Set up to close the primary care service gap between London and the rest of the country, the LIZ programme has achieved little beyond improved premises. And, say Richard Lewis and Susan Williams, the capital's underperformance still needs urgent attention

The Tomlinson report in 1992 was one of a long line of reports into London's primary care.1 Like many before, it came to the conclusion that primary care in the capital lagged far behind that in the rest of the country. GPs with large patient lists were common, as were single- handed practitioners, and GPs were significantly older than the national average.

Primary care was often carried out in sub-standard premises, and services were more limited than those offered in other parts of the country. This, it was suggested, had an impact on the use of secondary care, with London's hospitals managing a workload, much of which, outside London, would be managed in the community. One study, published in 1995, estimated that 41 per cent of patients attending accident and emergency at major London teaching hospitals could be classified as 'primary care attenders'.2

The Tomlinson report, like previous inquiries, brought a government response - Making London Better.3 This time, however, the response was accompanied by a large allocation of money, the promise of regulatory freedoms and considerable political and managerial will to make things happen.

A London Initiative Zone was set up in 1993, made up of all or part of 12 FHSA areas, to form an arena for concentrated action. The programme was to run until April 1999. FHSAs received a total of 400m for the six- year LIZ programme.

Several bodies were established to help in the task. These included the London Implementation Group, the Primary Health Care Forum and the Primary Care Support Force. Since LIZ was set up, the structure of the NHS in London has changed almost beyond recognition. FHSAs have evolved into integrated health authorities; four regional HAs became two and will soon be condensed into a single regional office for London. And the New NHS white paper promises important changes for London in the shape of primary care groups.

But although the environment has altered significantly, LIZ HA chief executives felt it was important not to lose sight of the primary care programme that had been working steadily through all the turbulence. They commissioned a review to see what difference LIZ had made and whether it had met its original objectives.4

This consisted of face-to-face, semi-structured interviews with the lead in each HA. These were followed up by telephone conversations, where necessary.

The LIZ programme had three key aims:

to improve premises and recruit a new cadre of GPs to the capital;

to introduce innovative approaches to intractable problems;

to develop cost-effective care outside hospital.

It is perhaps no surprise that 65 per cent of the 400m LIZ funding has been on improving premises and other basic support. HAs took the view that a firm primary care base was needed before extended models of care, or substitution, could be considered.

In 1992, before the programme began, more than 750 GP premises, or 62 per cent of the total stock, were below an acceptable standard. By December 1997, this had fallen to 42 per cent and is due to fall further, to 32 per cent, by the time the programme ends in April 1999. But standards vary between areas. By the end of LIZ, some of its constituencies will have all or virtually all of their premises at an acceptable level. Other parts of London will still have up to 60 per cent of their GP capital stock in an unacceptable state.

It is harder to provide a clear view of the impact of LIZ on the level and range of primary care services available. But using General Medical Services statistics, it is possible to provide at least a partial view of changes over the lifetime of LIZ.

Unfortunately, the results do not show a dramatic and consistent improvement in either the structure of the workforce or the services provided .

LIZ authorities still have on average more GPs aged 65 or over and this has remained stable, even though the proportion has decreased nationally. Meanwhile, the proportion of principals under 35 is falling significantly, as it is elsewhere. But in LIZ, new types of GP-assistant posts have introduced a fresh group of younger GPs to add to the workforce.

While nationally the proportion of GPs aged 65 or over is decreasing - to only 1. 4 per cent in 1997 - in the LIZ area it has remained stable at about 4 per cent of the workforce. But the proportions vary. In Brent and Harrow the level of older GPs has risen from 2.7 per cent to 6.3 per cent of the workforce over the LIZ period. But in Kensington, Chelsea and Westminster and Lambeth South and Lewisham HAs the proportions have fallen significantly from 8.8 per cent to 2.7 per cent and 6.8 per cent to 1.7 per cent respectively.

There has been a marked reduction in the proportion of younger GPs both nationally and within LIZ. But London has consistently fewer young GPs than the rest of the country. This position has worsened over the lifetime of LIZ with the percentage falling from 15.5 per cent in 1992 to only 10.5 per cent in 1997.

The proportion of female GPs has shown a steady increase both nationally and within LIZ. And London has a higher proportion (38 per cent) than the rest of the country (32 per cent)

To recap, a greater proportion of LIZ GPs are near to retirement, fewer are in the early stages of their career but more tend to be female than in the rest of the country.

The issue of single-handed practice is often raised as a key indicator of primary care.

Nationally, the proportion of single-handed practices is stable at 30 per cent. But in the LIZ area it is in the region of 46 per cent.

LIZ HAs recognise that single-handed practice is valued by many patients are prepared to support this model of service delivery. But they also recognise that it is more difficult and more costly to ensure that a full range of services is delivered through a single-handed model of care. The level of single-handed practice can therefore be seen as a measure of the developmental and financial burden on HAs.

