS is closely monitored.  Individual clinicians working within the NHS must undergo annual appraisal and doctors must undertake revalidation every 5 years. 

9.11 Clinicians must be registered with their appropriate professional regulatory body and contractors must register their services with the Care Quality Commission (CQC), who undertake regular assessments of those services. 

9.12 The use of medicines and medical devices in the NHS is governed by the Medicines Healthcare Products Regulation Agency (MHRA), which is a UK Government agency.

9.13 Guidance of the use of medicines and technology in the NHS is created by the National Institute for Health and Care Excellence (NICE).  NICE is sponsored by the UK DoHSC.

9.14 This regulatory framework allows for the state to maintain significant control of the healthcare agenda and of the quality of care provided whilst providing a mechanism of contractual flexibility to address local geographical needs. 

9.15 In this way, it provides the basis of a core national healthcare offer with local variations.  It also allows for organic variance of the private healthcare sector to address otherwise unmet needs.

9.16 The rationale for adopting a range of contracting mechanisms and broad qualifying characteristics for potential contract holders is to reduce barriers to access to the primary medical services market.

9.17 This should result in the increased availability of providers from which commissioners can exercise choice in the purchase of care. 

9.18 Whilst the increase in contestability to the healthcare provider market confers an element of market self-regulation, this particular market remains challenging to enter with a high degree of education and experience of industry being barriers to access. 

9.19 Where the market voice does not result in a system that reflects the principle of UHC, state sponsored systems can steer the healthcare provider market back to these ideals.

9.20 These governance arrangements ensure control over dominant providers where low measurability of their outcomes exists.

SR9 - Summary Recommendations

A UWS should

  • Meet national minimum standards
  • Be commissioned locally
  • Minimise the burden of regulation
  • Consider annual declarations of standard compliance
  • Require national registration and quality assurance of
    • Providers
    • Managers
    • Commissioners

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