While the managerialism of the 1980s, and the internal market in the 1990s, has been seen as inimical to primary care teamwork, these two developments were instrumental in placing primary care at the centre of health policy and in a pivotal role in the organization and management of healthcare. It is no surprise therefore that the 1990s witnessed the most concerted attempt to shape primary care through policy reform, in part because of the pressures and needs elsewhere in the NHS. Though autonomy has been valued by all professions throughout, and the legacy of the generalist/specialist separation and of the 1948 settlement persist, the government has become less deferential to the professions. For much of the century, the government was wary about upsetting the professions (primarily medicine) given their status within society and the power which they wielded. However, with the rise of managerialism, policies have made fundamental advances in shaping the organization and management of primary care. This is resulting in a wider and more inclusive definition of primary care, a greater managerial role in what had been a professional enclave, and a more central role for primary care in meeting NHS objectives. For example, in England the recent proposals by Lord Darzi emphasize the need for stronger primary care. However, while issues such as access, quality, education and professional regulation, and developing premises and facilities remain important, recent changes in commissioning and contractual arrangements (discussed later in this chapter) have shifted attention to how national and local policy makers can stimulate these changes. There are also changes in the organization of primary care and in the roles of healthcare practitioners such as GPs and nurses, and though an increasingly inquisitive and sceptical public is placing more demands on practitioners, primary care has thus moved from the margins to the mainstream of health policy in the UK. As discussed in Chapter 1, any discussion of healthcare organization must consider the effect of political devolution in the UK and the development of not one, but four NHSs. As in other areas of healthcare, this has had a significant impact on primary care services, and while on the whole unchallenged by much reform, the enduring nature of general practice may fundamentally alter in the future in England and certainly the shape of community health services will change, forging clearer divisions between England and the rest of the UK.

Central to the organization of primary care services in the UK are general practice and community health services and since the Second World War there has been an enormous expansion of these services. From the 1960s there has been a steady increase in the workload and, consequently, the numbers of staff. Today primary care is a major employer with, in England, Scotland and Wales, over 120 000 people now working in general practice with over 40 000 additional members of the primary healthcare team (PHCT) who also work in, or with, practices (Table 2.1).

A simple review of the history of UK health policy demonstrates little interest in general practice and community health services until the mid 1980s. As Moon and North (2000) argue:

Traditionally, the sidelining of general practice and community health in the UK is seen as a by-product of the establishment of the NHS in 1948. The settlement achieved ensured that the focus of government was on the secondary and tertiary sectors given the dominance of hospital-based services (Klein 2006). Two consequences of the establishment of the NHS were the independent practice status of general practice, outside of the mainstream NHS administration, and the retention of community and public health services within local authorities (Klein 2006, Ottewill and Wall 1992, Timmins 1995). For the UK this tended to push policy interest in these areas to the sidelines. This is not to say that these areas were ignored as there has been a continuing debate within the UK about the relationship between community health and hospital services (Ottewill and Wall 1992) and since the 1950s an interest in the development, quality and role of the general practitioner services (Moon and North 2000). However, the interest of government in primary care services rapidly escalated from the mid 1980s. This interest grew for a number of reasons but can be seen as arising from the coincidence of a number of trends as shown in Box 2.1 (Peckham and Exworthy 2003).

While identified as separate contributors to policy and organizational changes, there are clear interrelationships between these areas. In the UK, general practitioners have traditionally adopted a managed care approach, being both first point of contact for healthcare for the majority of the population, providing immediate healthcare to individuals and families and making referrals to secondary care (Fry and Hodder 1994, Starfield 1998). As Starfield notes, the UK system of general practice is the most universal and comprehensive in the world. Thus they have a critical role to play in dealing with long-term chronic illness. Similarly, the UK has one of the most comprehensively developed community health services which has increasingly become integrated with general practice. Interestingly this integration combines both primary medical care and, to a certain extent, primary healthcare. Thus the need to address changes in disease management from mainly acute episodes to the management of chronic disease places a greater burden on primary care and has perhaps led to the ‘rediscovery’ of the GP’s role. At the same time there have been significant changes in demand by patients leading to pressure on consultation times, length of time waiting for an appointment and particularly out-of-hours work. It is not clear, however, what the varying contributions of providers and patients are in this upturn in demand, nor is there any simple answer to dealing with these problems (Rogers et al 1999). All these issues are explored in more depth by Peckham and Exworthy (2003) but it is important to recognize the complex background that lies behind current developments in policy and practice.

This discovery of the important role of primary care within the UK NHS has occurred at a time when there has also been a re-examination of the role of the GP and developments in primary care nursing. It is perhaps the convergence of these factors which has provided an impetus to the exploration of new models of primary care organization. These developments have also led to a re-evaluation of the nature of primary care. Certainly recent debates about who should deliver primary care and the potential opening up of a community health services market with a greater role for private and non-profit organizations (in the form of social enterprises of community interest companies) in England may bring substantial changes to the traditional model of general practice. At the same time, the increasing use of performance and incentive systems and flexibilities around service payments introduced in the new General Medical Services (GMS) contract in 2004 have substantially changed the way practices are run (Guthrie et al 2006, Wang et al 2006). Before examining this and key issues relevant to primary care it is worth spending some time thinking about what we mean by primary care and recent developments in the UK.

