The author surveys shifts in macro-economic policy and thought from Keynes and Kalecki to the present, tracking the changing climate of economic opinion. As Kalecki foresaw, the success of Keynesian demand management was undermined when, in an era of full employment, the power of labour threatened industrialists’ authority over the economy. From the 1970s, this led governments to introduce pro-capitalist measures. Countering recessions with budget deficits was now seen as irresponsible. The rise of globalisation meant that domestic demand management became less effective, especially in economies highly dependent on imports. Opening up economies meant that their exchange rates and stock markets became more vulnerable to capital flights. As the reach of finance became increasingly global, those private credit rating agencies became the game changers. Today private credit agencies, through their rating of the investment climate and sovereign risk of a country, in effect rate the quality of its government. Capitalist democracies are now dominated by private finance. Management of the investment climate is increasingly done through the virtual rather than the real economy, creating artificial financial asset and housing market bubbles. At the same time, in the neglected real economy, inequality and unemployment have increased, and living standards are falling.

The Primary Care Deprivation Initiative (PCDI) has been established in a deprived part of inner-city Liverpool in three health centres, in order to improve the capacity of the primary health care teams (PHCTs) to address the health and social care needs of part of the practice populations. Non-professional PCDI support workers, supervised by an experienced nurse, offer advice, support, information and, where necessary, advocacy to patients referred by PHCT members who present with mixed health and social care needs. The aim of the present study was to discover whether the PCDI eases the burden on the PHCT by reducing presentations to health staff of primarily social problems, or whether PCDI clients might make increased demands on the PHCT as a result of the PCDI being available. Routinely collected data on the use of primary care services were compared. Data collected for 12 months before and after accessing the PCDI showed statistically significant reductions in GP consultations and new prescriptions. There was also a definite but statistically non-significant increase in prescribing as a whole. It is concluded that, in the case of patients presenting with undifferentiated heath and social needs, the provision of services to separate and address the latter appears to result in more appropriate use of primary care by patients and more effective prescribing by GPs.