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Round table: Access all areas?


Richard Armstrong Head of Primary Medical Care Contracting, Department of Health

Ben Bradshaw MP Minister of State for Health Services, Department of Health

David Haslam National Clinical Adviser, Healthcare Commission

Jeannette HoweHead of Pharmacy, Department of Health

Steve Poulton Commercial Operations Director, Pfizer

David Pruce Director of Policy and Communications, Royal Pharmaceutical Society

David Colin-Thomé National Director for Primary Care, Department of Health

Steve Field Chairman, Royal College of GPs

David Furness Health Project Leader, Social Market Foundation

Branwen Jeffreys Health Correspondent, BBC TV News

Julian Le Grand Richard Titmuss Professor of Social Policy, London School of Economics

Martin Roland Director of the National Primary Care Research and Development Centre, University of Manchester

Sue Sharpe CEO, Pharmaceutical Services Negotiating Committee

David Stout Director, Primary Care Trust Network, NHS Confederation

Branwen Jeffreys (chair) I would like to start by getting everybody to make a contribution from the perspective of the patient. Once, patients would have gone to their family doctor as the sole gatekeeper for the NHS. Now the white paper on pharmacy envisages that they might also go to a health advice centre at their local community pharmacy. They might get information online or at the end of a telephone. Ben, why do patients need more options?

Ben Bradshaw The options that have been offered to them hitherto have been rather restrictive and have not kept up with changes in healthcare provision, changes in emphasis towards prevention and changes in the way people lead their lives. For example, over the past 18 months we have been having discussions with the British Medical Association (BMA) over GP opening hours. Almost uniquely of public services and healthcare in particular, and in spite of record investment, the public are telling us very firmly that GP surgery opening hours were not convenient to them and to their families. When it comes to pharmacy, there has been a perception for a long time that pharmacy has not been able or given the space to develop its full potential and contribute to a more comprehensive primary-care offer, a more convenient one that a lot of people feel very comfortable with accessing in their local high street.

Branwen Jeffreys Professor Roland, is this what patients want?

Martin Roland I think they want better options, and better options might include more options. One of the things driving the need for better care is increased complexity, both of medicine and of people's problems as they get older and have multiple conditions. We need to drive a path between better options and not making the system so complex that care becomes more fragmented and made worse by trying to make it better.

Sue Sharpe We are seeing the development of pharmacists to help people keep well and manage their own health. As pharmacists develop the services and their interventions with patients around medicine taking, they will help patients feel more in control of their health and their treatment. Patients can get access to pharmacists, talk informally and it allows them options as to how they access the level of care they need. Some will need specialist help; some will need GP help. But increasing numbers will be able to manage their own health needs with better information.

David Stout Patients using pharmacists is not a new option. Patients have always gone to pharmacists for advice. However, there are issues around how we make a complex range of services understandable to patients. How do they navigate through this potentially complex field in which some pharmacists offer some services and others do not; some GPs offer some services and others do not. Are the people offering the services properly trained and equipped to give good-quality diagnosis or advice? We need to be confident that we have proper systems in place to ensure quality of care and address this navigation issue.

Branwen Jeffreys The Healthcare Commission highlighted that confusion recently. Do people simply turn up to A&E because there is a big sign saying, "This is where you come for help".

David Haslam Absolutely. I am a GP as well as an adviser to the Healthcare Commission and it is absolutely clear that there is a need for clarity, logic and simplicity; that patients understand where to go. Healthcare language is confusing - the term "primary-care access" does not mean much to most people.

Steve Field Access is important. Pharmacists have been around for years and there is potential in expanding their role, particularly on prevention and on minor illness. As we move more towards roles-based care, protocol-driven care, we need to free up GPs to have longer appointments to deal with illnesses.

GPs have to be brave in this, hand over a fair amount of what we do at the moment and extend the length of consultations to deal with the ageing population and so on. However, it will only work if pharmacists are part of the team and what I am worried about is fragmentation and pharmacists doing things that they are not trained for, just as GPs doing things that they are not trained for is also a problem. So the issue is how it fits into the jigsaw.

Branwen Jeffreys David Colin-Thomé, do you think that some GPs might be anxious about the changes?

David Colin-Thomé Of course, any change causes anxiety. I have probably been a GP longer than most of you here put together and my job was to be available for my patients when they perceived they had a need to see me. That relationship is the important bit and that tends to be confirmed by lots of studies.

