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National Health Service

On April 21 the Government laid before Parliament and thenation a discussion document* which is part of its review ofprimary health care. The Ministers concerned began their

foreword to the document: "The primary health care services areof fundamental importance to the public. They are used far morethan any other part of the health service and they account fornearly a third of total health expenditure. And yet they havenever been the subject of a comprehensive review by Governmentin the 40 years since the National Health Service Act was passedin 1946". As an extension of the review, Ministers in the

Department of Health and Social Security will be holdingconsultation meetings, "some of which will take place in parts ofEngland with serious inner city problems". Consultation

meetings will also be arranged by the Scottish, Welsh, andNorthern Ireland Offices. Moreover, theforeword concludes, "wewill look forward to hearing from anyone-consumer, provider,or observer-who wishes to send us views".

The main conclusions in the discussion document are

reproduced below. An editorial appears on p 1011.

The Government’s Agenda on Primary Health Care

THE Government is firmly committed to building on thestrengths of the primary care services and to continuing todevelop comprehensive care of a high standard, available andaccessible to all. Its key objectives are: to make services moreresponsive to the consumer; to raise standards of care; topromote health and prevent illness; to give patients the widestrange of choice in obtaining high quality primary careservices; to improve value for money; to enable clearer

priorities to be set for family practitioner services in relationto the rest of the health service.

Family Doctors

Raising standards.-The present structure of the generalpractitioners’ contract has undoubtedly raised standards. But itneeds to develop to meet new needs. There is a growing feeling inthe profession that the highest standards of performance-whichmay cost the doctor more to provide-should be encouraged andrewarded in the remuneration system. The Government has set outproposals for a "good practice allowance". On average only 45% ofa adoctor’s pay is related directly to the number of patients on his list.This proportion could be increased in order to provide a greaterincentive to doctors to practise in ways that will encourage patientsto join their lists.Information about services.-The Government wants the public to

have more comprehensive and accessible information about thedifferent types of services available from doctors in their area to helpthem choose the sort of practices they want. It wishes to seeinformation on every practice made widely available throughsurgeries, family practitioner committees, health boards, localconsumer groups, and the media.

Choice of doctor.-The Government believes that the freedom ofpatients to choose their doctor can be an effective influence on thequality of services. The system for registering with another doctor isalready simple but could be made easier still.

Training.-In 1981 the Government introduced compulsorythree-year vocational training for general practitioners. In addition,the Government wants to see greater emphasis in medical schools onthe role of primary care and its interface with hospital and specialistservices, and to increase the proportion of general practitionersinvolved in post-graduate education.Retirement.-The present arrangements under which there is no

upper age limit for general practitioners were introduced in 1948*Pnmary health care: an agenda for discussion. HM Stationery Office, 1986.Cmnd 9771. Pp 61 6 6

when there was a shortage of young doctors. They are now out ofdate. The Government believes that there should be a flexible

system which ensures that doctors do not continue to work past the

age when this is sensible. It is proposed, therefore, that doctorsshould continue to be able to retire at 60 but that there should be

compulsory retirement at 70-and doctors aged 65 and over wouldneed approval to stay in practice. The Government also intends toend the present system under which doctors can "retire" and rejointhe NHS almost at once and draw both their pay and pension.Prevention.-The Government wishes to see discussion on what

more might be done to promote prevention in primary health care.Child health services.-The Government wishes to increase the

number of family doctors involved in the regular checking ofchildren under school age.

Dentists

Availability of services.-The Government wants to ensure thatthe full range of NHS dental treatment is readily available toeveryone who needs it. Access to NHS services might be improved ifthe NHS dentists’ contract required them to provide NHStreatment for a given number of hours each week and also to providethe full range of treatment in the NHS fee scale.

Advertising.-The Government wants to increase patients’ abilityto make informed choices between dentists. A further relaxation ofthe restrictions on advertising could help.

