Delivering quality in primary care: progress report

4. Progress so far

This report takes stock of progress of which we are aware in the key areas identified. Each of the primary care provider groups, and the professions within them, have their own unique contribution to the national quality agenda shaped by their scope of professional practice and their distinct contractual frameworks for service provision. Whilst this has its benefits around designing and shaping services, it presents challenges in areas such as collaborative and partnership working between professions.

There are national work programmes covering, for example, general dental service and NHS pharmaceutical care – some of which is described throughout the key sections to this report. These work programmes are underpinned by the three main quality ambitions of the Healthcare Quality Strategy for NHSScotland – that is care that is person-centred, safe and effective to every patient every time. The contribution of these individual work programmes will have a prominent place in determining the way forward for the primary care team as whole.

Progress in each of the action areas as at the time of this report (June 2012) is summarised below. Two overarching points need to be borne in mind in considering this analysis:

• While a national action plan and strategic policy are necessary to provide direction, effective local delivery by all stakeholders is key for success. We have not attempted in this report to capture the full extent of such local activity;
• In most of these areas this is a snap shot of the progress made thus far – there is still
  much to do.

1. Work with the independent contractors on proposals for ensuring that all the contracts are better able to support the delivery of quality care.

A number of national level actions have taken place in support of the desire to work better with the independent contractors ensuring that contracts developed better support the delivery of quality care. These national level actions include:

New Quality and Productivity indicators which were agreed nationally and included in the GP contract in 2011/12. These focused on prescribing, emergency admissions and outpatient referrals by GPs. In Scotland we have agreed with the profession the continuation of part of the prescribing element of these indicators into 2012/13, given their discontinuation at a UK level. For 2012/13, new Accident and Emergency indicators have been agreed. These aim to reduce avoidable A&E attendance.

The Cabinet Secretary for Health, Wellbeing and Cities Strategy has signalled her intention to move to a more Scottish-focused GP contract. Preliminary discussion on the scope of this has begun with the Scottish General Practitioners Council (SGPC). The intention is to reflect Scottish health priorities and issues within the quality and outcomes framework indicators. Simultaneously the Scottish Government will be looking ahead to the vision for general practice in 2020, involving a wide range of stakeholders in coming to a view.

For 2012/13 changes have been introduced to the Scottish Enhanced Services Programme (SESP) to enhance local autonomy and the sustainability of the services its supports. To allow flexibility for delivery SESP funding will no longer be restricted to general medical practice but can be delivered throughout primary care services. This will provide greater discretion for Boards to consider how spend under SESP will assist primary care in delivering the aims of the Quality Strategy with focus on rebalancing care, support and service provision towards anticipatory care and preventative services.

The Tobacco and Primary Medical Services (Scotland) Act (2010) introduced a power for Scottish Ministers to make regulations to prescribe healthcare professionals (other than medical practitioners) as eligible to enter into GMS contracts with Health Boards. The effect is to allow the possibility, if thought necessary, of future changes to the list of those eligible to hold a GMS contract. The regulations will be able to limit the class of healthcare professional, for example, to nurses only. The RCN is undertaking a piece of work with current associate nurse partners to identify lessons learned in Scotland so far.

A Dental Practice Quality Framework, has been developed by the Chief Dental Officer & Dentistry Division of the Scottish Government in partnership with stakeholders, the aim of the framework is to ensure that:

• Patients would have improved oral health through a positive experience of dentistry and would receive evidence-based dental care in a safe clinical environment;
• The dental team would feel involved and supported in their clinical work and would reflect on and improve their professional practice;
• The NHS would be assured that the dental practice was "fit for purpose", delivered care which was tailored to the individual patient's need, could demonstrate improved oral health for the patient and makes best use of available resources.

The framework has identified dental practice quality indicators and associated outcome measures, many of which are currently in place or could be in place with minimal additional cost or effort on the part of dental contractors.

Discussion of the implementation phase is underway with stakeholders. It is hoped that several of the quality indicators and outcome measures will be available for report by the end of the year, including a website for patients to obtain information about their dentist and dental practice.