I was happy to see people with minor ailments because they were Mrs Jones or Mr Smith rather than because it was a minor ailment. Many of them did come with minor ailments because I was their clinical adviser but next time they might come with something major. It depends on your relationship, I think. However, we have to accept that patients might also want to see somebody else and that sometimes causes tension.

Branwen Jeffreys David Furness, how well equipped are different types of patients to navigate their way through the system?

David Furness The pitch is very mixed. While young people may be very adept at accessing information through electronic resources, they may be less familiar with the landscape of healthcare compared to their grandparents who are better at getting the appointment they want or the service they require. We need to recognise that diversity and hopefully we will end up with a system that reflects it.

I am quite sceptical about claims that moving more work into pharmacy would reduce the workload of GPs because we know that demand for healthcare has a way of expanding to fill the available capacity.

However, we have to recognise that this diversity of patients may choose things that do not look efficient or effective. They may be more expensive. People may choose to turn up at A&E for their first presentation with particular symptoms.

We cannot want both to give people choice and to expand the range of things available to them but then also try to manoeuvre people down a particular path when we know that identical people make different choices.

Branwen Jeffreys Julian Le Grand, should we be curtailing people's expectations of what they can make demands on the health service for?

Julian Le Grand In general, I have been in favour of expanding the pharmacist's role as they have skills that seem to be underutilised. The caveat is that it might lead to patients thinking that a pill will solve every ailment, whereas if you had gone to the GP, you might have got a recommendation to go to the gym.

David Pruce Actually, we have quite a bit of research to show that a lot of people that turn up at a pharmacy expecting to buy a tablet are actually sent away because either they need to go and see their GP or they need a different solution. So that is already part of our philosophy. We need to get to a place where GPs and pharmacists are able to work together more as a team and to learn each other's skills and where the boundaries lie - when pharmacists need to refer a patient on to the GP and when the GP has a complex patient with multiple medicines who would benefit from the advice and expertise of the pharmacist.

Steve Poulton Medicine is only effective if it is taken properly and in accordance with the directions of the clinician who has prescribed it. We are trying to work much harder with pharmacies to give them access to information about the medicines we produce. We would like to think we probably know more about our medicines than anybody else does but, for me, this debate is really about the shifting need of what primary care should be delivering.

The NHS is absolutely wonderful as a national treatment service. What it is not very good at is preventative medicine, catching people before they get broken. Extending the remit of the broader primary care team to include some of the skills and accessibility pharmacists have could really help that.

Ben Bradshaw Since 2004, primary care trusts (PCTs) have been required to publish an annual "Your Guide" and these have been of variable quality, so we have been doing work on this and we are about to issue new guidance. I think you are right that people do not know about services at local level. This should make it much clearer about the offer locally from the pharmacy - what sort of services you can go to your pharmacist for as well, and more and clearer information about GP access. We will also be addressing the issue of PCTs. We need to start calling it "NHS Devon" and "NHS Hammersmith and Fulham" so that most people understand what that name means.

Branwen Jeffreys David Pruce, where do you see the boundary between this new role that could develop for pharmacists and what GPs can do?

David Pruce GPs have particular skills around diagnosis, but pharmacists do not. If a patient comes into a pharmacy with a minor ailment, we are usually able to say, "This is something that you can treat yourself" or "This is something you need to go and see your GP about". Pharmacists have specific expertise around medicines and our expertise is likely to be better than that of GPs because we have spent more time on it. So we each need to recognise our limitations and see where we can work together. The whole makes more sense than each of the parts does. I do not want to be a mini doctor. I want to be a maxi pharmacist. That is something that most pharmacists would agree with.

Branwen Jeffreys Do you think the predictions in the white paper are right that as many as 60 million consultations a year could shift out of GP surgeries into pharmacies?

David Pruce I do not think that is how people behave. You are likely to see a shift if the care that is provided in pharmacies is part of the NHS and is free to the same extent it is in general practice. Currently, there is a barrier in that people have to pay for things they buy from pharmacies, whereas at the general practice you get it free of charge.

David Colin-Thomé As I say, a lot of primary care is about relationships and some will have a strong relationship with pharmacists and then move on to the GP. Some may have a relationship with a community nurse they are working with. We need flexibility. Even though that might seem more inefficient, primary care is much cheaper than going to secondary care. I think we shouldn't be too mechanistic about the cost efficiency of primary care because you will damage the actual relationship if you make it too simplistic.

Steve Poulton I think the danger is that we are not going to see a shift, we will just see a massive expansion.

