A Highland GP on life the universe and anything…

A World without QoF?

In a recent BMJ article Dr Margaret McCartney proposed that GPs be paid to provide service and move away from the micro-management we have been under from the 2004 GMS contract. This is exactly the proposed direction of travel that RCGP Scotland is proposing and this is my response: –

Dear Margaret,

Thank you for your paper that continues a dialogue contributed to by my predecessor Dr John Gillies et al. in the paper “Distilling the essence of general practice: a learning journey in progress” (1).

I am delighted to say that in Scotland we are close to moving away from the tick box world you describe. Colleagues from the Scottish General Practice Committee are in negotiations on a contract to replace QoF with new proposals that incorporate the Royal College of General Practitioners (RCGP) vision for a “peer-led, values driven” model of quality, leadership and governance. The Cabinet Secretary for Health has recently announced the phasing out of QoF and has endorsed the RCGP approach. Our vision is for the creation of GP “clusters” that will be responsible for quality planning for their locality, be given resource to undertake quality improvement and demonstrate the quality assurance needed of GPs in a modern health and social care system as described in the joint RCGP and Health Care Improvement Scotland document “Developing a Quality Framework for Scottish General Practice.

We have a long way to go and we do not underestimate the difficulty in delivering the changes that you are suggesting. The obvious barrier is the present climate when general practice is being resourced at record low relative levels and workload and workforce are ever increasing challenges.. Refocusing the agenda to one that has patients and locality needs as central and rebuilding professionalism will be a key to reversing some of the negative view of general practice that is so prevalent. It will also equip the NHS with primary care that will be able to deliver integrated and community delivered care as described in the Scottish Government “2020 Vision.

 

1. Br J Gen Pract. 2009 May;59(562):e167-76. doi: 10.3399/bjgp09X420626

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My talk to Pulse Live in Edinburgh on 19th May 2015 when I outlined how RCGP Scotland was proposing to ensure quality and governance of General Practice in Scotland in the 2017 GMS contract for Scotland

This is my introductory 8min talk on the stresses and strains GP is presently under in Scotland given at the Pulse Live conference in the Corn Exchange in Edinburgh on 19th May 2015.

Primary care and the role of the GP

Transcript of my speech at the Scotland Policy Conferences Keynote Seminar on 30th April 2015  at Crowne Plaza, the Roxburghe, 38 Charlotte Square, Edinburgh EH2 4HQ

I want a chance to speak to you really about how  General Practice is trying to meet some of the challenges that have been mentioned by Anne, I think we’re very well placed to do that; some of the barriers that we are finding to pick up that baton; but also, some of the progress, specifically some of the things that the RCGP Scotland is planning to do to make this work, and to see this realised.

Anne talked about changing cultures, I think culture is all to do about values.  I’m very glad to say that the value of integration is absolutely within the DNA of general practice.  It’s all about transforming patient care, so that it is truly patient centred, and tailored to individuals.  And, actually, I was absolutely struck by how similar our four characteristics of primary care are to the “What Matters to Me” list.

The first one I would state would be about contact; a general practice is the default place, the first point of contact for the vast majority of patients seeking access to healthcare for the first time.

It’s comprehensive; it’s not just about seeing the person and their presenting complaint, but seeing them in their whole lived experience.  And, it’s the ability actually to deal with the mental health problems as well, you mentioned this with the problems with comorbidity.  GPs are uniquely placed to deal with some aspects of medical, social, and psychological, obviously with the help of all of the rest of the primary care team, and I’ll come back to that later.

And, it’s about continuity.  We’re there from cradle to grave, we value the long term relationships with our patients, although we struggle sometimes to live up to that.  And we’re importantly, the guardians of their full medical records, which is increasingly becoming crucial to the way health and social care is working.  And, some of the ability to share our data with emergency care summary, and the key information summary, is really leading the way for us to actually get the information that people need out there.

And, lastly, it’s about coordination.  Critically, we’re able to oversee care being provided by multiple providers, and we also seem to act as a “system failure service” for the NHS, when anything goes wrong, we usually hear about it.

So, what about progress so far?  Much of the activity so far has been about legislation, and about setting up new models of delivery.  And, I’ve got quite a lot of familiarity with this in Highland, where we’re obviously slightly ahead of the game, although we seem to be following a different path to the rest of Scotland.  It does seem to be a very complicated and difficult process, but it does appear to be making some progress in streamlining services.  The process has not really sought much input from general practice so far, which has been a bit disappointing.  But now, perhaps, as the institutions are starting to be bedded down, we can really start to come to fore with what we bring to the table.