Preventive treatment.-There should be more emphasis in thedental services on oral hygiene and the prevention of decay. Toachieve this the Government proposes that: the pilot scheme underwhich some dentists are paid a capitation fee for their childpatientsrather than fees for individual forms of treatment should beextended. If the promising results achieved so far are confirmed theGovernment will give all children the opportunity of being treatedon this basis; the requirement to give proper advice on maintainingoral health could be more fully defined in the dentists’ contract andthis item given greater value in the payments system; healthauthorities in areas where dental health is poor or the level ofattendance at the dentist is below average should consider thebenefit of fluoridation with particular care.

Unnecessary dental treatment.-The Government will act upon thereport of the committee of inquiry into unnecessary dentaltreatment in England and Wales and take action on the majority ofthe recommendations later this year.

Pharmacists

An extended role.-The Government believes there is scope for

making better use of pharmacy skills in advising patients andproviding other services both for patients and doctors. It thereforewelcomes the recent reportt of the Nuffield Foundation into thefuture development of pharmacy. With the benefit of that report theGovernment will examine carefully and positively what additionalcontribution pharmacies might make to NHS primary care.

Supervision of dispensing.-Most modern medicines no longerneed specialised dispensing skills as they are supplied ready made bythe manufacturer. The Government is proposing that the stringentsupervision requirements for dispensing could be relaxed to enablepharmacists to spend more time dealing with the public, explainingand advising on the use of medicines.

Restrictions on the sale of medicines. -Some medicines are availableon prescription from a doctor; others can only be sold under thesupervision of a pharmacist; and some are on general sale. Somerestrictions on the sale of medicines are necessary as a safeguard forthe public but the operation of the system needs to be reviewed fromtime to time. The system was reviewed in 1982/83. TheGovernment would welcome views on whether it would be

appropriate to make further changes.

OpticiansThe Government has already taken major steps to improve

services to consumers. The opticians’ monopoly has been ended andtPharmacy: a report to the Nuffield Foundation, Nuffield Lodge, Regent’sPark, London NW1 4RS. See Lancet 1986; i: 866.

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businesses have started, budget-priced ranges of glasses have

appeared, and prices have gone down. Plans are in hand to issuevouchers in place of the present NHS supply of glasses to childrenand people on low income so that they too can benefit from a widerchoice available in the private sector.

Inner Cities

The Government is determined to make further progress in

dealing with the problems of providing high standards of primaryhealth care in inner cities. Many ofthe Government’s proposals willhelp but those directed specifically at the problems peculiar to innercities are: making the scheme for helping doctors provide purpose-built practice premises more sensitive to local needs; providingadditional financial incentives to doctors practising in inner cities;making services more accessible to ethnic groups; experimentingwith different contracts for doctors in inner cities.

Other ProposalsAssessment of the quality of services.-There are already a number

of forms of quality control in operation in the primary care services.But there may be a need for standards of service delivery to beevaluated more independently. As an experiment the Governmentproposes to appoint a team, composed mainly of health servicepersonnel, to make a study in depth in one or two areas in England ofthe ways in which primary care services are being coordinated,planned, and delivered.New ways of providing services.-The Government hopes that

primary care services will develop in ways that provide both analternative source of care and also means of comparing the presentservices with those provided under different arrangements. Therewould be advantages to the public in being able to get differentprimary care services in the same premises. To facilitate this, thelaw which restricts to dentists and doctors the running of dentalbusinesses for profit might be changed. And the NHS might, as anexperiment, enter into contracts with practices which wouldundertake to provide a range of primary care services.Number of practitioners.-The numbers of doctors and dentists

working in the family practitioner services over the years haveincreased faster than the population. The Government intends thatthere should be further increases, but to ensure that these areconsistent with relative future priorities for the family practitionerservices and the hospital and community health service it is

necessary to consider what action might be needed to influence thegrowth rate in the numbers of practitioners.Patient charges.-The structure of dental charges is complicated.

