Here is the briefing I issued via RCGP Scotland prior to todys debate on integration of care at Holyrood. It outlines the context for change, including the underfunding of General Practice, and RCGP Scotland’s vision for the future: –
The Public Bodies (Joint Working) (Scotland) Bill and associated legislation
The Public Bodies (Joint Working) (Scotland) Bill made provision for an Act of the Scottish Parliament in relation to the carrying out of functions of local authorities and Health Boards; further provision about certain functions of public bodies; further provision in relation to certain functions under the National Health Service (Scotland) Act 1978; and for connected purposes. The Bill has progressed through the Scottish Parliament.
The Bill received Royal Assent on 1 April 2014. Integration goes live in April 2015 and all integration arrangements must be in place by April 2016.
General practice as a hub for integration
General practice needs to be a hub for integration and that primary care was essential in locality groups to ensure the integration agenda worked on the ground. General practice has never existed in a vacuum; rather it is a key component of a web of health provision. There is no such thing as a single primary care team but for any one patient a team forms around their care from the primary care network.
Our next challenge is to have the “network literacy” to ensure patients receive the care they deserve. General Practice is just one node in this network but the strength and reach of its connections make it a major hub within the NHS.
We believe that much can be gained by improving the interface of general practice with other health and social care organisations. An example of this approach is the work that NHS Highland has started via its Highland Quality Approach. The Chief Executive of NHS Highland, Elaine Mead, in a project based at a practice in Dingwall, my practice, has shown the huge potential for improving patient care by improving the system of decision support between GPs and Hospital Specialists. This may drastically reduce the need for outpatient appointments and streamline patient care.
GPs are also providers of decision support and RCGP Scotland is piloting work with the Royal Pharmaceutical Society to improve communication between community pharmacists and GPs.
It will be less about planning and commissioning but rather about attending to the snags and significant events at all of these interfaces to allow the complex ecology of health to evolve. This should become a key role of GP locality clusters if they can be supported in this approach.
- Governance and quality has to be seen beyond the tight remit of measuring and rewarding achievement of single criteria. In its place we need an alternative structure where clusters of practices are responsible for peer led, values driven activity.
- General Practice must be recognised as the major hub in the network of community health provision. This is not about management structures or budgets but requires attention to the interface between all these providers.
- Most importantly resources to the key hubs of community services such as General Practice, Health Visiting and District Nursing must be protected and enhanced until they reach adequate, sustainable levels.
GP knowledge of and involvement with integration at a local level
RCGP Scotland undertook a survey of a small number of GPs in September 2014 regarding the grassroots awareness of the integration process and the level of GP involvement in this process at a local level. Although only a small number of people responded to the survey, the respondents covered a good range of practice types in terms of size, patient demographics and geographic spread. Respondents also included those working in Community Hospitals in rural and remote areas and those who worked regularly in an Out of Hours service.
Our survey found that although just over 90% of respondents were aware of GP involvement in the integration of care, only half thought their local process had so far been successful. Encouragingly, where respondents were not aware of GPs being involved locally in integration, 100% felt such involvement would be welcome. Three quarters of our respondents had received some form of communication locally on integration though members had concerns on the efficacy of what they had received.
General practice funding
The RCGP Put patients first: Back general practice campaign is asking for 11% of the NHS budget to be committed to general practice.
General practice is the cornerstone of the NHS – dealing with 90 per cent of all patient contacts. Patients value general practice very highly, and rank GPs as one of the most trusted of all professions. More and more patients are coming to see their GP each year, and general practice had accommodated these. In 2014 there were approximately 24 million general practice appointments in Scotland. The number of appointments in general practice has increased by 2 million appointments per year since 2005. This can be contracted with approximately 1.6 million A&E consultations during 2014.
Scotland also has a population which is both increasingly elderly and, at the same time, experiencing more health challenges such the growing number of people living with one or more long term conditions. By the time we are 50 we are likely to have at least one long term condition. Despite these increasing challenges, the amount of funding for general practice is shrinking, both in real terms and as a proportion of total NHS expenditure.
Between 2005-2006 and 2011-2012, the percentage share of the NHS budget spent on general practice in Scotland fell from 9.8% to 7.6% – a historic low. This is bad news for patients, who face the possibility of longer waits for appointments, fewer services and more difficulty in getting to see the GP of their choice. It is also bad news for the NHS as a whole – if general practice is not adequately resourced, more patients will end up receiving more expensive hospital care, leading to rapidly escalating healthcare costs.
Good access to high quality general practice is key to the future of the NHS. General practice leads to better and more cost-effective patient care, keeping people healthy for longer, enabling more people to successfully manage their conditions in the community, and avoiding unnecessary hospital admissions.
More resources will help support GPs to deliver consistent, high quality patient care and enhanced services, for example:
- Investment in practice staff such as more GPs and more nurses, as well as other healthcare professionals such as AHPs
- Shorter waiting times for appointments and more flexible opening hours
- Longer consultations, especially for those with long term conditions
- Improved care co-ordination and planning for the frail elderly and those with complex needs
- The ability to access more services closer to home, without the need to travel to hospital.