Everywhere else is setting up joint integration boards, unifying tasks and responsibilities, but really the next step is about this idea of a robust locality working.  This is very much described in the “All Hands on Deck” document of 2013, as being of vital importance.  GPs need to be central to this, partly as senior clinical decision makers, but also providing clinical leadership for the organisation.   In fact, each GP practice has been asked to nominate a GP lead for integration, but how those leads have been used has been very variable, and many of my colleagues say that they haven’t been called upon in any way at all.

The next thing I want to talk about is about networks and primary care teams.  A lot has been said about the primary care team, I don’t know what that is.  It’s not just my practice team, it’s not just the district nurses and  midwives, it now extends into pharmacy, podiatry, optometry, Macmillan, third sector, voluntary sector, social work- it seems to be ever increasing.  It’s pointless to think of all of that as one team.  The team is what happens for that individual patient, it’s far more useful to think of that as a network of care providers, and for each network, for each individual patient, we draw down a team to work with that patient.

So, we really need to think about a “network literacy”, if we’re going to get this right. It’s absolutely fine to be individual organisations within that, but it’s absolutely crucial that we’ve got a clear idea about what our role are, and what your roles are, so that, we understand each other, and crucially we get that communication bit right between the two of us.  Overall it is actually about meeting the needs of the patient for any individual in a way that we have to.  It will require a certain amount of flexibility, and this has been part of the problem with some of the approaches of managed clinical networks.  They work fine for single diseases, but actually the reality of people’s lived experiences makes that so much more difficult.  Crucial to that network literacy is the interfaces between the organisations, and that’s one of the key projects  that the Royal College of GPs is taking forward.

The next thing is about some of the barriers to GP involvement.  Now, it’s fascinating to think that, actually, the barriers when you start to list them, are exactly the reasons why we’re embarking on this endeavour in the first place.  We talk about the “grey tsunami”, actually Ranald Mair’s point is absolutely right, about patients spending shorter times in care homes.  That’s had a direct effect on us as GPs, we’re almost providing hospital care to patients in some of these care homes.  So, the demand has been huge on the care home sector to upskill and provide that care, and it’s been hugely demanding on the other community services, not just GPs, but also district nurses and the rest of the community, to support that endeavour, and we need to get that right.

Funding has been static or falling, despite what some politicians say, as far as the percentage funding to general practice.  I won’t rehearse the figures, apart from I will, it’s gone from 9.8% down to 7.8% of the NHS budget, which seems a bit bonkers, when we had to increase our consulting rate by 10% over the same period.  And, actually, we’ve increased our consultation length over the same time too.  It’s having a big effect on workload, and it’s becoming evident in a workforce crisis, that I’m sure all of you will have read in the papers in the last week or two.  The fact that it’s happening here in Edinburgh is a real sign that we’ve got a problem.

So, what about our vision from RCGP Scotland? 

The first thing is about interface working, we talked about this as the key part of the network literacy that we’re wanting to take on.  As GPs we are a key hub of the NHS, because of our links in that network we have a key role in the NHS.  How we interface with the rest of the NHS is going to be crucial.  For examples, how we get clinical decision support from our colleagues in hospital, it sounds straightforward, but actually the only formal ways of getting help from a consultant is by admitting them, referring them into an outpatient clinic, or writing a letter, each of those takes time and is costly.  We’ve got lots of work rounds to do with email and phone, but all of those have problems.  We want to streamline that, so that actually GPs can get the advice they need, when they need it, to keep people at home.

But, actually, we’re not just recipients of advice, we’re also the givers of advice, and we’ve undertaken some pilot work with the Royal Pharmaceutical Society, on actually what happens when patients go to the pharmacist and need additional help from their GPs.  Fair enough to say, “you need to see your GP”, but that becomes an urgent appointment, and the patient arrives with nothing, we have no ability to learn from the professional advice that the pharmacist has given already.  So, we’re developing an SBAR form for communication and to streamline things.  We need to start thinking about this across the sector, across the whole health and social care sector, if this is going to be right.

It’s also about quality improvement, and we’ll hopefully be developing some quality improvement methodologies for practices to use, to look at their interfaces and see how they fit within the NHS.  I suspect that  a lot of the things that we learn will have relevance across health and social care, and we’re delighted to start to get some real interest in the work we’re doing.  The Scottish Academy of Royal Colleges have lent  their support, and we’re now looking for partners from other Royal Colleges to make this work.

The next thing is about GP practice clusters.  Now, it seems a bit, sort of, insular for just GPs in these clusters, but actually we need some way that we can get together, and have our interface with health and social care, and plan the services.  We hope that GP practices can come together in groups, covering between 20,000 and 50,000 patients, not only to be closely involved with the planning of future healthcare provision, but also to work on our interfaces.  And to focus on some of the ideas of quality and governance, which is going to be values based, rather than some of the narrow definitions of quality that we’ve seen with our present contract. There’s going to be a new definition of quality, which is going to be peer based and values driven.