However, this will be the start of the improvement journey for primary care dentistry and not the end point. More challenging dental practice quality outcome measures will be identified in the medium and longer term which would more clearly demonstrate that a dental practice is delivering a quality dental service and contributing to oral health improvement. These could include Patient Reported Outcome Measures (PROMs) and the use of an Oral Health Assessment framework.

It should be recognised that dental practices are currently at different stages of readiness to satisfy more challenging dental practice quality outcome measures. Practices will need varying degrees of support from a range of sources in order to demonstrate improvement in support of the Quality Ambitions.

The NHS (General Ophthalmic Services) (Scotland) Regulations 2006, which set down the mandatory tests and procedures as well as patient specific tests and procedures, are kept under review and amended as and when required. Recent guidance was issued which clarified the frequency of NHS eye examinations. To support this individual optometrists/ophthalmic medical practitioners (OMPs) will be provided with practice profiles data on their patterns of eye examinations, together with comparable practices in order to spread best practice. Other relevant data are being developed to ensure optometrists/OMPs have available to them information to form the basis of clinician to clinician discussions on parameters relevant to quality of care.

The Right Medicine (2002) ^[18] set out the strategy for modernising and strengthening the role of pharmacists to deliver improved services to the public and patients. Over the last 10 years the Scottish Government has worked with its key stakeholders to modernise the way in which NHS pharmaceutical services in the community are provided and to make them more relevant to the needs of NHS services.

Since 2006 a more service-based approach to pharmaceutical care services has been developed and gradually introduced as part of a long-term strategy to move community pharmacists away from a focus purely on the dispensing of prescriptions to the provision of person-centred care as part of the wider primary care team.

This new service-based approach has been introduced through a phased implementation programme and covers four core services: Minor Ailment Service (MAS), Public Health Service (PHS), Acute Medication Service (AMS) and Chronic Medication Service (CMS). Together these services play an important part in shifting the balance of care by:

• Improving access for the public as they do not need an appointment to see their pharmacist for a consultation;
• Decreasing unnecessary workload on GP and nursing colleagues therefore freeing up their time to see patients with more serious complaints;
• Improving health outcomes and minimising adverse events from medicines;
• Helping to address health inequalities; and
• Making better use of the workforce by more fully utilising the skills of community pharmacists.

Building on these service developments, the Scottish Government aims to facilitate further shifts towards person-centred, safe and effective care which is fully integrated with the wider healthcare team across community and specialist settings.

An ePharmacy Programme provides the technology support to underpin the new community pharmacy services. It also supplies the platform for Practitioner Services Division (PSD) to modernise the way in which it remunerates and reimburses community pharmacy contractors as part of the ePay Programme. In turn, this provides better and quicker information to Information Services Division (ISD) which can be used for both reviewing and planning NHS services.

The ePharmacy Programme has introduced electronic support for patient registration, electronic transfer of prescriptions (ETP) including electronic claiming and pharmaceutical care planning. ETP improves patient safety through the assurance of patient and medication item selection, provides electronic prescribing, dispensing and claiming information that will allow Scotland to take a leading position in supporting research and development and improves information governance arrangements within the NHS. A central feature of the ePharmacy Programme is to promote better communication between community pharmacists and general practitioners.

2. Improve access for patients.

Effective primary are services are the foundation of the NHS in Scotland. Excellent access to these services therefore is a key ingredient of high quality healthcare and are crucial in ensuring patients are at the heart of how services are designed and provided. The more effectively access is managed, the better the outcome, the better the impact on the NHS as a whole and, crucially, the better the patient's experience of care. National activity to support better access to services includes:

The Scottish Government in collaboration with stakeholders through the SGPC, has produced guidance aimed at improving access to primary care services, particularly those of GP practices. The Royal College of General Practitioners (Scotland) (RCGP), in consultation with a range of key stakeholders, has developed a fit for purpose best practice access toolkit that can help those practices for whom access is a problem to improve access levels equivalent to that already enjoyed by many patients in Scotland. The toolkit follows a medical model which is familiar to practices. It describes the symptoms that exist when access is a problem, how to accurately diagnose the level of access present in a practice and gives advice on how to treat access problems where they exist. The best practice access toolkit has been rolled out to all NHS Boards across Scotland and will support Boards to assist those practices with the greatest challenges.