Steve Field I think Ben is right that when you talk about access, access is not just to a human being but to information. Diabetes used to be the realm of endocrinologists and now really is much better managed by patients on their own with some advice. In future, many patients will get that advice from pharmacists, hopefully working with GPs. As things become more roles based or the patients do the investigations and monitoring at home, then they need access to information. For me, it is about how we empower the patient to manage their own care. They might manage it through using the internet for information or by popping along to the pharmacist.

Prescription charges are an important point. In inner-city Birmingham, where I work, many patients come to us for cough mixture and things that I would not prescribe and David would not advise as a pharmacist. So we need to work with patients to understand what is best for them. That is more important in the long term.

Branwen Jeffreys Some PCTs have started playing around with commissioning a wider variety of services from pharmacies. How is that working?

David Stout It is anything from minor ailments services being commissioned as an alternative to general practice for minor ailments through to designated specific services which are additional to what is already in place - contraceptive services and anticoagulation services and so on. So it is working very variably, I suspect.

Generally, people see this as a useful addition in terms of choice for patients. However, there is a fundamental value-for-money question that as we offer more services people start to shop around. Can we afford all of these choices, ultimately? Is this the best use of resources? In what PCTs have put in place so far, I think they have seen these services as useful, value-for-money additions.

Ben Bradshaw One of things I have been picking up is a lethargy on the part of PCTs, for example, with the vascular screening that is supposed to be rolled out in the New Year by a range of providers, including pharmacists.

David Stout I have not picked that up so if that is people's perception it would be interesting to know.

Sue Sharpe I think that is right. We have PCTs that are very varied in their ability to look at and think of ways of engaging pharmacy. Some pilots in London are working well in the early stages but we have tremendous inconsistency across the country and I think, as we develop better use of pharmacy, we need to tackle this consistency of offer around the piece so that patients can become much more aware of choices. I think the "NHS Devon" that you cited, that clear branding of where patients go for help, rolled through to pharmacy, will be helpful.

Branwen Jeffreys Do you see a distinction in the uptake of these new ideas between the larger pharmacy chains and the many thousands of individual community pharmacists who may feel less able to cope with all of these changes? Will they gradually be edged out?

Sue Sharpe Yes. I think the larger chains have seen the strategic direction and have organised themselves to make the change rather more consistently, as you would expect, than the independents. There are some excellent examples in independents but there is more variation.

Martin Roland It just strikes me that it is tinkering around the edges. If you came down from Mars you would not do it like this. You would not have one bunch of people who are particularly skilled diagnosticians and another bunch who are particularly good with complex medication regimes and stick them in different places with records and tell them to get on with it.

In my practice in Manchester, we employ a pharmacist four days a week. She works with repeat prescriptions, with the doctors coping with patients. It is hugely beneficial. How can a pharmacist help a patient with a complex medication regime when they do not have their medical records? So we need to think more radically if we are going to make the best of what the two professions have to offer.

Jeannette Howe I think it is important to think about pharmacy as a mixed model because there are models where pharmacists can work very closely with general practice and we want to encourage that. But, being on the high street, pharmacists are very accessible and can provide services to people who do not actually use the health service regularly. Our conundrum is to balance both of those things. In the white paper, we said we would work with the leading edge PCTs around access to patient records because it is a very sensitive issue.

We need to develop exactly how pharmacists will get access to the care-record service and then we can develop services further. Where services are developing, GPs do give pharmacists access to their patient records, so we need to make that more general.

We are trying to make pharmacy mainstream within PCTs' commissioning. That is why we are consulting and doing a pharmaceutical needs assessment as the basis for decisions around the commissioning of pharmaceutical services.

The white paper recognised the need to support service development with commissioning to the public. We are working particularly with people with long-term conditions, to find out what they understand about pharmacy, how they want to access pharmacy, terminology and so on.

David Haslam From a regulatory point of view, for the Healthcare Commission and, from next year, the Care Quality Commission, the real drivers are going to be both quality and safety, and safety is absolutely key. It is absolutely spot on about the communication issues and the illogicality of the gaps.

We have to find a way, realising that we cannot completely restructure the health service. Medical records are part of that but, as the population ages, and we have more people with multiple problems and multiple comorbidities, all the simple disease guidelines cease to be as valuable. It is absolutely key that pharmacists, GPs and secondary care are working coherently together.

