Lord Darzi has carried out his “investigation” into the NHS, and recently published his findings.  It is a meaty tome at a 163 pages, but what does it mean for general practice?

Unlike some other NHS reports, general practice features heavily throughout, and is not added on as an afterthought.  In the summary letter the second issue highlighted (after the NHS not being able to keep its promises) is that people are struggling to see their GP:

“GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level. There are huge and unwarranted variations in the number of patients per GP, and shortages are particularly acute in deprived communities.”(Summary, 6)

This kind of positioning is not going to be followed by a lack of action.

Does this mean more money?  Well, there is a clear recognition that there has been a failure to invest in general practice, “We have underinvested in the community. We have almost 16 per cent fewer fully qualified GPs than other high income countries (OECD 19) relative to our population” (Summary, 13).

However, there are also criticisms of the GP contract, “the current GP standard contracts are complex and can mean that doing the right thing for patients can require doing the wrong thing for GP income. That cannot be right.” (5, 36).  And when it comes to primary care estate, “It is just as urgent to reform the capital framework for primary care as for the rest of the NHS.” (5, 37)

The idea that pervades the report when it comes to general practice is that it needs to be invested in but it also needs to change.  The basis for this change centres around the need for community based multidisciplinary team working.

In chapter 3, on quality of care in the NHS, when discussing long terms conditions it states, “As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace. GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure and authority that this requires.” (3, 32)

Again in Chapter 5, “People with two or more conditions (whose prevalence is growing over 6 per cent) may require care from different specialists and the expertise of GPs and others to understand the interactions between their conditions, treatments, and medicines. Since healthcare is organised around groups of professionals with similar skills (such as GP practices, mental health or community trusts, and hospitals), it requires organisations to work well together.” (5, 8)

The report calls this shift of resources out of hospitals and into the community a “left shift”.  However, the report is clear that such a shift must come alongside a change to the operating model, “Changing both the distribution of resources and the operating model to deliver integrated, preventative care closer to home will be strategic priorities of the NHS in the future because they are derived from the changing needs of the population.” (5, 21)

The report calls much of what has happened so far within integrated care systems as “collaboration”, but not “integration”.  It clarifies the difference between the two, “Collaboration and integration are often conflated, but they are not the same. Service or clinical integration is about a fundamental change in the way health services are organised for patients rather than the degree to which NHS organisations cooperate with one another as institutions.” (5, 23).  The report raises a concern that current collaborations are not effective and states that, “there is a real risk that they amount to displacement activity from the strategic priorities of delivering integrated, preventative care closer to home” (5, 25).

Primary Care Networks, interestingly, receive only one mention in passing in the entire report.  They are certainly not presented as the solution to the need for effective multidisciplinary team working.  So even though PCNs would seem to tailor perfectly with the Labour idea of a neighbourhood NHS, it may be that they are viewed more as “collaboration” than “integration”.

In his conclusions, the themes Darzi pulls out include these:

“Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen.

Simplify and innovate care delivery for a neighbourhood NHS. The best way to work as a team is to work in a team: we need to embrace new multidisciplinary models of care that bring together primary, community and mental health services.” (Conclusion, 6)

These two recommendations sit alongside each other.  So the good news is there will be new investment, but the bad news is that it will almost certainly come with a requirement for a whole new way of working.  What this will look like remains to be seen, but the government has been very keen indeed since the launch of this report to stress that any new investment will be accompanied by a requirement for reform.