Primary Care

We now think of Primary Care, particularly general medical practice, as first point of access in the NHS for the whole population, with an emphasis on comprehensive, co-ordinated and continuous care. That was certainly not the case before the NHS was established in 1948. Before then, the “panel” system operated by GPs provided free care only for those in employment; many other services in the community, even if available, came at a cost.

But even in the new NHS of 1948, the organisation of community based services was not designed to deliver the integrated care that we now expect. The GPs, along with the dentists, chemists and opticians, kept their independent contractor status, and were paid largely through capitation or item of service arrangements. The other community based staff – e.g. district nurses, midwives, and the small number of allied health professionals at that time – were employed by local authorities, and tended to operate in isolation. And all of them were in separate organisations from the bodies that ran hospital services.

GPs mostly worked from their own homes, with limited facilities and often supported only by family members. The other contractor groups worked largely in isolation from the rest of the healthcare system. And all of them experienced overwhelming demands at the beginning of the NHS. It was the first time that the whole population could visit or be visited by a GP, have a prescription made up and dispensed, have their teeth examined and decay treated, and have their eyes tested and glasses supplied – all at no direct cost to them. Very soon, charges for all the contractor services, except GPs, were introduced, but the growing demands from the patient needs that had been so long unmet continued unabated.

Changes had to come, and the 1960s saw a new charter for GPs which financially encouraged group practice, staff support and better premises. Closer working with community nurses and the other contractor professions became the norm. 1974 brought organisational integration to all parts of the healthcare system, although the benefits would take many years to realise. The growing importance of vocational training for the professions was recognised and better reward systems implemented.

The next two decades saw an increasing emphasis on care based in the community and a variety of organisational approaches to support that. The better integration of care was supported by improved information systems, and by closer working with the social care and community services provided by local authorities. The emphasis in Scotland on co-operation rather than competition led to improved pathways of care for patients, but still with primary care as the gateway into the system.

More recent changes, such as the introduction of NHS24, a revised contract for GPs, and new reward systems for other community based professionals, pose challenges for integrated Primary Care, as does the changing age structure of the population, and of its health needs, particularly for chronic disease management. But there is international recognition that a strong Primary Care system is both effective and efficient, and Scotland has the opportunity to ensure that not only is more care provided locally but that it is indeed accessible, comprehensive and co-ordinated.

Dr Hamish Wilson
Chair NHS 60th Steering Group and previously Head of Primary Care, Scottish Government