David Furness It seems we have identified the tension between wanting to create solutions with locally commissioned services involving pharmacy and the problems of lack of uniformity. Sometimes we want to have our cake and eat it - to have uniform national standards across the country but then encourage local autonomy and decision-making appropriate for a local population. That circle has not been squared in the NHS over 60 years. Perhaps the variety in services is something we need to start promoting the benefits of to local people.

Julian Le Grand Something we have not mentioned so far is the incentives in the system. GPs have an incentive to economise on prescribing because they have got to think about all the possible demands on their prescribing budget.

Pharmacists cannot over-sell prescription medicine but they can sell over-the-counter medicines and their incentive might be to sell a little more than might be wholly appropriate. These incentives work in opposite directions. We must have a system that operates with checks and balances.

David Pruce In Canada, they have looked at that by having a "non-dispensed fee". When a pharmacist actually says, "No, you really do not need this," the pharmacist gets a fee from the equivalent of the PCT for stopping the medicine, which I think is a very interesting model. It incentivises pharmacists to look at what the GP has prescribed and say, "Actually, you know, you can rationalise this".

We currently have a system of medicines use reviews being started up within the NHS in England and Wales that asks patients: "Are you actually taking these medicines?" "Are you having problems taking them?" We know from research that patients do not take about 50 per cent of statins prescribed. We spend a lot of money getting the prescription right but much less getting the patient right.

Sue Sharpe On pharmacists' incentive to sell medicines patients do not need, I think it is important to get that in perspective. Ninety per cent of a pharmacist's income comes from the NHS. Only 5 per cent of total income comes from selling medicines and that has been reducing year on year as supermarkets have taken up much more of that sort of need. So I think it is important to look at pharmacy as an NHS business now, not a private-sector business with a very healthy front-of-shop turnover. That changes the way you think about how you use that resource.

David Stout As the conversation has gone on, I have been thinking that there are two effects going on here. One is around use of medicines, minor ailments and so on, where we clearly want pharmacists and general practice to work together as a team, and then there are other services where pharmacists are actually competing with general practice. Vascular screening might be an example; the practice might want to offer the same service that a pharmacist might and they will be competing for business. One of the conundrums we need to manage is that relationship between competition and collaboration. If you are competing with each other, you might not be collaborating when you should and if you are only collaborating you might not be getting the competition you need. So how do we manage those two pressures simultaneously?

Branwen Jeffreys Steve Field, how do you see that referral working from one to another?

Steve Field We have a pharmacist in the surgery for quite a bit of the week. We also work with our local pharmacy "shop", if you like. We do joint advice across the divide. One of the ways of incentivising this is to prioritise joint bids for work between pharmacists and GPs. If you had a joined-up system and you encourage that through the commissioning cycle, just as you would do through a pathway of care, diabetes or whatever, I think the world would be a better place and would also allow for some choice. We are at our best when the pharmacists are working in the surgery looking at the complexity of medicines and trying to reduce the number of medications people are taking or stop them. However, we know that a lot of our city patients want to go to their local pharmacy because it is open at different hours and it is not as far for some of them to walk. That is their choice and that is fine while you have got that referral backwards and forwards between the two. I think joint commissioning is the way forward.

Branwen Jeffreys So, in the same way that GPs group together to bid as consortia, do you think that is how it might work with GPs and local pharmacists getting together to make a joined-up offer to provide a package of services?

David Colin-Thomé I hope so because that is the thrust of our core policy in the Primary and Community Care Strategy from the Darzi Review. One of the problems with that, maybe, is our immaturity around some of the market issues. We either kick hell out of each other or we collaborate too cosily. The issue is how do you work together as a coherent whole but allow some choice within that? How do you keep that choice element so that people can go to the doctor; they can choose between different GP practices within this integrated-care approach? It will be a test of our mettle as to whether we can do both.

Steve Field That is why we are promoting the federated model between pharmacists. Actually, the future will be aggregations of practices and pharmacists and other healthcare professions working together.

At the moment, we do not trust all our PCTs to make appropriate commissioning decisions. We have a lot of mistrust in the system down at ground level, partly because of the new centres that have been put in and the way a lot of the discussions and consultations have not worked. Integrated care is something we support very strongly but we need PCTs to commission appropriately.

Ben Bradshaw In terms of their relatively enthusiastic advocacy of the state of the NHS, GPs have never been quite in the forefront! [Laughter] Perhaps that is the most diplomatic way I can put it. Second, their morale is considerably better than it was before the new contract was introduced.

