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A Labour government with an unbelievable majority. What could it mean for primary care and other related community based services and what specifically did their election manifesto commit to? As ever the main short term focus is on secondary care and even I can accept that expedient focus given the news grabbing appalling waiting lists. And yet ‘A major new research project has found that the public wants the government to focus more on improving primary and community care than hospitals and is willing to pay more taxes to improve NHS services’ (Health Foundation May 2024).

Labour historically apart from the Blair years has favoured a statist approach to the NHS with scant appreciation of the self employed primary care contractors despite their popular achievements. The Labour manifesto is committed to primary care advancement. A dental recovery plan and a return of the family doctor are headline priorities together with promising detail for general practice, community pharmacy, dentistry and optometry. And most significantly ‘The National Health Service needs to move to a Neighbourhood Health Service, with more care delivered in local communities to spot problems earlier. To achieve this, we must over time shift resources to primary care and community services.’

Labour offers a promise to primary care but given the precarious nature of public finances coupled with national economic woes, a fair chance as with previous initiatives such as a ‘primary care led NHS’ the promise may remain unfulfilled. Labour’s mission is ‘to build an NHS fit for the future. Investment alone won’t be enough to tackle the problems facing the NHS; it must go hand in hand with fundamental reform’. As a long time NHS reformer, I agree. Seemingly to get policies in the manifesto two fundamental questions had to be answered: ‘Can we keep this promise?’ and ‘Can the country afford this promise?’.  New Secretary of State Wes Streeting subsequently publicly admitted he wishes Labour’s manifesto was “more ambitious” in its promises around social care. Why not for primary care?  Israel from 1995, well before its present shocking war, and Ireland 2 years ago perceptively recognised if we wish for an integrated health and care service it must be primary and community care led. Social care cannot stand alone. UK general practice, uniquely population based at local service level, is described as ‘soul of a proper, community orientated, health-preserving care system (Donald Berwick)’ and is significantly more advanced than in pre reform Israel or Ireland. Sadly focusing on hospital centricity is also embedded in NHS leadership. With the notable exception of Simon Stevens, all chief executives have been from the hospital service, likewise senior medical leaders and yet despite been steadily given an increasing share of the NHS budget, continually languish last of CQC service ratings, general practice being first.

Leadership for a health preserving reform must emanate from the government. Ireland’s rationale resonates, ‘profound change will not be well served by the status quo. Health systems around the world have invested heavily in hospitals and specialist services to reduce the burden of disease from heart attacks, strokes, and cancers, but it is not enough. The imperative to address an ageing population, the burden of chronic diseases (as they describe), and the lessons from recent global health crises have spurred Ireland to usher in a new era of healthcare, placing community care at its heart’. England and Wales already have the two essential tiers that the 2 leading countries lacked prior to their reforms, population based local general practices within larger primary care networks that can both flex the size of their responsible populations to respond to need. When I originated the primary care home brilliantly developed by NAPC, the precursor to networks, it was about creating energy and fulfilment to facilitate service advances. Change must be organic and vitalising whereas NHS reform has traditionally been functional, top down, structural, inheriting status quo leaders and frequently disabling. There was a fear of energy and initiatives stalling when moving from a bottom up primary care engendered service initiative to government engendered national networks. My concern was allayed somewhat when at the beginning of March 2024 three years into the programme, two thirds of the 60 sites that make up the NHSE funded Complete Care Community Programme NHS sites came together for two days to celebrate their impressive achievements in tackling health inequalities. A significant example as with the preceding 200+ primary care home sites of small amounts of enabling support transforming traditional access services and expanding the vision and achievements of community based services.  Neighbourhood health centres if true to traditional NHS reform will simply become a buildings programme rather than the fulcrum to enhance existing innovation.  A reforming primary care centric national policy with a supportive NHS leadership would be a swift emancipating enabler while awaiting the future growth in finances.

The overarching priority for health and wellbeing is to enhance social capital, community solidarity, resilience and sustainable development for individuals and communities. Professor Barbara Starfield’s internationally acclaimed research provides the evidence of how successfully primary care has delivered care and improved the health of people. UK Primary care has a positive long experience of reform and innovation, an international recognised heritage buoyed by successful exemplars in Israel and Ireland. Our failing NHS needs a radical new approach. Primary care more than any other NHS service is primed for a purposeful reforming leadership role.

Summary

I have worked 40 years in the NHS of which 36 as a GP in an area of significant deprivation, some 15 years initially at senior policy in the NHS culminating as National Clinical Director of Primary for the Department of Health. I have coupled this with many years as a local authority councillor and academic. My overarching opinion garnered from that experience is that healthcare must be primarily at the centre of a social policy focused on communities and their individual citizens.  In short, a primary care led NHS. My hope is the new government would agree. I would welcome my fellow NAPC members and others to proffer views, opinions and solutions as how to progress. The ‘how’ is the essence.

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