Dr Phil Hammond, broadcaster and GP returner in Bristol

Brace yourselves for ‘Health outside Hospitals’, a White Paper due to be published at the end of this year. It could promise, among other things, to shift 15 million hospital outpatient appointments to community settings. But just how new is this idea?

Way back in 1967, the Lancet published an article by Peter Draper called ‘Community-care units and inpatient units as alternatives to the district general hospital’.

Community healthcare then was a higgledy-piggledy affair, with poorly resourced GPs dotted all over the place in practices of various sizes, none of them talking to each other. Meanwhile, expensive hospitals with overflowing outpatient departments mopped up all the money.

Draper’s solution was to group GPs and other health workers into large, properly resourced health centres, which would provide most of the health and social care for the community, including much of the work previously done by hospitals.

Hospitals would then be downsized to deal only with acute emergencies and highly complex care – just as Labour is now suggesting. So why has it taken us 38 years to put the idea into practice?

The main reason, I suspect, is that politicians are a little in awe of the powerful consultant lobby which has ensured the survival of huge, empirebuilding hospitals at the expense of cheaper, friendlier, closer to home alternatives.

Whether Labour really has the courage to close down hospitals and open up primary care remains to be seen, but it’s always comforting to realise that very few ideas are original.

A 2002 BMJ article in praise of the Kaiser Permanente healthcare system – which had its origins in the California shipyards of World War II – had a big influence on the Labour Government’s policy making. The following year, John Reid addressed the National Association of Primary Care on the topic of ‘Learning from Kaiser Permanente: how can the NHS make better use of its resources and improve patient care?’

The Kaiser approach has been lauded because it doesn’t pay doctors on the usual fee for service basis. Instead, all its members’ subscriptions are handed over to its hospitals, clinics and doctors, who are then responsible for providing care for the members.

This model reverses the usual economics of medicine – both doctors and hospitals are better off if their patients stay well. It isn’t like the NHS, where doctors can pass the buck between primary and secondary care. By giving an organisation responsibility for both, staff are forced to think in terms of what’s best for the patient rather than for themselves.

Alas, primary care organisations just haven’t been able to deliver this Kaiser vision. Instead, we’re embarking on a hideously expensive and uncoordinated programme of market competition, target bonuses and payment by results (or rather activity), which could suck up every last penny without making patients appreciably healthier.

So where will all the money end up? The answer may well be found in a recent book, Whiplash and other useful illnesses, which shows how doctors, lawyers and patients have colluded in blowing dubious diagnoses out of all proportion to create a multi-billion pound compensation industry.

Guidelines in Practice, September 2005, Volume 8(9)
© 2005 MGP Ltd
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