The first effect of policy is on expectations. In every case I can think of, the effect is inflationary. And policies created on the promise that payments can be linked to outcomes are a stand-out example. In this case, the hype – delivery gap is more like a tectonic chasm. 

It’s difficult to be precise, but the decade after the election of the Coalition Government in 2010 probably saw the peak of enthusiasm for policies based on this approach. 

“Dad, why are all your ‘peptalks’ about death?”

Children can be a source of fundamental insight. They seem to specialise in feedback of the unvarnished, unmediated and fully caffeinated variety. The kind of feedback that cuts straight to it.

My youngest daughter, mid-way through our sunny walk down the hill to school, pressed on:

“And you wear black all the time. You look like a crow…”

Fundamental insight, and now fashion advice. This was quite the school run.

About 20 years ago, I attended a lecture given by Andrew Stevens, a rather formidable and austere Professor of Public Health at the University of Birmingham.  He was setting out his epidemiologically based approach to health care needs assessment. He and his colleagues, James Raftery, Jonathan Mant, and Sue Simpson edited a series of books on the topic that sit on the shelf behind me¹.  I refer to them on a regular basis.  They remain both grounding and inspirational reference material.

“…personal contact was a vital element in general practice from the beginning. By 1959 50% of people in England regarded their GP as a personal friend.”

In our recent paper we explore why levels of care continuity have been declining and what might be done to turn things around.