Primary care is where a member of the public receives their first (primary) element of their care. Acceptance of this definition is important before moving forward and we must not get confused with the word ‘primary’ when it is taken to mean ‘most important’. Although we could argue that the first element of care is always the most important in determining the pathway, the outcome and the cost to the NHS.
This means that general practice, community pharmacy, optometrists and dentists form the core elements of primary care. We must add into this out of hours services including hospital based accident and emergency services, ambulance services and a wide range of other provider services including housing and social services.
We must also build into this the person themselves, knowing that many people make their own primary care decisions either alone or supported by family and friends or by internet based information such as NHS choices.
There are two important issues to consider:
- Can people access information from reliable sources and make their own primary care decisions with minimal support. Many people can access the NHS Choices website, but I am surprised that we provide so few opportunities for those who cannot access the internet, have poor computer literacy, limited ability to read or are unable to make a decision without some support/advice.
- Are all providers of primary care working together to make the first contact count.
The answer to both of these issues is simply no. I think that we know that and have known that for years, but made very little progress. There are some simple solutions that the NHS could consider:
- All community pharmacies should make a move to healthy living pharmacy status and the availability of a touch screen computer linked to NHS Choices should be a fundamental requirement.
A community pharmacy is an ideal place to direct people who wish to explore their symptoms or better understand their condition and available treatments. Healthy living pharmacies can supply advice, a variety of services and should have easy access to a range of treatments.
- All services that provide primary (first contact) services should be supported to work together within a locality based contract that operates 24/7.
A number of publications on emergency care have described primary care services into a continuum, from self-care through to A&E, but none of them have suggested contracting first contact services together as a group. From a single budget all providers can offer first contact services, but each provider must be able to offer a full service for a defined population. The starting point is an understanding of the triage principles – who goes where and for what. Each contract has a target number of first contact episodes such that to share in the profits of the contract all providers are interdependent. The positive metric is completed first care episodes in the appropriate environment and the negative metrics are referrals to other providers. The local population must be involved so they can better understand where they could go and what each provider can actually provide.
If we focus on the person then they should understand when to visit the optometrist service, the dentist, the community pharmacy, the GP, the A&E and other local providers. The services should also work out how to work together in hours and out of hours.
All community pharmacies in a locality should be involved. They all should work towards healthy living pharmacy status and should all provide access to NHS Choices to their local community. They should all offer a range of health and wellbeing services and should link together to provide inter-pharmacy referrals.
All community pharmacies should provide minor ailment / common condition / pharmacy first services in which they provide an increasing range of services based on advice and treatment. The contract should be set with targets that support closer working between all providers to make sure that each element delivers on their commitment and all providers benefit when targets are met.
There are no excuses – we have to get primary care right – we have to firstly support people to access appropriate information and advice in a wide range of settings and when they touch the primary care provider, they have to get the best care in the most appropriate setting.