Primary care: a national asset

A previous health minister and eminent healthcare leader, Lord Darzi, recently said:

‘Too often politicians have seen healthcare as a cost to be contained rather than an opportunity to deliver better lives and greater national prosperity.’ ¹

Darzi was urging us to view healthcare funding as an investment in the national economy rather than as a taxpayer cost, constantly to be curtailed. His comment came in response to a well-argued think tank report on the potential for investment to reduce secondary care elective waiting lists, both surgical and medical.² The report by LCP Health Analytics provides a breakdown of the economic benefits of investing in the NHS Elective Recovery Plan, aiming to achieve a 30% increase in capacity relative to pre-COVID levels for inpatient and outpatient treatments by 2025. If successfully implemented (a big ‘if’, considering workforce capacity shortfalls and the impact of industrial action), overall economic benefits would amount to £73 billion over 5 years, with an additional £14 billion savings on health and social care costs and on informal care services.

Such a staggering boost to the national economy needs to be considered from a primary care perspective. Annual funding for primary care, currently running at almost £15 billion, pales into insignificance in the face of such large projected benefits from further secondary care investment (2021/22 data).³ So how have the authors calculated the benefits of ‘elective recovery’ and how does this relate to primary care?

ITEMISING ECONOMIC BENEFIT OF HEALTHCARE INVESTMENT

The LCP Health Analytics report found that reducing the waiting-list backlog would generate £18 billion through people returning to work or working longer hours; £55 billion benefit from unpaid work such as childcare, caring for elderly relatives, or volunteering; with further potential for £14 billion benefit through lower spending on additional health and social care.² A series of models were used to derive these benefits including the Wider Societal Benefits model, Time Use Survey, categorised by paid and unpaid patient productivity, and gains in quality-adjusted life years (QALYs). QALYs themselves are calculated using age-adjusted, health- related quality of life scores derived from EQ-5D-3L questionnaire survey findings, following a methodology developed by the National Institute for Health and Care Excellence (NICE) Decision Support Unit.⁴ This battery of tests is then applied to a model of all patients on the elective waiting list, further categorised by clinical groupings such as orthopaedics, general surgery, dermatology, ENT, ophthalmology, plastic surgery, gynaecology, and so on. The highest estimated gains were, by quite a large margin, for ENT and ophthalmology.

There is just no comparable data about the costed benefit of primary care interventions. The more complex world of primary care interventions is far harder to examine using ‘before-and-after’ analysis of ‘benefit’ compared to say, length of elective hospital care. Also unknown are the relative contributions of primary care and secondary care in terms of addressing national economic productivity, particularly in those of working age. Much has recently been made of the exodus of workers aged ≥50 years from the workforce, the drag this is having on national economic growth, and the extent to which poor health has contributed to this exodus.⁵ But there is little if any data to show whether investment in primary care can contribute to improving employment rates for the over 50s.

PRIMARY CARE DATA AS EVIDENCE OF ECONOMIC BENEFIT

Although NICE regularly review data on healthcare interventions and the costs of gaining one more additional year of quality of life (QALY), this data is not available to primary care in a digestible format. In fact, studies using QALYs are rare in primary care economic evaluation.⁶ As a result, this has weakened the evidence base for investing in primary care.

In public health terms, mortality is a more robust measure than ‘years of healthy life expectancy’ because of difficulties of defining ‘healthy life’. We already know that primary care saves lives through the accumulated achievement of various clinical and screening targets (mortality reduction). Taken together, this translates into 4.7 lives saved per full-time equivalent (FTE) GP, per year.⁷ Ten years later and these estimates have not been updated, leaving us with a lack of data on which to build the case for primary care investment. More pressing, we simply have no comparable data for years of health that we in primary care add to the lives of our patients, even though this is likely to be where primary care yields the greatest public health benefit. Without evidence of ‘healthy years’ or Quality of Life Scale (QOLS) scores, primary care cannot begin to develop the data infrastructure used so effectively to argue for investment in secondary care.

In a World Health Organization review, some focus has been given to the debate about where to find evidence for the effectiveness of primary care investment.⁸ The review highlighted three areas: health outcomes; health system efficiency; and health equity. But even finding the evidence on health outcomes is no easy task.

THE ECONOMIC BENEFIT OF TALKING THERAPY HEALTH INTERVENTIONS

In the early days of setting out the funding case for a national talking therapy service (Improving Access to Psychological Therapies, or IAPT), economists and clinical researchers collaborated to argue that the costs of setting up a national service would be largely offset by reducing the cost of mental health problems to the nation (welfare benefits and medical costs) and increasing revenues (taxes from return to work and increased productivity).⁹ As a result, in 2007 the UK Government set up an ‘unprecedented, large-scale initiative for ... depression and anxiety disorders within the English National Health Service’.⁹ Subsequent cost-effectiveness analysis confirmed the economic argument for investing in talking therapy, although costs per QALY were higher than originally predicted and gains more marginal.¹⁰ In recent years, the IAPT policy focus has shifted toward mental health outcomes rather than return to work, but the initial argument for funding was only successful because the case was set out for boosting national prosperity. If this argument could be developed for talking therapies, can we do the same for investment in primary care?.

WE HAVE DATA ON PRIMARY CARE QUALITY — BUT NOT THE RIGHT DATA TO SHOWCASE PRIMARY CARE AS A NATIONAL ASSET

Quality and Outcomes Framework (QOF) data provide a unique insight into national achievement of clinical targets for 21 clinical domains and five public health domains. However, QOF is now 20 years old and target achievement is under increasing criticism. The recent Hewitt review published in April 2023 called on NHS England to reduce national targets and place a greater emphasis on prevention.¹¹ Primary care has a central role to play, but we need the data on which components of prevention activity translate into ‘healthy years’ for our patients and contribute to national prosperity. In a perceptive opinion piece, Shemtob et al¹² highlight the reductionist approach to primary care, stuck in a rut of ever-increasing ‘units of piecework’, neither adequately representing productivity nor quality. In its place, we in primary care urgently need data of the sort utilised so effectively by the LCP Health Analytics think tank. Data that demonstrates primary care health outcomes of significance to patients — and health economic outcomes of significance to NHS policymakers.

Only a new approach linking clinical researchers and health economists can generate the data required to justify primary care investment. If mortality reduction data is anything to go on, it’s likely that primary care has a substantial and as yet unmeasured effect on ‘healthy outcomes’ and QALYs. As a spin-off, being able to demonstrate improved lives with population data is likely to offer a big morale boost to primary care teams. The data we need in primary care will be less about targets, and more about health outcomes.

Funding

Veline L’Esperance was funded by an NIHR doctoral research fellowship (reference: DRF 2017-10-132) for this research project.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.