Summing up three years of consultation and inquiry into the interaction between health and the economy, the launch of the IPPR hosted Commission on Health and Prosperity brought together senior figures from the third sector, business, the NHS, academia, trade unions and politics to set out what they call “the most ambitious blueprint for the nation’s health since the Beveridge report”.
The report – Our Greatest Asset – makes a number of recommendations based on five “foundational pillars” which set out aspirational shifts from:
- work that harms health to work that creates it;
- tolerating health harms to an active industrial strategy for health;
- waiting for sickness to health creation at the start of life;
- places that make us sick to empowered, healthy communities, and;
- reactive services to preventative, primary care-led healthcare.
Co-Chaired by Lord Ara Darzi and Professor Dame Sally Davies, former chief medical officer for England – the report labels the UK as “the literal sick man of Europe – with long-term health conditions rising, healthy life expectancy stagnating, economic inactivity increasing, a growing mental health crisis, and regional health inequalities intensifying.” And posits that the UK’s worsening public health crisis is linked to faltering economic performance.
The second significant health policy document to be published under Lord Ara Darzi’s Chairmanship in less than a week, key to both reports are the assumption that reformed health services could solve many of Britain’s most pressing economic challenges, including low growth and productivity; and that general practice is struggling in the current climate.
Whilst last week’s Darzi Review stopped short of recommending specific changes to the current GP Partnership model, the IPPR report calls for a move from what they term “a reactive, sickness orientated 20th century healthcare system” into “a proactive 21st century health creation system, working in parallel to the NHS’ ‘sickness service’.” They set out a series of proposals for the new Government’s health mission towards achieving their proposed shift – covering:
- a bold new childhood health programme, a comprehensive health industrial strategy to penalise polluters and support innovators,
- nationwide restoration of critical community infrastructure,
- higher standards for health at work and
- new integrated health and employment support services (note: these could be similar to the Darzi walk-in-centres and interfacing, area-based initiatives of former Labour administrations).
Specific proposals
The recommendations include:
- “Tax health polluters: including tobacco, alcohol and unhealthy food companies to raise over £10billion per year by the end of the parliament, which could fund new good health schemes such as a fresh fruit and vegetable subsidy.
- Establish ‘Health and Prosperity Improvement (HAPI) zones’: modelled on Clean Air Zones, with new powers and national investment to rebuild local health infrastructure – such as swimming pools and green spaces – in the most health-deprived areas.
- A ‘right to try’ for people on health or disability benefits: an ironclad government commitment of a guaranteed period where people in receipt of benefits can ‘try’ work with no risk to welfare status or award level, lasting months, for everyone with a long-term condition or disability, regardless of what other reforms to health benefits look like.
- A new ‘neighbourhood health centre’ in every part of the country: a one-stop shop for diagnostics, primary care, mental health and public health with a focus on prevention.
- Create a new health index: Like GDP, the health index will provide a snapshot of how the nation’s health is changing – in a single number – to help monitor progress.”
Government response
Speaking at the launch event on Wednesday 18 September, Secretary of State for Health and Social Care, Rt Hon Wes Streeting, talked about the slow pace of change in Whitehall and his desire to reform faster, his desire to see more staff in community settings where clinical numbers are in decline as opposed to figures showing increasing numbers of clinicians being employed in secondary care. He also spoke about his commitment to AI, the financial and clinical value of increasing the deployment of virtual wards, and reiterated points made elsewhere about growing numbers of sessional GPs and the need to reconsider the mechanism of general practice and primary care. Though in response to a direct question from a health journalist at the launch event he stressed that he wants to work with GPs to deliver reform, supports rebuilding general practice and continuity of care, and added that “… the partnership model itself is not my first consideration”.
The presence of the most senior health minister and his words about the report shows that the Government is aligned with the report, including a clear desire to move to a scaled-up, employed hub and spoke model of general practice primary care.
Hub and spoke model
Pages 99-104 of the report, titled ‘Where healthcare is done: creating the neighbourhood NHS’ explains the authors’ perceived failings of the current general practice model and what changes they believe are necessary.
They identify these problems with the existing model:
- “It leaves GPs on the outside of the service, often meaning that acute providers are prioritised for new capacity, resource or power. The system often gives these things to the parts of the health system it has more levers to direct.
- It encourages small scale providers who, without means to deliver at scale, struggle to provide the broad range of services the population increasingly needs.
- As a unique operating model in the NHS, it allows siloes between providers – notably, but not exclusively, between primary and secondary care.
- It is increasingly shifting risk onto general practice partners – including the risk of not being able to find new partners to take their share in a small business when they want to retire.
- As the business and bureaucratic demands of primary care and general practice have increased, it is a growingly unpopular career choice for junior doctors – many of whom want opportunities for research, clinical work and leadership, rather than to run their own small business.”
The report goes on to recommend:
“At a minimum, we suggest new primary care hubs – one for each neighbourhood, possibly piloted in the first instance within Health and Prosperity Improvement Zones [see page 90 of report] – which join up primary care, community care, mental healthcare, diagnostics, social care access and some public health services (eg services provided through the ringfenced public health grant). These would come within a single site, where patients can access ‘teams without walls’ under one roof.
“Hubs would not have directly registered patients but would instead act as a second order mega list of all patients covered within a PCN. This will ensure that local relationships between GP practices and communities are not eliminated, but the benefits of scale can be realised. In turn, we suggest all population health management and enhanced service provision responsibilities are shifted to hubs and away from individual GP practices, allowing them to focus on patient-facing care and continuity of care.
“At their best, these hubs would be opportunities to genuinely engage communities and strengthen their ownership of their local NHS services. Tangibly, this would mean starting the design of new hubs, not with ICSs but with communities themselves. Hilary Cottam, among others, has argued that primary care services should begin by deliberating with people who have a range of needs, including complex needs, about what they would like to change in their life. This can identify both where there are untapped assets in communities that can be brought into a mission, and where resource needs to be shifted, to create new capacity or services. What emerges often blurs the line between healthcare and wider social policy – and between state delivered healthcare and civil society (see Cottam 2022).
“This might best be facilitated by a shift from loosely federated partnerships (PCNs) and towards a model of Neighbourhood Care Providers (NCPs), as previously recommended by IPPR (Thomas & Quilter-Pinner 2020). If ICSs provide a vehicle to formalise system work, to begin working together as a single team, to facilitate partnership and to deliver real population health management for large populations, then it is striking that there is little equivalent at the neighbourhood level. Creating one could help align culture, strategy and incentives – but more importantly, it could also provide a vehicle for population health planning. NCPs could either be newly created or formed by existing community trusts, more advanced PCNs or multi-speciality community providers (MCPs). Over time these NCPs should take on the contracts for primary, mental health and community care. They could also deliver social care and public health in order to really fulfil the possibility of population health.”
The authors suggest that the cost of new premises and equipment would be the main financial impact of switching to this model. The cost of building one Neighbourhood Health Centre (hub) per PCN population of 30,000-50,000 patients over 10 years is estimated at £12.5bn, with a maximum cost of £20bn. Funding for this would need to take up £1.25bn per year, which is suggested should be provided by additional funding.
Londonwide LMCs note: In 2022-23 the NHS spent £17.2bn on primary care, of which £11.5bn was spent in general practice. If £1.25bn annually was spent on existing general practice services rather than constructing and equipping hubs it would represent an uplift of around 10%, close to the 11% that the BMA say would be required to restore practices to the same financial position as 2018/19. Practices could choose to use this additional funding to modernise premises, upgrade equipment and release some staff time improve coordination with other local services.