Steve Field That is true. I think my point is not about the fact of these centres, because we welcome the investment but, when you start to look at commissioning, it is the local trust that is important. I think what your "NHS Devon" needs to do is work with its GPs and pharmacists to develop use of language locally, and demonstrate that they are working with pharmacists and GPs and nurses and others. Unfortunately, I think what happens is that that is quite patchy at PCT level.

Branwen Jeffreys What needs to happen to make sure that there is not a huge difference between richer and poorer areas and also urban and rural areas in terms of providing a good variety of choice and making sure that everyone is equipped to use it?

Julian Le Grand There is a problem with engaging in competition (if you believe competition is a good idea) within rural areas because rural areas do not have enough services, effectively. So you have to think of some way of making sure that those services meet the needs and wants of patients.

Actually, 90 per cent of the British population live in urban areas, so, in terms of population, rural areas are extremely small. In trying to think of system change and reform, we really ought to concentrate on problems in urban areas and try not to worry too much about the rural situation.

David Haslam In many of the urban areas, there are significant numbers of transient or immigrant populations who simply do not understand the way we work. Their default position is to go to hospital because, in many of the cultures that they come from, that is what they have done. Also, because of the complexity of our model, their ability to know about the alternatives is limited. The Healthcare Commission has been pretty keen on developing a single-access phone number for non-urgent care as a means of getting around this. There are all sorts of arguments for and against but it looks as if that is one way of bringing clarity into the system.

Over the past couple of years, we have been talking a great deal to the Academy of Royal Colleges, the BMA, the Royal College of Nursing and others about what high-quality care looks like? Clinicians really want to buy into this and the vast majority are signed up to delivering improved care. So, engagement with them is the key, rather than a position on them.

Ben Bradshaw I think I am right in saying that your report last week showed that patient satisfaction, as well as your grossly misrepresented findings on GP access, were generally better in rural areas than they are in urban areas. The trajectory of improvement in London is significantly slower than the rest of the country and a lot of that is about primary care and GP access.

Second, we have to be cognisant of the debate there has been about dispensing GPs and the particular role that they play in rural areas, while addressing some of the problems there have been with market entry. Although there are serious problems with the system at the moment, we would not want to do anything that had a disproportionately negative impact on rural areas. Inevitably, if you live in an isolated rural area, how real will your choice of GP ever be? At least the GP-led centres will give people a choice. For example, people who commute from rural Devon into Exeter, whose own GP in their village does not have extended opening, for whatever reason, will still be able to access a GP in the evenings or at weekends in the place where they work.

David Colin-Thomé NHS Direct is another option too, rather than always going to the clinician.

David Furness I think what we have are policy trends going in the right direction. If you offer diversity, then perhaps that makes it easier for people to access services most appropriate for them, which makes them more likely to do so. If people get on particularly well with their pharmacist, why not go and see them rather than their GP as the first port of call?

There are issues around supporting people's choices and PCTs have a big role to play in that. There is a challenge to overcome in terms of variation. It might also be about on-site support. Perhaps there are things we can do to make consultations with pharmacists and GPs more effective. A company in the US has people sitting in GP waiting rooms waiting for the pharmacist to help them work out what questions they want to ask, rather than receiving the information dump that can be a feature of GP consultations. So there are options.

There is not really any evidence of frivolous demands on the health service, so we probably need to focus on the small percentage of people who do not access the NHS at all and who should be accessing it.

Branwen Jeffreys But how do you get to the people who are not using the health service enough?

Steve Field It might not be the normal suspects. Men commuting into cities do not access health systems particularly and that is partly because of the timing of accessing the surgery. I would agree with Ben when he says somebody having to take a day off work to see the GP is a problem. However, you have to balance access with maintaining continuity of care. If you have a patient with a long-term condition or multiple conditions, they need someone to help them navigate their way through all of that.

Ben Bradshaw The other thing the government announced last year, along with the new health centres, was an investment in extra practices in the 50 or so least well-provided areas.

Also, we are changing the Quality and Outcomes Framework (QOF) in a way that will help incentivise GPs to look for and find those people that are currently hard to reach.

Martin Roland I think there is some agreement about choice. Choice has a tendency to increase inequality simply because the articulate are more able to navigate the system and they happen, also, to be the sicker people. The London Patient Choice pilots provided patients with advisers to help them make those choices and also provide some financial support for transport if they were going to go to a different hospital. It is important to recognise that choice does increase inequalities and we do not have to accept that. We can actually do something about it.

