Background
Primary and community care services are regarded as the first level of contact that individuals, families, and/or communities have with the NHS. Primary and community care services bring basic health care as close as possible to where people live and work. Having a strong and vibrant primary and community care sector – one that is accessible and universal – is important. International studies consistently show the clear benefits of this in terms of both health gain and cost-effectiveness1.
Policies of the previous government sought to strengthen the role of primary and community care services through a strategy of shifting the balance of care away from hospitals (see Our Health, Our Care, Our Say: A new direction for community services and NHS Next Stage Review: Our vision for primary and community care).
What are primary and community care services?
In the NHS in England, primary care services are provided by GPs and the ‘primary health care team’, including nurses and other care professionals. Primary care also includes:
- pharmacists
- dentists and optometrists
- out-of-hours care providers
- walk-in-centres
- polyclinics
- and a growing variety of other locally available care and treatment services.
Community care encompasses a broad and complex range of services. The ‘core’ of such services centres on district (or community) nurses who provide care for (mainly older and disabled) people at home or in residential care facilities, and health visitors primarily providing early intervention and health promotion to families with babies and/or young children. Community care also includes a number of specialist services including:
- podiatry
- speech and language therapy
- dieticians
- physiotherapy
- occupational therapy
- school nursing
- community mental health care.
Broadly speaking, community health services cover a number of key functions, including:
- promoting healthy behaviours
- supporting primary care in screening and vaccination programmes
- promoting well-being and independence
- delivering care at home; supporting rehabilitation
- and providing end-of-life care.
Despite the apparent synergies in the role and nature of primary and community care services, the two have, for the most part, operated and evolved entirely separately.
The evolution of primary care services
Primary care services in the NHS have undertaken a significant journey, with general practice in particular evolving from GPs working in single/dual practices to the majority working in larger group practices and health centres. Over time, changes to the national contract between GPs and the previous government increased GPs’ professional status and pay while shifting the basis of rewards to a mixture of capitation-based fees, target achievement (such as for immunisation and screening) and pay-for-performance through the Quality and Outcomes Framework (QOF).
Since the early 1990s, the promotion of a ‘primary care-led NHS’ also led to a policy of devolving health budgets to general practices – a move designed to achieve clinically led commissioning with decisions made closer to patients. This was initially done through GP fundholding and then through practice-based commissioning (PBC). The coalition government is committed to extending GP commissioning so that GPs hold 'hard' budgets as opposed to the notional ones that they held under PBC.
The evolution of community care services
When the NHS began in 1948, community health services operated under the control of local authorities. They later became integrated into acute care in 1974 – a move seen as helping to deliver a better co-ordinated service. However, following the 1989 White Paper Working for Patients2 which established the building blocks of the purchaser–provider split in the NHS, community service providers progressively established themselves as separate trusts in the hope of stimulating a shift in care and resources away from powerful acute hospitals towards community-based care.
Following the election of the new Labour government in 1997, most community trusts were merged with the newly founded primary care trusts (PCTs) in a move designed to better integrate their activities with their primary care counterparts. Since 2005, community health care has been in the process of yet more change as PCTs have started to contract out community services in an effort to minimise their role in provision and to concentrate on being commissioning-led organisations (see Shaping PCT Provider Services: The future for community health). The coalition government is committed to PCTs continuing to divest themselves of their directly provided community services (see Revision to the Operating Framework for the NHS in England 2010/11)
References
- Goodwin N (2008). ‘National Health Systems: Overview’, in Kris Heggenhougen and Stella Quah (eds), International Encyclopedia of Public Health, Vol4, pp 497–512. San Diego: Academic Press.
- Department of Heath (1989). Working for Patients. Cm 555. London: HMSO.
