The worsening relationship between primary and secondary care

Edin Lakasing is a GP, trainer, and tutor in Hertfordshire, England

The worsening relationship between primary and secondary care requires acknowledgement and action by clinicians and NHS managers.

When the Covid-19 pandemic first struck and the UK went into lockdown in March 2020, few would argue that the NHS’s response was less than superb. The Dunkirk spirit kicked in: hospitals mobilised staff from all disciplines to attend an extraordinary spike in admissions of seriously ill patients, whilst primary care successfully transitioned to provide a predominantly telephone and video-based service,¹ and was largely responsible for implementing the highly successful immunisation programme, to much admiration both at home and abroad.²

Yet since the easing of restrictions, it is evident to both workers within, and users of, the NHS that the system is struggling. A massive elephant in the room is waiting times for elective secondary care, rising from 4.46 million in November 2020³ to currently 7.2 million.⁴ This has undermined public confidence and had had a deleterious impact on primary care, with GPs and their secretarial staff regularly facing requests from patients to chase or expediate appointments that are frequently cancelled, and coping with rejected referrals, which rose from 238,859 in February 2020 (the last full month pre-lockdown) to 401,115 by November 2021.⁵ Beyond mere statistics, the impact on individuals is dreadful. Someone waiting unduly long for joint replacement surgery is denied the chance to be economically productive or to enjoy an active retirement. Today’s delayed TURP is tomorrow’s emergency admission with acute retention. Today’s depressed adolescent on a lengthy waiting list for a service that is arguably the least fit for purpose is more likely to be tomorrow’s underachieving young adult. Collectively, this is contributing to a worsening of public health. The fact that some specialties such as emergency medicine, oncology and obstetrics have fared rather better is not mitigation, rather, it should stoke concern that the NHS is being pared down to an emergency-only service. This should galvanise professional and public discourse far more that it has done.

Why has this happened, and what can be done about it? Notwithstanding that the UK entered the pandemic with poorer staffing levels relative to comparable developed countries,⁶ the speed and extent of these negative trends is concerning. As it is over a quarter of a century since I last stepped into a hospital to work a shift, I have no first-hand experience of the current culture within secondary care. Nevertheless, conversations with consultant colleagues and postgraduate students reveal common themes: poor clinical-managerial engagement, and demotivation as likely to be caused by mental as by physical exhaustion. Beyond concerns for current service provision, this is surely impeding the training experience of junior doctors, particularly in practical procedures, as well as being corrosive to the relationship between primary and secondary care.

Primary care has not got its own house in order either. Many patients report difficulty accessing primary care, and irrespective of one’s personal beliefs, when wider society is genuinely back to business as usual, it is hard to justify why many practices still significantly restrict face-to-face access in favour of remote contact. Criticism has come from both the public⁷ and from within the profession, with Jim Boddington and colleagues mounting a robust case for the face-to-face consultation remaining the default method of communication.⁸

I believe that much can be done to improve the situation, but it requires leadership that is both robust and sympathetic. GPs and consultants must openly and honestly acknowledge their fractured relationship, and that retreating stubbornly into silos only serves to worsen patient care. ICBs must prioritise getting the two cadres around the table. Poorly performing hospital trusts may need external facilitators to assess what factors within their internal culture impede efficiency. Dangerously high waiting times cannot be benignly excused with platitudes about the ‘new normal’. Pointless bureaucracy, such as a gastroenterologist having to request that a GP makes a referral to a colorectal surgeon working in the same trust, must also be challenged. Primary care must also act, especially on access. There is also room for further innovation, for example, with poor morale in the ambulance service, many paramedics may find a happier home in primary care, providing a comprehensive domiciliary service and possibly reducing acute admissions to hospitals. But ultimately the biggest challenge is getting more doctors to commit to the frontline. The fact that millions of hours of potential doctor time is lost by graduates working part-time, emigrating, or even giving up medicine entirely is well known, and general practice must offer satisfactory remuneration and – arguably more importantly – manageable workload to entice graduates to make a substantial commitment. I fear the publicity around this is often badly handled, to our detriment. Pictures of expatriate doctors grinning on Australian beaches is perfect fodder for those seeking to portray our profession as indolent and pleasure-seeking. Our climate is no more the sole reason for doctors leaving than it is the sole attraction for the bankers and oligarchs who flock to London, and we must grasp the real issues.

The last decade-and-a-half have been the most politically and economically fractious for the UK in over two generations, beginning with the financial crisis of 2008, through to Brexit, the pandemic and latterly hyperinflation. During this period, which has spawned six prime ministers, austerity, sold in 2010 as a temporary measure to balance the books, has persisted more for ideological reasons than for any evidence of tangible benefit.⁹ From a healthcare perspective, it has increased inequalities ¹⁰ that have in turn increased demand on healthcare.¹¹ The predictable political response, to implement radical reform should be robustly resisted by health professionals, given that frequent reforms have never solved problems,¹² and that sensible, clinician-led fine-tuning is much more desirable. Similar critical analysis should apply to any opposition suggestions: Wes Streeting’s proposal to scrap the GP partnership model for a salaried service¹³ would almost certainly alienate a large cadre of partners who provide both clinical service and business leadership. If anything, it is the broken social care that should be a greater political focus.¹⁴  For all its imperfections, the NHS continues to provide excellent value for money.

References

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10. Institute of Health Equity. Health Equity in England: The Marmot Report 10 years on. Institute of Health Equity 2020. the-marmot-review-10-years-on-full-report.pdf (instituteofhealthequity.org) (accessed 27 Jan 2023).
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12. Alderwick H. Rhetoric about NHS reform is misplaced. BMJ 2023; 380:
13. Sylvester R. Wes Streeting: We must think radically—I want to phase out the existing GP system. Times2022 Jan 6. https://www.thetimes.co.uk/article/wes-streeting-we-must-think-radically-i-want-to-phase-out-the-existing-gp-system-tmpb0wqt6 (accessed 27 Jan 2023).
14. Alderwick H, Tallack C, Watt T. What should be done to fix the crisis in social care? Health Foundation, 2022. https://www.health.org.uk/publications/long-reads/what-should-be-done-to-fix-the-crisis-in-social-care(accessed 27 Jan 2023).

Featured photo by Nick Fewings on Unsplash