On the QOF, my hobbyhorse here is around continuity of care. We have never had a means of looking at the extent to which practices are providing continuity of care, allowing patients to see the GP they want to see, but we will have that from the new year because it is going to be in a new questionnaire that Richard has commissioned. That will go out to millions of patients in the new year. I think that is an important aspect to bring into the discussion.

Branwen Jeffreys Sue, how do you ensure that someone does not have that terrible experience of going to the GP surgery, perhaps going to a walk-in centre, perhaps going to a pharmacy and constantly retelling their story?

Sue Sharpe It is a problem in secondary care as well as in primary care. Easy access to shared records among all the clinicians who are participating in care is the only sensible way that we can get the infrastructure to support that.

I wanted to make a point about people, and particularly men, who are more reluctant because of work pressures or whatever to access care. There was a very interesting NHS-funded pilot in the centre of Birmingham where Lloyds Pharmacy undertook some heart checks. Seventy per cent of people who walked into pharmacies to go for a heart check were men and that compares with about 20 to 30 per cent of normal users of pharmacies who are men.

Branwen Jeffreys Is it that they simply felt that they could not or should not be bothering their doctor or that it was just opportunistic and offered to them on the spot, so it was convenient?

Sue Sharpe We do not know why, but we need to find out. My guess is it is both of those.

David Colin-Thomé Fewer men go to pharmacies than to GPs. That is why this pilot was so different, because it was counterintuitive.

David Pruce Continuity of care is right for some conditions but not for everything. We know that from work we have done in pharmacies. Patients with long-term conditions will often use the same pharmacy. But patients seeking advice on minor conditions or seeking anonymous advice will go anywhere. We have seen that with pilots around chlamydia screening where anonymity is important to people. Not everybody actually wants continuity of care.

David Stout PCTs are not just working on developing new health centres. They are focusing efforts on tackling health and equalities as well - targeted intervention.

We often describe patient choice as wrong, in a way. If it is a relatively minor condition we say going to A&E is wrong. I think we need to change our mindset around that. If that is an individual's choice and that is where they have gone for healthcare then let us make sure that we have the services that can deliver, if that is the pattern of care in the locality. Smart commissioning will be designing services to meet local needs, not a national template.

Branwen Jeffreys David Haslam, could I ask you to talk a little bit about this idea of investing more in guiding people through the system?

David Haslam You just have to deal with the person presenting where they are with the right sort of service. If people present at A&E with a problem that is not an A&E problem, you need to have worked out a way to get a good generalist there, ideally a GP, who is much less likely to admit or investigate or whatever than a junior hospital doctor. There is plenty of research showing that that is what is required.

As I said, the Healthcare Commission is enthused about the concept of clearly signposted navigation, mainly through single phone numbers. We need to consider the genuine meaning of "patient-centred" rather than it just being a mantra. It is looking at what the patient really needs and wants and that may be different on different occasions.

If I get crushing chest pain I really do not care who treats me as long as they are qualified. But if I get a long-term condition flaring up again, I do not care if I wait a fortnight to see my GP because that matters to me. We need to build that flexibility into the system.

Branwen Jeffreys How much are patients already exercising the choices that they have?

David Furness The evidence is slightly mixed. It has always been accepted that you need relatively few people exercising choice to have a big impact on providers but I think we need to recognise that this is a different sort of choice. We are not talking about, "Where would you like to have your hip done?", after you have been admitted into the system and had those diagnostics. We are talking about what, for most patients, will be a more important sort of choice, which is a range of services that you can pick from on everyday healthcare stuff.

Ben Bradshaw We have only had free choice for six months, have we not? There has been a manifold increase over those few months of people exercising choice for secondary care. We do not have true choice in primary care everywhere yet because, as we know, some people find it difficult to change their GP. Some people are not aware that they can. Awareness of choice is still too low, partly because patients are not being told loudly enough or regularly enough by GPs and PCTs and others that they have a choice that they can exercise.

I would just like to challenge Martin on something. It is logical that the more informed you are and the bigger elbows you have, the more you are going to exercise your choice but I think the evidence also suggests that choice does help drive up standards across the piece. The anecdotal evidence from some of these new health centres that are opening with extended hours is that it is blue-collar workers using the services because they are paid by the hour and otherwise they would lose pay.

The potential for choice to drive up standards across the piece should not be overlooked. Alan Johnson made the point about health inequalities recently that, yes, the gap has widened over the past ten years, but the lowest two deciles are now at the level that the upper two were ten years ago. So would we have achieved that massive increase across the board if we had not introduced some incentives, including choice?

