Health: Primary and Community Care Debate 24th June 2010

Lord Mawson: My Lords, it is a privilege to be able to lead this debate on the future of primary and community care at this early stage in the new coalition Government. The vision that the Government have set out for primary care, where resources are deployed in the hands of practitioners close to the ground, has significant risks but is full of opportunity. As a social entrepreneur, I welcome this bold step.

As noble Lords will know, over the past 13 years in an area of great deprivation and health need, where the health authority had left a gaping hole in primary care provision, we, with the local community of Bromley by Bow, have set up a health centre which is integrated with housing, education, businesses and the arts. I declare an interest as the founder and, now, president of the centre, and that, in my professional life, I am increasingly working across the country advising on this area of health development.

The Bromley by Bow Centre is about health, not sickness, which is reflected throughout the building. You enter through a beautiful cloistered garden, recently full of purple wisteria. There are no gruesome pictures of human bodies on the walls greeting our patients, the kind of images that used to haunt me as an imaginative eight year-old at our local doctor’s surgery in Bradford. Instead, you walk into an art gallery and open-plan reception made of natural timbers and bathed in natural light. A high-quality environment, a focus on human relationships, open communication and customer focus are the keys to the Bromley by Bow approach. Doctors come out into the reception to chat and greet their patients in person. In the consulting rooms, patients and doctors sit side by side around curved wooden tables, looking at the computer screen together. At Bromley by Bow, doctors, nurses and patients work in partnership together.

Patients are not merely prescribed pills, referred and sent on their way. The drug we give to a patient with depression is only part of what our GPs prescribe as a fully comprehensive care programme. At the centre, we can offer on-site career advice; support to overcome debt; vocational training qualifications, and even a university degree programme; business support, including the opportunity to set up your own business; and practical housing and legal assistance.

Over the past 13 years the Bromley by Bow Centre has become an exemplar of an integrated approach to health and social care. It inspired the £300-million healthy living centre programme, run by the then New Opportunities Fund, and the £2-billion NHS LIFT initiative, which is of course the public/private partnership programme for building primary health and social care centres in the most disadvantaged areas across the UK.

Others have developed integrated approaches to health in other parts of the country. Dr Angela Lennox built a police station in her health centre in Leicester and reduced crime in the housing estate where it is based. The Westbank Community Care Centre in Exeter promotes healthy living across Devon. The Gracefield Gardens health centre in Streatham works in partnership with Lambeth PCT and Lambeth Council to deliver better healthcare. We ourselves now run three health centres for over 18,000 patients and are the largest primary care provider in the London Borough of Tower Hamlets.

I apologise for not being able to speak last week in the debate on the big society, but are these not all examples of where, in the micro, a big idea like the big society might take root? If integrated models of health and community care were encouraged in every community up and down the land, and the necessary local relationships and partnerships brought together, this important idea-the big society-might not become subject to yet further cynicism and be seen as more meaningless government spin with little substance underneath. It might actually become the fertile ground within which a wholly new definition of what it means to be a healthy society-a thriving community-took root. Of course, such an approach would need to be given time and consistent leadership.

There is a wealth of untapped social entrepreneurial talent in our country. Many of these entrepreneurs have it in them to generate creative and innovative approaches to primary and community care. There are hundreds of latent and undernourished third-sector organisations in this country with the capability to become like Bromley by Bow and take on the task of transforming how public services are delivered in communities up and down the UK. Our task is to find these people and organisations and put the wind in their sails. Over the past 10 years I have travelled up and down the country and discovered social entrepreneurs who are massively frustrated at how hard it is to be trusted and resourced to take on public contracts, including in the areas of health and social care. Despite the positive rhetoric from successive government Ministers, it has been intensely difficult for dedicated and talented social entrepreneurs to develop creative solutions.

My noble friend Lady Finlay and I offer the Minister a visit to some of these centres and the opportunity for him to see in detail what a successful integrated approach to health and community care actually looks like in practice, and what conditions need to prevail if it is to grow exponentially and to take root. The sad fact remains that these examples of an integrated health model are still few and far between. Despite all the rhetoric and promises, there has been little practical encouragement for these integrated approaches to health. It was ironic that our approach, which everyone now thinks is a great idea, was physically blocked by a boulder across our road to delivery back in the mid-1990s. The boulder was not local people but the local health authority at that time.

I am not convinced that things have moved on much. Yes, money has been spent on building new buildings and, yes, there has been investment in services, but the principle of broadening the base of primary and social care delivery and engaging social enterprises has barely been understood. I am aware that the language of social enterprise is spoken inside Whitehall, but I am profoundly doubtful as to whether it is understood. Indeed, the evidence is that it is not. Our public services need to be known for doing and achieving, not just endless talking, restructuring or writing yet another new stack of policy documents. In a modern enterprise economy, we are nowadays returning to the sensible practice of “learning by doing”. The idea that we learn much through the writing of endless documents that are out of date within weeks can seem rather outdated. There is nothing better than getting your hands dirty in the practicalities to really understand what is going on. When I spoke to the recently departed chair of NHS London, he told me that his mission was to build stand-alone “medical model” health centres without what he called “the distraction of social and community care”. Evidently, the complications inherent in the lives of disadvantaged Londoners were outside the brief of the chair of NHS London.

