Cowper’s Cut: Primary colours

As I discussed last week, the summer has been a silly season in more ways than one. The latest figures from the NHS Commissioning Board outline how demand continues to rise. For July 2018, accident and emergency attendance was up 4.7 percent on July 2017 and four hour breaches up 16 per cent (and for the 12 months to July 2018, 2.9 per cent up on the preceding 12 month period to July 2017).

At a time when (as Sam Coates of The Times rightly noted), the cadre of politicians is seriously underwhelming, it’s difficult to feel that anyone’s really got this problem. The public have now for five years told NatCen pollsters that they are consistently willing to see their taxes rise to fund public spending (even though no politician is willing to say how much), as the Nuffield Trust’s iridescent chief economist John Appleby pointed out. 

It’s of course a vital starting point that at least we can see the data for acute and ambulance performance. I’d like to see it for mental health, community services and of course primary care.

But I can’t, because we somehow don’t collect it. NHS Providers’ CEO Chris Hopson noted that anecdotally, community and mental health are reporting huge pressure.

But we need to see the data to understand how healthcare demand is rising; whether it could be met early or forestalled upstream (and much probably can’t); and whether our pattern of spending is correct.

Primary colours

Primary care is the risk sink for the NHS. What primary care does (using a mix of medicine, social work, community activism and performance art) is to try to differentiate between the trivially and self limitingly ill and the seriously ill – and to manage people with long term conditions to have as good a quality of life for as long as possible.

At its best, primary care is population health and resource husbandry. It’s a big, demanding old job. And there must be levels at which a rising workload becomes unsafe.

Small is beautiful?

I started thinking about the issue of our data around primary care when Stephen Black (whose excellent recent HSJ comment piece on the real lessons from winning the Battle Of Britain bears frequent re-reading) posted this challenging thread about the current received wisdom (expressed by the newly departed NHS Commissioning Board primary care head honcho Dr Arvind Madan) that small GP practices are in some way bad.

As his source, Steve used “an old NHS Information Centre experimental dataset produced in 2012 or 2013 on NHS activity and related data attributable to GP practices (aside: I’ve no idea why the IC stopped producing it)”.

Steve points out that what data we have does not tend to support the hypothesis that bigger GP practices are better. He concludes “Maybe small practices are bad in some other way. But if that is so, there will be some solid, robust statistical analysis behind NHSE and Madan’s belief that bigger is better. But I’ve never seen that analysis. And I doubt it exists. Now would be a good time to prove me wrong if NHSE want to keep pushing for bigger practices”.

We’re back to H L Mencken again, from The Divine Afflatus: “There is always a well-known solution to every human problem: neat, plausible and wrong.”

I started a conversation on Twitter about this, and the replies and related “at” mentions are a fascinating read. Many individual primary care organisations are apparently doing some iteration of data collection.

Data will not solve the demand problems, of course, but in its absence, we are trying to navigate the dark by guessing. Most of the problems affecting the NHS are as much about the absence of well functioning relationships as they are about data. As I pointed out in last week’s problems, the NHS has parochial incentives but is now being asked to work ecumenically. (Next week’s column will be about the dismantling of fences.)

Seeing the Larwood for the trees

There is good news to be had in the world of primary care. Dr Steve Kell and colleagues at the Larwood Practice have made some simple changes to improve relationships within and beyond their practice.

These changes are not rocket science: they are about relationships, accountability and civility. They require consistency, willingness. And crucially, they demonstrably work both to improve the working lives of the staff team and outcomes for the patients.

Larwood’s team have seen a 5 per cent fall in prescribing costs and in medicines related A&E visits; a new way of working in care homes reduced the number of unscheduled GP visits to care homes by over 50 per cent while hospital admissions by care home residents fell by 67 per cent; in the first half of 2017-18, prescribing costs were £38,000 down on the same period last year and the cost of emergency admissions was £290,000 lower. (Outpatient appointments did rise – costing the system around £65,000, but it is thought this was due to earlier detection of disease and may have contributed to the fall in emergency admissions.)