Primary care has long been acknowledged as one of the major strengths of British health and social care arrangements, with its focus on universality of access, emphasis on continuity of family and individual care, and its role as a gateway to other services (Starfield 1998). However, the theory and practice of primary care has been undergoing re-evaluation and change (Macdonald 1992, Starfield 1998, WHO/UNICEF 1978), a situation reflected in the re-examination of primary care in the UK (Peckham and Exworthy 2003).

This re-evaluation from within primary care services has been accompanied by impetus for change coming from national policy and growing concerns about how well practices are supporting people with long-term conditions and supporting self-care and public health (DHSS, 1986 and DHSS, 1987, Department of Health, 1996, Department of Health, 1997, Department of Health, 2000a and Department of Health, 2006). Initially, the main thrust for change was on quality and then, with the introduction of the internal market and fundholding, on the purchasing role of primary care, which was intended to lead to greater efficiency and responsiveness (Le Grand et al 1998). At the same time, there has been a reassessment of the role of general practice, and latterly, more radical solutions have been sought, with a range of new developments, from the mid 1990s onwards. These included primary care act pilots (PCAPs) which are exploring new organizational arrangements for general practice, total purchasing – where groups of practices held the whole purchasing budget for their population, and GP commissioning which brought together GPs and health authorities on commissioning. These latter two were the forerunners of, primary care trusts (PCTs) and care trusts – in England, Scottish local community health partnerships, local health and social care groups in Northern Ireland and local health boards (LHBs) in Wales.

One central feature of this new focus on primary care is the increasing tension over what we mean by primary care itself. In particular current policy developments and responses to the challenges of increasing technological advances and increasing specialization, public health, self-care and supporting people with chronic conditions highlight a tension between traditional approaches to general practice as primary medical care and wider understanding of primary care as community-based care and support (Peckham and Exworthy 2003). Current government policy across the UK emphasizes the promotion of primary and community care, with the intention of ensuring a more efficient response to the needs of vulnerable groups, by managing the care of these groups as much as possible in the community and by developing interagency work and focusing on long-term care. In a sense this recognizes the need for general practice to change although at present general practitioners remain the central figures, and general practice the pre-eminent organizational structure in UK primary care.

Primary care became seen as both an issue (‘problem’) to be tackled and also as a solution to ‘difficulties’ elsewhere in the NHS during the 1980s and especially the 1990s. As the contribution of primary care to the wider NHS became increasingly recognized, there was a greater need to incorporate it into the NHS’s organization and management. Perhaps the most significant trigger for this was a process of managerialization which took place right across the public sector – the rise of new public management (NPM). It established new patterns of policy, organization and management. Although it initially had a marginal effect on primary care, NPM began to permeate primary care through the introduction of managerialism in community health services and other providers, the shift in focus from family practitioner committees to family health service authorities and the more managerial approaches (often associated with information technology) within individual general practices.

This process of incorporation continued into the 1990s with a series of reforms which were an attempt both to reorganize primary care and to act as an additional lever upon secondary care. This was most clearly evident in the GP fundholding scheme and Trust status but also through a series of policy statements. Although the internal market had profound inter- and intraprofessional consequences, the policy direction continued to move towards further integration with the introduction of primary care organizations (PCOs – primary care trusts in England, local health boards in Wales and community partnerships in Scotland), not least because these were not voluntary schemes. Once community health services had been reorganized into PCOs, primary care was effectively incorporated into the NHS. A process which had begun some 30 years earlier had finally been realized.

However, such incorporation has not been absolute and nor is it complete. Primary care has always been noted for its diversity, in terms of service provision and quality. Despite many initiatives oriented around quality improvement (often associated with NPM) in the 1980s and 1990s, the linkage between management and quality only formally became established with the introduction of clinical governance in 1997 and now somewhat enshrined in the new GMS contract. As mentioned previously, primary care is also becoming increasingly characterized by diversity in its organizational form. Incorporation has not been, and is unlikely to be, a uniform process, applying to all areas and to all services, equally. Devolution has created further complexities and diversity in primary care (Exworthy 2001, Peckham 2007) but there are common themes in policy across the UK such as the new GMS contract introduced in 2004 (discussed below) which demonstrate a new emphasis on developing primary care services with the potential to change the traditional general practice model of organization. In addition, recent developments in England point to increasing divergence with a greater role envisaged for new forms of organization to deliver primary and community healthcare services including private companies and social enterprise and community investment organizational models, while in Scotland and Wales the emphasis has been on service planning, partnership and collaboration and developing organizational and clinical networks. These changes, while focusing on organizational models, reflect a growing interest and recognition of the need to support self-care and informal care (Department of Health 2006, Kerr 2005) with a growing recognition that long-term and chronic health problems are not satisfactorily addressed within the UK NHS (Coulter 2006). Self-care is increasingly perceived as central to developments in health and social care and various English policy documents such as Our Health, Our Care, Our Say (Department of Health 2006) have stressed the importance of self-care and the role of the NHS in supporting it; the public health White Paper Choosing Health introduced health trainers and placed a greater emphasis on building skills of people for preventing ill health (Department of Health 2004) and the Green Paper on adult social services Independence, Well-being and Choice highlights the need to support people with long-term conditions to manage independently (Department of Health 2005a).