And, finally, the other thing is, I’m afraid we are going to be seeking investment.  If we’re going to see 2020 vision appear, if we are going to be stepping up to the role that’s being asked for us. We have actually been stepping up since 2006, there’s been clear evidence that we just soaked that up.  But, if we are going to get beyond this workforce crisis that we’ve got at the moment, we need some really creative ideas, and we really look forward to working with Scottish Government to see how we can make that happen.

So, it’s a long way to go, my  advice from a GP who works in the Highlands is that, don’t look for early changes with this integration work, it’s going to be hard work.  The changes will happen, but they may not be as quick or as dramatic as we expect, but let’s all go through it together.

Thank you very much.

Celebrations

Dr Sue Farrar

Dr Sue Farrar

On Friday 17th April 2015 RCGP Scotland had the pleasure of holding a new members and fellows ceremony and also an awards ceremony for the RCGP Scotland Alistair Donald Award, RCGP Scotland GP of the year and the RCGP Fraser Rose Medal.

The RCGP Scotland GP of the year was won by Dr Sue Farrar.

The RCGP Scotland Alastair Donald Award by Dr Jane Bruce.

Dr Jane Bruce

Dr Jane Bruce

Prof Ryuki Kassai

Prof. Ryuki Kassai

Fellows were represented from faculties across the country and across the world. We were delighted to present Prof. Ryuki Kassai, of the University of Fukushima, Japan with his fellowship.

Drs Kate Dawson & Louise Scott

Drs Kate Dawson & Louise Scott

My address is here: –

It is my great pleasure to welcome you to our college for this celebration of achievement.  We have members and fellows here today from Scotland, England, Northern Ireland, Wales across the world.

I am delighted that we have the opportunity to celebrate 3 important milestones in our careers: membership, fellowship and individual award winners.

I know how hard the new members have worked to get here today. Not only to get into medical school and qualify but also to take on what must be one of the most demanding specialty curricula and exams. However I am confident your endeavour will have equipped you well to start your career as independent practitioners. I hope that now you have completed specialty training, you will see the college in a much wider context than just the AKT, CSA , workplace based assessment and wrestling with the ePortfolio! We have a great deal to offer you.

The college is a membership organisation; it exists to ensure we are all the best GPs we can be for our patients: setting standards, encouraging innovation and providing education and leadership.

It is for these attributes that the new Fellows are being recognised here today. I hope the process of fellowship has given you an opportunity for a reflective pause in your career and us a chance to appreciate and celebrate what you have have reached out to do for your patients and for our profession.

The College was created in 1952, giving a clear identity for general practice across the UK. Scotland has played a significant part. The first Professor of General Practice, worldwide, was Richard Scott, appointed here in Edinburgh in 1963, and the first vocational training schemes were pioneered in Inverness some years later. It was RCGP Scotland who originated the Quality Practice Award in 1995 and it is from my predecessor, John Gillies, that we take the Essence of General Practice. We are supporting the work of the “GPs at the Deep End” group who have been hugely influential in raising issues of health inequalities and at the other end of the spectrum leading policy on Remote and Rural practice. In fact, today Dr Gillies and Dr David Hogg of Arran are speaking at the WONCA Rural conference in Dubrovnik, presenting our work.

I know that the values of general practice have remained constant since 1952 but by necessity we have adapted our work to a changing environment. Patients are living longer. In the next 5 years the population between the ages of 70-75 will increase by 21%. And patients now live with multiple long term conditions. Scottish research shows on average people have 2 or more long term conditions by the age of 65, increasing to 3 or more at 75 years. The NHS England Five Year Forward View and Scottish 2020 Vision both call for integration of services and for radical changes to the way care is delivered. General practice will be key to making these changes.

We face difficulties meeting these challenges. Scottish GPs now see 24m patient contacts per year, 11% more than 10 years ago. At the same time, funding for general practice has fallen from 9.8 to 7.8% of the NHS Scotland budget and recruitment is static. The widening funding gulf & increasing workload are proven disincentives for doctors to choose our specialty.

RCGP Scotland has 3 priorities: –

  • Firstly, we will continue to campaign [i] for recognition of the role of general practice and for fair resources to build our workforce and capacity to do our work.
  • Secondly, we will work for new quality and governance structures, recognising the need to audit our care, but moving to a more nuanced measure of the care we give. We propose a system that is peer based and values driven. Where clusters of practices define the values they aspire to and then undertake audit and quality improvement to demonstrate their practice is congruent with those values.
  • Thirdly, we will work to ensure general practice is valued as the central hub of the NHS. Our interface with others is essential for good patient care and the functioning of the NHS. We will work to improve not only the mechanisms for us to get clinical decision support from our hospital colleagues, but also the way others in the community access our assistance.