- Improved IT infrastructure and software to enable the better sharing of patient data to ensure excellent care both in hours and out of hours. This also required better broadband and mobile connectivity in many areas of Scotland to facilitate the use of technology.
- Improved general practice premises
- Working more closely with pharmacy colleagues based both within general practice and within community pharmacies
Achieving these outcomes will require a substantial increase in the number of GPs, as well as other primary care professionals such as district nurses, health visitors and pharmacists, and investment in better, more modern and accessible premises.
This request for general practice to receive 11% of the NHS budget was backed on 14 March 2015 by the LMC conference in Glasgow, where GP members raised this as a real issue. GPs attending the annual Scottish Local Medical Committee (SLMC) conference in Clydebank voted overwhelmingly to support a motion which urges ministers to boost their share of health service funding from less than eight per cent to at least 11 per cent under the terms of the new GP contract, due to come into force from 2017. The backing came despite warnings from the committee chairman.
Patient feedback on general practice
The Health and Experience Survey found that on over 3.3 million occasions patients found themselves unable to get to see either a doctor or a nurse until the third working day. This figure represents almost one out of every seven times a request was made. The ComRes poll reported one in four Scots unable to obtain an appointment with their GP within a week. To make the situation even more alarming, when this happened, 11% of people said they would neither take the late appointment nor seek help elsewhere, causing continuing concerns over their health as their condition remained untreated.
The Health and Experience Survey also found that on 1.6 million occasions patients did not feel they had enough time with their GP. This figure represents a rise of 8.25% since only 2011/12. Too short a consultation time increases the likelihood that conditions and complicating factors may be missed. For patients’ safety to increase there must be an acceptance that longer consultation times are required.
- One in four Scots (26%) cannot obtain an appointment with their GP within a week.
- Over half (54%) of Scottish people believe that there is a waiting times crisis in general practice.
- Three quarters (75%) of Scottish people say there are too few GPs.
- Over 70% of Scots believe that funding should be moved to general practice from other parts of the health service.
The Scottish Government Draft Budget 2015-16 shows that the budget for general medical services is due to be flat in cash terms, at its 2014/15 level of £709.6 million. This represents a real terms decrease of 2.2% (GDP deflator, HM Treasury, June 2014). Investment in general practice in Scotland has reduced by 3.9% in real terms since 2009/10 (excluding reimbursement of drugs, HSCIC).
Workforce planning and recruitment
In general practice, there are increasing issues of recruitment and retention. The increasing intensity and complexity of GP workload, combined with the movement of more specialist care from hospitals into general practice has resulted in general practice at full capacity at all times. Additional resources are urgently required to meet the challenge of demographic change and increasing multimorbidity.
There is an urgent need to encourage medical students to consider general practice as an attractive career choice both in urban and in remote and rural areas. NHS England are currently supporting RCGP to raise the profile of general practice in England by providing specific funding and resources. The low morale in the professional cannot fail to have an impact on the way medical students see general practice. There is also an urgent need to address specific remote and rural recruitment and retention. RCGP Scotland is currently pursuing a scheme of Dewer Bursaries to give medical students work experience in remote and rural areas.
The general practice workforce has increased by only 0.9% since 2007, despite an increase in the Scottish population as a whole of XXX%. This has not kept pace with the increase in population, or indeed with the increasing general practice workload relating to multimorbidities and the demographic change to an increasingly elderly population.
The BMA survey found that 17% of practices surveyed had at least one vacancy for a general practitioner, whilst three-quarters said that they were unable to secure locum cover on at least one day over a one-month period. In other cases some practices reported being unable to secure cover for 15 days or more.
Vacancies and use of locums
The Royal College of General Practitioners (Scotland) [RCGP Scotland] looked into NHS Scotland Health Board spending on GP locums. Information was available from ISD for 2012/2013. Locum usage data does not yet appear to be available for the year 2013/14.
The headline figure, based on day rates for locums across Scotland in 2013, is that £32.8 million was spent supplying them. Of course, this figure should be reduced by the £24 million or so that would be spent on paying incumbent GPs. The estimated locum use for Scotland is 289 whole time equivalents WTE. The highest NHS Board is Greater Glasgow and Clyde with locum use of 80 whole time equivalents (WTE). The lowest is Shetland with locum use of 2 WTE.
- The cost of paying for the 289 WTE GPs using average GP salary of £85,200 is £24.6 million.
- £85,200 is taken from the 2012/13 Health and Social Care Information Centre report into GP Earnings (http://www.hscic.gov.uk/catalogue/PUB14924/gp-earn-ex-1213-rep.pdf).
- The average weekly rate is £1,817.50; the average daily rate is £388.21.
- The maximum cost for providing 289 WTE is £32.8m (based on max day rates).