The British Dental Association has proposed a simpler systemunder which when people have to pay they would pay a fixedproportion of the cost of the services they have individuallyreceived. This would give the public a greater interest in the costs oftheir dental treatment. It would be possible to consider relatingprescription charges more to the cost or importance of themedicines.

Complaints.-There is a statutory complaints procedure for

dealing with serious complaints about doctors, dentists,pharmacists, and opticians in the family practitioner services. But itis complicated and time-consuming and the Government believes itcan be made simpler, more accessible, and more effective. The timelimits for making a complaint may not be long enough and patientsmay need more help in presenting their cases. There should also beinformal conciliation procedures to settle less serious complaintsquickly and effectively.

Community Nursing ServicesThe report of the review of the community nursing services in

England has been published simultaneously with the government’sdiscussion document. Ministers intend that there should be

*Neighbourhood nursing: a focus for care. Report of the Community NursingReB iew (chairman, Julia Cumberlege, chairman, Brighton Health Authority).HVI Stationery Office, 1986. Pp 110. £3.

consultation and comment on that report as part of the primaryhealth care debate in England. The main proposals in that report onwhich views are sought are that: community nursing services shouldbe planned, organised, and provided on a neighbourhood basis;there is scope for making more and better use of nursing skills; theeffectiveness of the primary health care team needs to be improved;there should be a more integrated approach to the training of allnurses working outside hospitals; consumer groups could have astronger voice. Separate reviews of community nursing services areunder way elsewhere in the UK.

* * *

The Government wants to promote a wide public debate on allthese issues and others that relate to the primary health careservices. Ministers will therefore be holding a series of meetingswith representatives of the professions, of consumer organisations,and of other interested bodies. But it also wants to hear from localbodies and individuals-those engaged in providing care, thosereceiving it, and others with an interest in improving this vital partof the health service.

Comments should be sent by Dec 31, 1986, to: (England) Primary HealthCare, DHSS, Eileen House, 80-94 Newington Causeway, London SE 6EF;(Scotland) Primary Health Care, Scottish Home and Health Department, StAndrews House, Regent Road, Edinburgh EH1 3DE; (Wales) Primary HealthCare, Welsh Office, Cathays Park, Cardiff CFl 3NQ; (Northern Ireland)Primary Health Care, DHSS Northern Ireland, Dundonald House, UpperNewtownards Road, Belfast BT4 3SF.

Commentary from Westminster

The Government’s Agenda on Primary CareA Boycott-like Approach

SINCE the last election there has been a continuing andopen division within the Cabinet between those who believethat the Government should push on as hard and as fast aspossible with radical Thatcherite policies and those whoprefer to consolidate and safeguard the gains already made.The first camp point to the popular success of policies ofprivatisation, sales of council houses, and the rest and arguethat the more radical the policies become, the better thepublic like them. Their rivals cite the gradual and piecemealway in which changes were made in the law on trade unions.Had the Government gone for the lot from the start, theysubmit, it would never have carried public opinion with it.The changes which matter are the changes which stick, whichyour opponents cannot later reverse: to push for too much toosoon puts existing gains in jeopardy.On the whole, the consolidators have been getting the

better of the argument. The collapse of the Shops Bill, pushedahead, in obedience to the governing ideology, against thebetter judgement of consolidators who knew how grievouslyoffensive it would be to many of the party’s natural

supporters, has strengthened their hand. And the publicationlast week of Mr Norman Fowler’s consultative document on

primary health care has some claim to be regarded as the highpoint so far in this softly softly approach. We had beenwaiting for two years or so for a green-paper; but what

appeared last week fell short even of that. It was publishedsimply as a "consultative agenda" around which a greatnational debate on primary health care, complete with localdebates chaired by Ministers (though only before invitedaudiences) would subsequently take place. That process willnot be completed until the end of the year. That leaves littleprospect of any changes, unless they are whollyuncontentious, being pushed through before the next

election.