Julian Le Grand The crucial point is that non-choice systems also favour the better off, possibly even more. They are much better able to manipulate and manoeuvre our systems. There is some very preliminary research out that is not yet published, so early days, but it is beginning to look as though in 1997 the poor tended to wait longer than the better off for certain elective procedures. It now appears as though they are waiting less time than the better off. I would like to think it is because of the introduction of choice. There are probably a number of reasons.

Branwen Jeffreys Is there any reason we can draw on to tell us anything about primary care and whether or not poor people will benefit from the introduction of more choice in terms of their everyday health services?

Julian Le Grand We do have this problem at primary care level, that many of the poor areas are not well served by GPs. Certainly increasing the sheer availability of GPs and GP services in those areas will be desirable, quite apart from anything we think about the incentive effects of choice.

Richard Armstrong There is quite good evidence that the more primary care clinicians - not just GPs - you put into an area, the more you drive up the standards of health. Partly that must be because of choice in that there is choice to have those clinicians, but, generally, it is because investing in more primary care clinicians is a much more cost-effective way of improving health and healthcare.

Steve Field That is why we welcome the investment in inner cities. We would have done it in a slightly different way but, in some areas, you do need new centres. In other areas you need to build on what you have. Across all of it you need to get clinicians working together. Pharmacies and GPs working in a federated way would be better than simply putting in small practices. One of the problems we have is a lot of smaller practices. They need to work together more efficiently.

David Colin-Thomé There is some evidence in the US that the threat of choice gets providers to sharpen up. However, the other aspect of choice that we have not been good at in the health service is patients might like their provider but it is a choice of what happens to them that we are maybe not so good at. The Commonwealth Fund suggests that British doctors, not necessarily primary care, were less participatory in their consultation style than doctors in other countries. For chronic disease/long-term conditions, that shift in culture is fundamental and might even help some of that drug uptake if people felt it was shared decision-making.

We hear many stories where patients were just told, "This is good for you".

Sue Sharpe Around choice, there is an interesting example in Hackney, which is a very under-doctored area. Pharmacies in Hackney started to undertake regular flu jabs for patients and City and Hackney PCT moved from near the bottom of the league table for targeted flu jabs to right towards the top, just in the year that they introduced pharmacy-based flu jabs. So, there is an indicator that extending access might help in those sorts of areas.

David Pruce On patient participation, we know from patients coming to us as pharmacists that they often do not understand what their tablet is, what it is for and so on. We also know that the more information we give people about their medication, what is it for, what the side effects are and how long is it going to take to work, the more it encourages people to stick with that medication. This is particularly true for things such as antidepressants, where it takes four to six weeks before you see any effect, and most of the side effects occur in those first four to six weeks. So, providing the patient with that information is likely to improve uptake, compliance and so on.

Patients only take away a fraction of what you actually tell them. That may be as low as 30 per cent, particularly if the GP has just given the diagnosis. That clouds everything.

Steve Field It needs rephrasing and reinforcing. I agree completely. The problem we have is that some practice is poor.

Branwen Jeffreys I would like to go round the table again and this time ask you where you think we will be in five years' time. Do you think that patients will be exercising their choices and options and that this will benefit them?

Julian Le Grand Yes, I think we will be in a situation of more choice and I think it will benefit patients too. I am not that worried about the massive range of opportunities open to people. I think having a range of options is a good thing. I think there are loads of under-utilised skills that we could make more use of. So, yes, I think there will be more choice available and I think it will indeed benefit patients.

David Pruce It depends what we do over the next five years. It depends whether the professions put effort into working together, whether government puts incentives into people working together and whether the PCTs or "NHS Devons" facilitate it. If it is left to happen on its own then probably it will not happen.

Steve Poulton In terms of point of entry to the system then, inevitably, we will have more choice and people will be exercising more choice. I hope that, once people are in the system, we will have a more holistic view of the whole pathway, that is: awareness, presentation, diagnosis, treatment, prescription and advice.

Primary care is focused on the bit between presentation and prescription but there is also the upstream bit around awareness and presentation and the downstream bit around compliance. I think that is where pharmacy can really add value.

Ben Bradshaw Commissioning will clearly be key. We have not talked about the economic context and the importance of delivering all of this and, at the same time, delivering value for money, which is where commissioning will have to come into its own. How far the public are encouraged to and actually do exercise their choice will be important if it is to work.

Branwen Jeffreys Do you think there may be more services but also more demand?