The directed enhanced service (DES) for extended hours has been extended, giving incentive and increased flexibility to practices in how they deliver extended hours in the best interests of their patients. The new Quality and Productivity (QP) indicators for 2012/13 which aim to reduce avoidable Accident and Emergency (A&E) attendances will help practices assess if the level of access to clinical staff in the practice is appropriate in light of the patterns on accident and emergency attendance.

There has been continued progress on improving access to NHS dentistry through a variety of means such as improved premises and workforce. The Scottish Dental Access Initiative has been targeted on those limited areas of the country where there continues to be issues with dental access.

Following a review of community hospitals the Scottish Government has produced the Community Hospital Strategy Refresh. This strategy refresh develops the work started by the Developing Community Hospitals: a Strategy for Scotland (2006) ^[19] by providing a new direction and fresh focus. The strategy delivers a bright vision for the future development
of community hospitals through:

• Ensuring that people who utilise community hospitals are the centre of care pathways;
• Providing provision for the development of the workforce in community hospitals; and
• Identifying how community hospitals can de developed to better provide for local communities.

The Scottish Government will be promoting the development of community hospitals and community hospital staff through the creation of an Improvement Network and a short-life working group. The Improvement Network will be developed in collaboration with community hospitals and hosted by NHS Education for Scotland (NES). It will provide a portal for development opportunities for community hospital staff. The working group will provide support for the development of the clinical side of community hospitals.

In addition to the working group and the improvement network, a set of actions has been drawn together in this strategy that will be taken forward by NHS Boards. The outcomes of these actions will provide the blueprints for NHS Boards and community health partnerships to not only develop modern, locally sustainable community hospital services that are responsive to local community needs; but to also provide community hospitals with the resources to fulfil a valuable role in a modern Scottish health and social care service.

The Minor Ailment Service (MAS) has played an important part in opening up access in primary care in recent years; it supports the provision of direct pharmaceutical care within the NHS by community pharmacists.

MAS enables people who are eligible to register with the community pharmacy of their choice for the consultation and treatment of common conditions without the need to visit their GP. Under the service, the pharmacist advises, treats or refers the patient according to their needs.

The service which has been rolled out across Scotland is particularly valued by patients and NHS 24 in the Out of Hours period. Most recent figures show that there are some 840,000 patients registered with MAS. It is estimated that, on average, there are over 11,500 consultations a day in Scotland where a pharmacist advises on, or treats, minor ailments.

3. Develop and implement a patient safety programme for primary care.

Healthcare Improvement Scotland's (HIS) development of the Patient Safety in Primary Care (PSPC) programme objective is to reduce the number of events which could cause avoidable harm to people from healthcare delivered in any primary care setting. They aim to do this by aligning and integrating learning from existing improvement programmes and engaging primary care professionals and other stakeholders in the development, application and roll out of the programme.

The programme is being developed around four work streams:

Safer medicines: including the prescribing and monitoring of high-risk medications avoiding harmful co-prescribing.

Safe and effective patient care across the interface by focusing on:

• Developing reliable systems for medication reconciliation in the community when a patient has been discharged from hospital;
• Improving shared care of patients attending outpatient clinics by reliably implementing recommendations made after clinic attendance;
• The reliable and safe management of test results; and
• Implementing care bundles to ensure reliable care for patients with long-term conditions, such as congestive heart failure (CHF) and pressure ulcers.

Reduce healthcare associated infections in the community, for example develop community-based interventions to improve antimicrobial prescribing and promote hand hygiene.