Writing in the BMJ recently, Glasgow GP Dr Margaret McCartney wrote[ii]: –

General practice encompasses health and sickness, benefit and harm, living and dying. You are a prescriber, diagnostician, and font of evidence—but also an advocate and avoider of medical harm. You get things wrong sometimes, as everyone does. But you also have days when your heart sings.”

When we leave here we all have the opportunity to contribute to the future of general practice. Our college is uniquely placed to help. Please consider this: –

  • What might that look like for you?
  • How can you make the college a good fit for your career?
  • Is there a local First5 group?
  • Can you offer help with representation with other stakeholders?
  • Can you contribute to consultations on policy issues?
  • Can you get involved in the activities of your local faculty or at a national level?
  • Will you lead the college in the future?

I trust you will. Thank you.Princess St Gdns April 2015

[i] http://www.rcgp.org.uk/campaign-home.aspx

[ii] Margaret McCartney: General practice is still the best job in the world BMJ 2015;350:h1721 http://www.bmj.com/content/350/bmj.h1721

A grat day in a great venue and I hope one that we can repeat in future years.

 

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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

Headline Figure

 

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.

 

 

Source: http://www.gponline.com/locum-rates-2012-13-locums-booked-directly-practices/article/1227547

 

  • 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:

  1. To clarify the scope of the service;
  2. To adequately invest in the service;
  3. To make it easier for current GPs to undertake OOH work; and
  4. To offer appropriate support for leadership.

 

 

 


Sources

 

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.

 

Background information

http://www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration

 

Planning and Delivery Principles

http://www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Principles

 

Implementation of Integration

http://www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Implementation

 

Draft Statutory Instruments and Regulations

http://www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Implementation/Regulations

 

Guidance to support integration

http://www.scotland.gov.uk/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Implementation/ImplementationGuidance

 

NHS Highland website – Argyll & Bute Integration Consultation December 2014  http://www.nhshighland.scot.nhs.uk/ourareas/argyllandbute/pages/healthandsocialcareconsultation.aspx

 

RCGP Scotland Position Statement

February 2015

The review of out-of-hours care (OOH), to be led by Professor Sir Lewis Ritchie and announced by the Scottish Government on Friday 30 January 2015  is a crucial opportunity through which Scotland could access a world class out-of-hours service that is fully fit for purpose.

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, GPs must not be expected to work beyond hours which are safe.
  • The impact on GP in-hours work of any OOH recommendations. The GPs clock only has so many hours each day.
  • Any solution/s to current problems has to be able to incorporate 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.
  1. Clarify the Scope of the Service
  •  The scope of the OOH service for Scotland must be established with clear responsibilities and boundaries.
  • Increasingly, the OOH service is asked to provide cover and extend its role, for example through attendance at sudden deaths in lieu of forensic medical services.
  • The review should allow the role of general practitioners within the service to develop towards GPs as Senior Clinical Decision Makers.
  1. Adequately Invest in the Service
  •  There must be investment in Primary Care Emergency Teams. Only in this way can the service be guaranteed to be more than a lone GP as the bare bones of care. The service should emphasise a team approach, including nursing, paramedics, administrative and service support.
  • The current OOH ‘Hubs’ should be dissolved. Their functions should be devolved to the Primary Care Emergency Centres (PCECs), in order to allow more localised decision making, intelligence, planning and dispatch, based on team capacity and liaison.
  • IT technology, both hardware and software, must be closely, properly interfaced with both hospital and in-hours services.
  • The welfare of staff employed must be ensured in terms of accommodation, security and sustenance. This requires the establishment of Green Light Centres, akin to current Fire Service Stations.
  1. Make It Easier for Current GPs to Undertake OOH Work
  •  It must be made easier for serving, in-hours GPs to interleave OOH work with their present commitments. The current, market driven system has proven inadequate due to the falling availability of doctors.
  • Better contractual security should be offered through terms and conditions and opportunities for training and CPD. The review must take a realistic view of the effect of OOH on current GP tax structures and pension development.
  • Their must, similarly, be a recognition of the understanding that in-hours practices must make adaptations to allow the release of GPs for OOH work. This must be valued by the system.
  • GP trainees must have sufficient and well supported training opportunities.
  1. Offer Appropriate Support for Leadership
  •  Support for leadership at a Locality level should be offered towards Quality Improvement and Interface Working.
  • We propose mirroring the suggested direction of travel for Locality Clusters and peer-based, values driven Quality Improvement and Governance.

Each of these four areas must be satisfied in order to successfully establish an OOH service fit for purpose both in our current context and in light of our changing demographic needs.