Written evidence submitted by Aiming for Health Success from Professor Nick Bosanquet and Andrew Haldenby (FGP0035)


What are the main challenges for general practice in the next five years?


  1. After 25 years of priority for hospital care, can primary care give a new lead to the NHS?


  1. The main challenge to the NHS is to improve outcomes and quality of life for patients with long term conditions. These patients with diabetes, COPD, chronic heart disease and arthritis have lower and falling life expectancy. For example, the TORCH study led by Professor Vestbo in Denmark followed up 6,000 patients with COPD over three years. It showed that if they adhered to their medication, there was a significant fall in mortality, from 26 per cent if they did not adhere to 11 per cent if they did. Earlier diagnosis and continuing support by a team out of hospital are the key for improving outcomes for these patients who are currently treated all too often with revolving door hospital admissions.


  1. Development of these high capability primary care teams is key to reducing inequality. Risk factors – smoking. poor diet inactivity and obesityare twice as high in local populations with highest level of deprivation than the average. The main service response has been through higher levels of A&E attendance and emergency admissions. There were 3 million A&E attendances in the most deprived decile in 2018-19 compared with 1.5 million in the least deprived.


  1. This investment in out of hospital services is key to improving access to hospital care. Hospitals can be high productivity hubs for the many services which improve survival and quality of life: transplants, dialysis, elective surgery and paediatric care. Most of these services were not widely available even thirty years ago. We now have great teams in the NHS who could treat many more patients if the Service can move on from the General Hospital model – which would only be possible with out of hospital investment. The Vanguard programme has already given some positive evidence of how admissions can be contained.


  1. The NHS England Long Term Plan, which is the most positive strategy document in the whole history of the NHS, included a commitment to £4 billion of investment in primary care. This can be used to develop new kinds of teams. The 20,000 extra staff planned would allow a wider range of skills in practices to promote lifestyle change and to improve early diagnosis, including in cancer. GPs would have a key role in promoting the health of local populations. GPs amount to at least 50 per cent of experienced medical time in the UK. They should have the resources needed to improve outcomes.


  1. Between 2015 and 2020, the Government failed to deliver on a pledge to recruit 5,000 more GPs, as GPs either retired earlier or moved to part-time. The current manifesto commitment to “employ “6,000 more doctors in general practice” will also be breached, as the current Health Secretary has said. Policymakers need to let go of the comfort blanket of manpower edicts. A better approach is to see experienced general practitioners and their staff as a limited resource that has to be used most effectively.


  1. These teams and their activities would show results from local initiative. There are already new investments in North West Cumbria, in Crediton (Devon) and in York (see appendix A). The primary care organization and response in the pandemic has generated a new energy for building the wider practice team, with GPs as leaders in developing and monitoring quality of care for the 20 per cent of practice patients with serious health problems and promoting lifestyle change.


  1. The enlarged team would make it possible to have personal contact and quick access with patients who need it. For all its defects in the past, general practice had one great strength which was the personal contact. Health Foundation research has shown that if elderly patients see the same doctor this reduces emergency admissions. The enlarged team would include counsellors and specialist mental health nurses. These long-term conditions involve a spiral of decline in which disease leads to inactivity and depression.


  1. GPs have been the NHS pioneers in developing and using IT. They can now lead on using digital methods for in improving practice quality of care. Econsults – by which patients send in advance notice of their needs can save time both for patients and NHS staff. Digital means easy sharing of information and consultation about finding the best team member. Digital can also expand the role of the nurse practitioner who can lead clinics for patients who need immediate attention for more minor problems. The wider team has choices on how to improve the quality of the service to improve outcomes.


  1. The new out of hospital service can be created in months not years. It can offer recruitment and training within local communities. It can also be developed with lower costs than a hospital service (see diagram in appendix B from the Devon ICS). The new teams can build confidence with patients and staff, delivering improved quality of life and reduced admissions within two years.


  1. The new primary care needs stronger research on outcomes and much more research on patient experience. In the last two decades there has been a huge shift of research towards new high-cost drugs. GP-led research such as the pioneering work of the late Sir Donald Irvine (GP in Ashington, Northumberland) on prevention in heart disease has declined. The new initiative in out of hospital care needs a strong research foundation.


  1. The proposition that out of hospital care is key to improving population outcomes has strong international backing. The experience of Finland has shown how to move forward with out of hospital prevention and treatment programmes and not just in North Karelia. The ten-year primary care-based programme on asthma, from 1994 to 2004, reduced the number of Finns on long term disability benefit, asthma related, from 8,000 to 1,000. Kaiser Permanente has stronger primary/secondary collaboration in the US. The greater longevity of more affluent, older Britons is partly the result of lower risk factors, with retired MPs, retired Professors and doctors among those benefiting.[1]


  1. In summary, the next five years will see GPs becoming key leaders of healthcare hubs for improving population outcomes.




Appendix A – recent investments in enhanced primary care


New base for primary care, Carlisle


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there will be better space for bringing together the wider combined team, to deliver a fully comprehensive package of care from a range of health and care professionals for the most vulnerable patients. This will include colleagues from other community teams, mental health, voluntary organisations and social services. Carlisle Healthcare also plans to ensure the building will have the facilities to support it to become a teaching hub to train the staff to deliver the service into the future.


Source: North Cumbria CCG



Nov 2021


Crediton Health Hub


Redlands Primary Care in Crediton


“Dr Peter Twomey said: ‘Crediton’s population is set to rise over the next 5-10 years, and with that the demands on our practice will also increase. We are very keen to maintain and improve the care and the continuity of care we provide to our patients as we seek to meet this anticipated escalation in demand and expectation. The way GP practice services are being delivered is changing and working in a modern, purpose-built facility will bring huge benefits for our service. Different ways of working will enable us to offer a wider breadth of services whilst maintaining continuity for the patients who need it.’


Source: Devon CCG




Nimbuscare, York


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“Our membership includes 11 GP Practices who are all passionate about delivering high quality local care for local people. We work collaboratively across the York area, delivering new, innovative and sustainable health care services.


Building on the strengths of our individual member practices, we can also share the workload and meet the increasing challenges we face. This approach allows us to share resources, expertise and services; work as one single entity to tender for services; and improve the way that services delivered by different GP practices and providers integrate.”


Source: Nimbuscare



Appendix B – Devon ICS



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Source: Devon ICS


Appendix C – organisation and biographical details


Aiming for Health Success is a new initiative which will develop the case for new public / private collaboration in health and care to deliver extra services and support. It will combine the insights of its network of NHS and care leaders, and leading companies, with the latest academic and policy analysis. It will produce frequent publications and online communications and hold events with policymakers and health care leaders. AFHS is run by Andrew Haldenby and Professor Nick Bosanquet.


Nick Bosanquet was until recently Professor of Health Policy at Imperial College London. He is a former special adviser to the House of Commons Health Select Committee and member of the Government Cancer Strategy Group. He is a trustee of the charity Brendoncare, which provides care homes, independent housing and care and friendship clubs. He was investigator for part of the large community-based Salford Lung Study.


Andrew Haldenby has been a key figure in the Westminster and Whitehall policy debate for the last 25 years. He was head of the political section of the Conservative Research Department, a position previously held by David Cameron and George Osborne. Most recently he was director of the think tank Reform for 14 years.





[1] There have been two centenarian MPs, both Labour so far: Bert Hazell, Norfolk North (1907-2009), Sir Patrick Duffy, Sheffield Attercliffe (1920-). In the 16th century, William Badger MP (1523-1629) represented Winchester.