Similarly, the vision of the noble Lord, Lord Darzi, of a network of polyclinics, announced in your Lordships’ House, was in practice another missed opportunity. When you get into the practical detail with those of us who are practitioners, you see that it was not at all a vision of polyclinics, but of monoclinics-that is, health centres that are almost solely about the clinical model of healthcare. It is a sophisticated clinical model and, invariably, these clinics are full of state-of-the-art equipment and procedures. However, I am vexed to say that they pay scant lip service to the lessons many of us have learnt about integration and the bringing of different disciplines together in the way I have described-that the route into addressing the pressing and underlying health needs in some of our most challenging communities in this country lies in getting GPs to work with their non-health colleagues. It is as simple and as complicated as that.

We need our health service to be open to working in partnership with the third sector and social enterprises in integrated schemes which address the real, practical day-to-day issues that face patients. These include poor social housing, underachievement in education, credit card debt and fear of bailiffs, concern over street violence and anti-social behaviour, and the lack of opportunities to take control of their lives. We are not asking the NHS to solve all these problems. We are simply asking that the health profession be willing to work more collaboratively with others who have the tools to change our communities for the better, including by addressing their physical and mental health needs.

What those of us who have had real experience of running successful integrated health centres found was that the definition of a polyclinic changed on a six-monthly basis, and each new definition was communicated by NHS London with such clarity and certainty that real players and practitioners in the field were left totally paralysed. This meant that important health centres still remain not built, with enormous potential abortive costs. I know of one health centre that has had to go through so many NHS London-inspired redesigns that it has incurred over £1.5 million of design fees and still sits in NHS London’s in-tray. I truly wish I could say that this is the only example I am aware of in London but it is not. I am afraid that the last Government were rather fond of initiatives that never in practice happened, and of trusting the reports of young consultants at McKinsey rather than those who do the job.

I welcome a world envisioned by the coalition Government where resources are put in the hands of practitioners on the ground with a real understanding of their neighbourhoods and local needs. However, this vision is far from straightforward. Not all GPs will deliver the integrated model of healthcare that I described earlier. Many GPs who support an integrated approach tell me that their colleagues who do not support it fear loss of status and title, without realising that real status in communities is based on the strength of their relationships with patients. Often in deprived areas there is a stark lack of GPs with the capacity to rise to the challenges that they now face. This new approach has important implications for the ways in which doctors are now trained.

The Government need to ensure that GPs are encouraged not to resist change, nor protect an expensive biomedical model of health. We need to show our doctors that an integrated approach to healthcare will address the profound problems that people in disadvantaged areas face, with considerable savings to the public purse. At Bromley by Bow, we run our health centre like any successful customer-focused business. For example, 20 per cent of consultations are conducted on the phone, which saves not only the patient’s time but the GP’s as well. What we all have to realise is that the NHS has access to people across the country which any business would die for. Eighty per cent of consultations in the NHS take place in general practice, and 90 per cent of the population is seen in any one year. If we encourage entrepreneurship in the world of health, then the more capable practitioners will step into these gaps in the market and ensure successful delivery of care.

As the new Government begin to formulate their health policy, I have three questions for the coalition and the Minister, who I wish to thank for a very helpful discussion earlier this week on this subject. First, what is the Government’s vision for the future make-up of primary and community care? Will they simply leave it to the marketplace? Will they promote the standard medical model or the integrated approach of the type I have described? A clear approach is essential for the dedicated medical staff, who have had to suffer countless changes in direction over the last decade and now feel disillusioned, confused and frustrated. Secondly, once the Government have clarified what their future model of primary care and community care will be, how will they deliver and develop this approach effectively? This has simply not been happening. Finally, who in the coalition Government will lead with consistency and longevity, and pursue this course? Under the previous Government, we saw a succession of initiatives and restructuring led by “here today, gone tomorrow” Ministers, which has left the health service, frankly, in ill health. Who will be the leader? That is my key question.

The Government are rightly opening up a world of opportunity and I welcome that. However, the devil, as ever, will be in the detail and perhaps most importantly in consistent leadership not from civil servants but from practitioners-GPs and others who have done the job and understand the practical details on the ground. I encourage the Minister and his Government to lessen their reliance on academics and theorists, who have often never built anything, and to embrace the world of the practitioner and the social entrepreneur; to create a culture where we learn by doing, and not by talking and writing endless expensive documents and papers. We cannot afford this expensive, rather old fashioned way of doing things any more. Let us support-and learn from-people who do the job.