Access to primary and community health care

Plenary on 2014-06-18
Session date: 
June 18, 2014
Question By: 
Steve O'Connell
GLA Conservatives
Asked Of: 
Lord Darzi, Chair of the London Health Commission


How can access be improved to primary and community health care, and how will this benefit patients and health care in London?


Answer for Access to primary and community health care

Answer for Access to primary and community health care

Answered By: 
Lord Darzi, Chair of the London Health Commission

Professor the Lord Darzi (Chair, London Health Commission):  You have very kindly asked me what the issues are in access to primary and community services.  We have significant challenges facing us in London in primary and community services and that goes back, even to 2006 and 2007, when I had the privilege of being part of that review.  If you look at our access figures, we are worse than the rest of the country.  If we look at our utilisation of information technology, like email consultations or email access or web access bookings, we are doing worse than the rest of the country. 


If we look at the access in terms of the estate in primary and community services, these were the new figures.  You may or may not know that a third of our primary care estate does not meet the Disability Discrimination Act [1995].  Two‑thirds of our primary care estate and community estate is in urgent need of refurbishment or even a complete rebuild.  We have been talking for a long time about shifting care to the community, getting primary care more involved, having an impact on reducing the accident and emergency admissions, but we are spending in London - nationally, as well - less than 8% of our budget in primary care.  There are challenges in terms of the capital expenditure and in terms of the recurrent expenditure. 


We also have significant variations in the quality and article framework between different practices.  In London we have some of the best and some of the worst, and these variations actually could be in the same borough, so there is an issue of tackling quality.  Access is one of the attributes of quality, so we need to look at it as a whole package.


This Commission is very much focusing on what the enablers are and what we need to do to address these very serious challenges of quality, access and safety when it comes to the use of primary care.


Roger Evans AM (Chairman):  Thank you. 


Steve O’Connell AM:  Yes, thank you very much.  It is alarming to hear that our access is far worse than other parts of the country and, particularly around the estates, a third do not have disability access.


There is or has been a new structure of healthcare following the Health and Social Care Act [2012] and I would ask you what opportunities and benefits have been offered with the new structure and how can these opportunities be fully exploited to improve the healthcare of Londoners?


Professor the Lord Darzi (Chair, London Health Commission):  In terms of what the landscape looks like now, there is more emphasis on localism, which I have always supported, and I could see certainly early shoots of collaboration at a local level between the CCGs and the boroughs, for example.  In the patch I am in, in north west London, they are coming together, including in the creation of these academic health sciences networks in which the commissioners and the primary care providers are actually members, and they are taken on themselves in tackling these variations in the quality when it comes to primary care.  They also, in north west London, have looked at this population segmentation and more or less are asking themselves, “If this is what we are spending on this subgroup of patients and these are the patient experience data that we have, we probably should start thinking about our primary care provision in a completely different way”.


Most of the forces are really driving towards enablers in terms of core commissioning between the boroughs and the CCGs, or core commissioning between NHS England, which commissions primary care services, and CCGS.  All of these things take time to mature.  These changes, which were to happen about two years ago, are just about coming together and they are starting to think about how to really bring core commission services together, based on the patient pathway rather than the historical structures or buildings that we provide services from.


Steve O’Connell AM:  When you form your recommendations, you will be looking at these strategic questions about the success of the change in landscape?


Professor the Lord Darzi (Chair, London Health Commission):  I am not looking at the actual structures that we have, but I am more or less identifying what the gaps are, what needs to be done and what are the things that have worked that could be disseminated.  The NHS is a very unique organisation.  If you woke up this morning, despite all that we say about it, headlines from the Washington Post saying that the Commonwealth Fund - the only thing they got wrong that it is Washington-based; it is not, actually, it is a New York-based NGO - has rated the NHS as the number one health service in the world.  The NHS has this ability to morph itself whatever structure change we have seen over the last 20 years, and eventually focus on what matters most; that is patients.


Steve O’Connell AM:  Thank you.  I would like to move toward something slightly more specific, which is about what can be done to reduce the need for patients to attend A&E at their general hospitals.  We will all have experiences in our boroughs and our wards of the pressures on A&E.  At your halfway mark, where are your thoughts heading towards there?


Professor the Lord Darzi (Chair, London Health Commission):  It has been a challenge for a long time, even back to 2006.  We have one of the worst inflationary rates in A&E attendance than anywhere in the country.  Pointing the finger at one thing is the wrong thing to do.  There are a number of different issues here that could be at least addressed by firstly the commissioners in terms of access to primary care, access to urgent care provision out of hours.  You are fully aware of the expansion of the opening hours from 8.00am to 8.00pm that I had something to do with a long time ago in one primary care centre per borough - now it is expanding to a larger number of primary care centres - expansion of primary care access out of hours in certain geographical areas up to 10.00pm seven days a week.  All of these things will help from a primary care perspective.  There are also some misaligned incentives in terms of hospital setting, which actually brings the patients in, its activity. 


Thirdly and most importantly, how do we build the confidence of the public and the patients that in actual fact you do get as good care in your primary community setting that you may get going and sitting in an A&E department like St Mary’s where I work, to be seen with something that could probably be sorted out better by your GP?


I just add that there are a large number of other things: use of information technology, getting access, email consultations, making your bookings on the web.  There are all sorts of other things that every Londoner is able to do when they book their flights, they do their banking; we need it really to work in relation to healthcare so you do not have to go and wait at 10.00pm but you book your appointment for the next morning at 8.00am or whenever it happens to be.


Steve O’Connell AM:  Your comment earlier was that the access for Londoners to their health services is, comparatively, probably the worst in the country.  Your last point was around how Londoners interact and access health services.  Could you elaborate a little bit more about how health services can become more accessible and user-friendly, and what sort of recommendations may you be moving towards in that particular aspect?


Professor the Lord Darzi (Chair, London Health Commission):  The population segmentation is a great start.  Asking the patients what they need, what care they are looking for, what experience they are looking for.  Before, we did ask all patients to tell us, but I make the point that the needs of my son, who is in his second year in a university, are very different than the needs of his grandfather.  It is fascinating.  I am in the business myself; I had not really thought about it in that way.  London is a very unique city because it does have a young population.  It also has, in actual fact, a group that is aging and the demographics are very different from the rest of the country, so London has a bigger challenge than the rest of the country to meet the different age groups and the different categories of disease, or illness - ‘disease’ is the wrong word - in terms of their needs.


To do that, I am not coming up with new models that I will describe.  That is not the work of the Commission.  The Commission is saying, “This is the burden of illness.  This is what the patients want.  This is how much we are spending.  Providers need to be much more flexible, much more customer-focused, much more dynamic and creative in coming up with the delivery models”.  That is really the way forward.  The idea that the Commission will dictate what a provider will do would take us to the wrong place.


Steve O’Connell AM:  You commented on the fact that different Londoners with different levels of conditions expect different sorts of access, which is an interesting recommendation.


Professor the Lord Darzi (Chair, London Health Commission):  Absolutely.