Average list sizes are higher in the LIZ area than in England as a whole, although a high level of 'list inflation' may contribute to this difference.

In 1997, the average list size per GP principal in the LIZ area was 2087, compared with 1881 in England.

But in terms of practice nurses, the gap between the LIZ area and the rest of England has closed. Indeed in 1996, the level in LIZ was actually higher.

In terms of services provided by GPs, London is still lagging behind England as a whole. For example, in 1997, 94 per cent of GPs in England provided disease management for asthma and diabetes, whereas in the LIZ area the number was only 85 per cent. The proportion of LIZ GPs providing minor surgery is also below the average for England.

It is clear that while primary care in London may be improving it is not doing so any quicker than the national average, with the possible exception of practice nurse levels. This situation is disappointing given that LIZ HAs had hoped to accelerate the developmental process and 'close the gap'.

But it may be that there is a time lag between developing good premises and the delivery of improved services.

There has been a significant reduction in the number of inadequate premises over the lifetime of the LIZ programme. The number of premises classed as inadequate by HAs has fallen from 759 to 531 and it is expected to fall to under 389 by the end of the programme. This represents a reduction of almost a half and constitutes an important change.

A vital characteristic of LIZ was the ability to agree flexibilities in the national GP contract. Four types were negotiated:

Enhanced improvement grants - allowing reimbursement of up to 90 per cent of capital expenditure;

HA 'ownership' powers - allowing a temporary interest in property to help facilitate capital developments;

Workforce flexibilities - incentives to encourage recruitment of GPs and inter-practice collaboration;

Educational flexibilities - resources and educational opportunities to assist in professional development and improve morale among GPs.

The new opportunities in capital development were essential in breaking down the log-jam that had built up in premises development in many parts of London.

What was learned from these flexibilities can be useful for the NHS more widely. Many experiments that took place in LIZ could now form the basis of a local GMS development scheme. or a PMS pilot. Similarly, professional development opportunities initiated under LIZ could sit well in primary care group organisational and personal development programmes. But one flexibility that will end with the demise of the LIZ programme is that of HA property ownership powers. While capital development in primary care may well cease to be a HA responsibility, in the new world of primary care trusts this is still some way off.

LIZ HAs would argue that, in the interim, the power to temporarily own premises in order to kick-start developments is an essential tool in equipping primary care for its new role. If this applies to urban HA in general, it certainly applies to Health Action Zones

Although most of the LIZ resources went into improving premises, some went into schemes covering the primary/secondary care interface. So far in the LIZ programme, 20 schemes are in existence providing primary care services either in an acute hospital setting, or in a stand-alone minor injuries clinic.

One of the most interesting experiments of LIZ has been in developing intermediate forms of care in the shape of hospital-at-home schemes. The previous government placed great emphasis on this aspect of the programme. It was intended to improve the range and quality of primary care and was seen as a means of facilitating the proposed acute hospital reductions. More than 30 schemes were developed within the LIZ area, avoiding admissions or allowing early discharge from hospitals.

It has been striking how many schemes have ended following evaluation. These decisions have often been difficult for HAs because, in their own terms, the results have been impressive. Patients have expressed high levels of satisfaction with the service and there have been no differences found in the quality of care compared to a traditional hospital stay. The stumbling block for the schemes that foundered has been cost. Evaluations have found that hospital-at-home schemes do not necessarily substitute days of care on a one-to-one basis. The combined cost of the home and hospital stays within a hospital-at-home stay is higher than that of the inpatient-only episode.5 In some cases, the differences in cost have been substantial. Perhaps inevitably, it has also proved difficult to extract any savings from the hospital budget.

But some hospital-at-home schemes have proved financially sustainable. Wandsworth's intermediate care scheme, for example, demonstrated a significant saving per episode for admission avoidance. The community detoxification service in Haringey has delivered good clinical outcomes and large financial savings compared with inpatient detoxification services.

LIZ has had some outstanding successes of which the improvement of premises is the obvious example. It has also led to many innovations and even though many of these have withered, the process has helped providers and HAs understand more about meeting needs effectively.

While LIZ was a pan-London phenomenon, sharing good practice across the 12 HAs has not always been easy.

It is clear that London still lags behind England in important respects. LIZ has not 'solved' the London problem even if it has tackled some of its worst aspects. The job is far from finished. A crude estimate by LIZ HAs suggests that more than 140m will be needed for capital schemes alone. New resources for London's primary care have been signalled and a key task will be to devise a sensitive allocation process to ensure equity of service within London.

The role of HAs and primary care is set to change fundamentally. It may well be that in London, with more small practices and fewer natural communities, the development of strong primary care groups will take longer than elsewhere. In the meantime, it is crucial that London's HAs and primary care providers are encouraged and empowered to continue progress.