- In this scenario:
- The NHS Board with the largest locum bill is Greater Glasgow and Clyde with £10.0m.
- The NHS Board with the lowest is NHS Shetland with £260,000.
- Therefore the maximum value is £32.8m less £24.6m = £8.2m additional spend on locums annually.
- The minimum value is £26.5m less £24.6m = £1.9m additional spend on locums annually.
- The average value is £3.7m additional spend on locums annually.
- This is based on an arithmetic mean across 6 different rate cards – 3 day rates and 3 weekly rates.
Cautionary Notes on locus usage and cost calculations
- All figures are work in progress and subject to review.
- Some assumptions have been made for NHS Boards without fee data e.g. NHS Grampian did not have weekly rate card and therefore the average of other weekly rates is used.
- The maximum figure is probably unlikely in that it would require all sessional doctors to have charged day rates. However, this could be offset to some extent by those that use more expensive rate cards e.g. two-hour surgery.
- The source for rates is 2012/13 and figures have not been adjusted for inflation. Therefore the overall numbers would be higher.
Scottish Government Out-of-Hours Review
GPs are the hub of the NHS. That role does not change depending upon the date or time of day. In Lothian over the Festive period, for example, the out-of-hours service dealt with over 8,000 patient contacts, a staggering 1,000 per day. They recorded their busiest day ever for home visits on 02 January. GPs are crucial. There has been a £3 million drop in real term funding from the Scottish Government for the Out-Of-Hours service over the last five years.
This review should concentrate on answering two specific questions. Firstly, how can the funding, capacity and workforce of GPs be increased to allow proper care to patients? Secondly, how can we improve the connections, the interfaces, between general practices and the rest of the NHS? Patients would be surprised to learn how much room for improvement there is in order for different parts of the NHS to effectively share information with each other.
There is, inevitably, an overlap between the ‘normal hours’ care that GPs offer and the extraordinary work they carry out at all times of the day and night. They act as emergency doctors and, at the same time, as senior clinical decision makers when the NHS is presented with a complex case entailing more than one illness. That’s the great, individual specialism of general practice – the ability to deal with the increasingly complex nature of the health of our changing population.
RCGP Scotland hope that this review will recognise that and give its weight to the growing body of evidence, outlined by our Put patients first: Back general practice campaign, that shows the need for adequately increased resources into general practice. If it does so, the Cabinet Secretary will have gone some considerable way to achieving the 2020 Vision for the NHS in Scotland.
RCGP Scotland has set out the issues and believes that throughout the review, contributors must be mindful of three major contexts through which to evaluate options.
- Everything must be based on patient safety. From this, general practitioners must not be expected to work beyond hours which are safe.
- The impact on general practitioners in-hours work of any out-of-hours recommendations. The general practitioners clock only has so many hours each day.
- Any solution/s to current problems have to be able to be incorporated into the spectrum of contexts throughout Scotland, from the inner city to remote and rural life.
RCGP Scotland believe that, to achieve this vision, four priority areas must be addressed. They are:
- To clarify the scope of the service;
- To adequately invest in the service;
- To make it easier for current GPs to undertake OOH work; and
- To offer appropriate support for leadership.
The Scottish Government publication, Health and Care Experience Survey 2013/14, ‘Volume 1: National Results’, may be found here: http://www.scotland.gov.uk/Resource/0045/00451272.pdf
The ComRes study may be found here: http://www.comres.co.uk/poll/1127/rcgp-general-practice-study.htm All figures quoted cover Scottish responses only. The study was carried out by telephone between 29th and 31st August 2014.
The Scottish Budget: Draft Budget 2015-16, ‘Chapter 4 Health and Wellbeing’ may be found here: http://www.scotland.gov.uk/Publications/2014/10/2706/7
Further information on the Put Patients First: Back General Practice campaign may be found here: Put patients first: Back general practice
The Deloitte report, Under Pressure: The funding of patient care in general practice, showing the continued fall in NHS percentage spend on General Medical Services and the potential 25% funding gap in Scotland by 2017/18, is available here (see P.12):Deloitte report on GP funding . Please see Page 12 ‘Figure 5’ and ‘Table 5’.
The NHS Scotland Information Services Division report showing a 10%/10 years rise in consultations may be found here: ISD: GP consultations up 10%. Unfortunately, it cannot describe how those consultations increase in complexity with multimorbidity and our aging population.
The Scottish Budget: Draft Budget 2015-16, ‘Chapter 4 Health and Wellbeing’ may be found here: Draft Budget, Chapter4. The budget holds the allocation of funds to general practice (General Medical Services) flatlined in cash terms, resulting in a further 1.2% cut in funding due to inflation.
Planning and Delivery Principles
Implementation of Integration
Draft Statutory Instruments and Regulations
Guidance to support integration
NHS Highland website – Argyll & Bute Integration Consultation December 2014 http://www.nhshighland.scot.nhs.uk/ourareas/argyllandbute/pages/healthandsocialcareconsultation.aspx