Ben Bradshaw We may already be seeing this with a somewhat mysterious rise in GP referrals in some PCTs. It would seem that part of it is that GPs are actually referring, whereas before they would not have bothered because the person would have had to wait too long.

Martin Roland I am fairly pessimistic. Unless the professions put effort into working together, and unless there are incentives for them to do so, I do not think a lot will change. If we want things to change in the way that people clearly have a vision that they could, we need to do more than we are doing at the moment.

Sue Sharpe It is a big challenge. The NHS must play its part in promoting pharmacy as an NHS resource, and inter-professional working. Shared records are absolutely key. We must have a degree of commonality or consistency of what is on offer around the country in order to support patients having the understanding of the range of options as they go and access care.

David Stout I am optimistic that the effort we are putting into commissioning is driving this system in the right direction but it is dependent on multiple perspectives working together. It is about the professions, commissioners, the public and regulators dealing with poor performance. The media have a role in telling the story of how this operates. Push the policies in the right direction and I am optimistic that, if all those groups work together effectively we will see better services, better access and better outcomes.

David Haslam One area we have not talked about at all is the really important concept of encouraging self-care, which I know the Department of Health (DoH) is very enthused about. I have been doing some work for the Academy of Royal Colleges with the DoH on an educational curriculum on this.

The trouble is that the more you open up access to expertise such as doctors, nurses and pharmacists, the more self-care seems to move back. Not to knock it, but it actually does something to the building up of expertise and it will require doctors and pharmacists to do an awful lot more education as opposed to prescription.

The boundaries between primary and secondary, NHS and the independent sector, health and social care are falling away. They have become less and less relevant and important and the role of a regulator like the Care Quality Commission (CQC), which will be across all these sectors, has real potential.

If we focus around good, safe quality and get rid of some of these boundaries and recognise that the strength of primary care is generalism and the strength of secondary care is specialism, and bring those together, I think we have a different model.

Steve Field I am an optimist, but I think the key is this integration, horizontally and vertically. The professions need to understand that they are not under threat. Once you feel under threat, it is difficult to move but there are massive opportunities for pharmacists and for GPs. I think one of the issues in the past nine months has been GPs feeling threatened.

Yes, integrated care, with care moving towards the patient and out of hospital buildings into closer areas. My only concern is that the future will actually be smaller units, not at PCT level but conglomerations, aggregations, practices, pharmacies, dentists and physiotherapists.

I think PCTs are too distant from that, so forming clusters around health economies is going to be key. Inevitably, unfortunately, there will need to be a restructuring to support that because some PCTs are too distant from where the patients are.

David Colin-Thomé Five years is quite a short time. Yes, there will be more choice. I think also, in certain areas in particular, we want more demand. One of the issues, especially in working-class areas, is that we need to be more proactive about looking for problems.

Sometimes the professions are in such a dependency culture that they want the incentives to hit them between the eyes. That is why I am quite keen on pilots. Historically, we have tended to concentrate very much on the underperformers and our national trades unions, rather than saying, "Give some of the guys who want to do stuff their head." I think the integrated care worker will say, "Here are the keen guys. Let them fly," rather than constraining them. If that splits the profession, all well and good.

The hope for fast tracking some of this stuff is in the use of incentives, because we can use that best, rather than saying, "The government should do this and the government should do that". A number of people are hoping to get involved in these integrated approaches.

David Furness I think, echoing David's last point, it is spot on to be focusing on where we can get pockets of good practice and the challenge will be to roll those out across the whole system. That is why I think there are two key challenges here. One is commissioning and the organisational capacity of PCTs in different parts of the country to deliver this as well as what the top guys will be doing.

The second is a regulatory issue. We know there will be a lot of change and disruption over the next months and years. The introduction of CQC and its role in spreading good practice could be crucial but may be difficult to deliver, given that it will be dealing with a whole new set of challenges. So many different positive things. I think we have got the policy-keepers all facing the right way but there are lots of different stakeholders that need to get together and deliver it. Obviously we hope that, in the end, the winner will be the patient.

Branwen Jeffreys We hope indeed. Thank you very much for taking part in this round table.

This round table report is one of a series of reports based on the New Statesman & Pfizer Policy Forum, a programme of events and publications. Launched in April 2005, the programme aims to explore, through dialogue and debate, a range of issues that concern policy-makers and the electorate alike.

Previous reports can be found on our website.

This article first appeared in the 03 November 2008 issue of the New Statesman, Israel v Hamas