Leadership and culture using trigger tools (structured case note reviews), safety climate surveys and significant event analysis (SEAs).

HIS is revising the enhanced service specifications for Anticoagulation and Near Patient Testing. These new specifications will include Board and practice level measures that will be used to help demonstrate improvement in safe care. HIS are also developing tools and spreadsheets to capture data that will support the roll out of this enhanced service.

4. Ensure we have in place an up-to-date, agreed suite of care pathways.

The agreement and implementation of care pathways has been a priority issue for the NHS in Scotland for some time. National activity in this includes:

The GMS contract for 2011/12 included new Quality and Productivity Indicators under which GPs signed up to three pathways for each of outpatient referrals and emergency admissions. The aim of which is to reduce emergency admissions and variation in referrals. While the choice of pathways were made at the NHS Board level to reflect local priorities, the following high-level pathways were developed as national care pathways, based on current priorities:

Referrals:
Orthopaedics: hand, knee and back pain.
Dermatology: skin lesions and acne.
Neurology: headache.
Endoscopy: dyspepsia.
Imaging: brain.
Emergency admissions: falls, adult respiratory disease and heart failure.

For each of these HIS, the Scottish Government Quality and Efficiency Support Team (QuEST) and others prepared high-level pathways, guidance notes and updated versions of priority condition-specific pathways. Practice reports will be evaluated to assess the outcomes achieved.

Additionally, through a short-life task and finish group unscheduled care pathways for people with long-term conditions were considered and a set of transferable principles developed which could be applied across a range of common presentations. The focus of this work was on the group of older people who present to unscheduled care with a fall or as a result of a frailty syndrome such as increased confusion or reduced mobility, both of which are common presentations of patients who are frequent callers to the ambulance service. These presentations will inevitably require further assessment, early intervention, treatment or adjustment of care and support. The result of this work is a series of recommendations which aim to deliver redesign pathways and which:

• Identify opportunities to improve/redesign aspects of the existing pathway;
• Develop a common triage/initial assessment tool for use in the home;
• Consider the role of robust and responsive clinical decision support for practitioners; and
• Describe the anticipated benefits for patients, practitioners and for the system.

Implemented, it is hoped that these recommendations will see more people supported at home and fewer unnecessarily taken to hospital after a fall or minor illness and an increased rate of referrals to the appropriate community-based services.

5. Develop, as part of the quality measurement framework, national quality indicators for the delivery of primary medical services Out of Hours.

National quality indicators will support the delivery of consistent care, allow comparison between different NHS Board areas, and enable continuous improvement within local primary care Out of Hours services. The aim is to improve the quality of care provided so that:

• People have the best possible experience of their local primary care Out of Hours service;
• People receive an accurate assessment of their immediate problem;
• People needing a home visit are seen without undue delay;
• People receive the correct treatment and/or care from their primary care Out of Hours service; and
• Information about a person's Out of Hours consultation is available to their own primary care and, if necessary, hospital staff at the time of the person's treatment.

Draft quality indicators have been agreed and were published in Summer 2011. The testing phase of the indicators is underway (September 2011 to June 2012) in NHS Greater Glasgow & Clyde and NHS Highland to determine how the draft quality indicators can be measured and monitored to improve the quality of services, identify the changes that may be required to improve the quality of services, and test these on a small scale before wider roll out across other NHS Boards.

Additionally, the 2011/12 patient experience survey included, for the first time, questions about Out of Hours services which will help NHS Boards better understand patients' views.

Work has been taken forward between NHS 24, the Scottish Emergency Dental Service and NHS Boards to develop dental key performance indicators which will monitor the patient journey in Out of Hours. As all dental practices are not linked electronically some specific measures may take longer to implement locally.

6. Continue to give priority to anticipatory care.

Changing demographics to an aging population with multiple long-term conditions and complex needs underpins the need for a planned and systematic approach to influence and provide strategic direction in the primary prevention of ill health and reduce health inequalities. Sharing best practice and influencing what happens in primary care by encouraging participation, involvement and challenge of all key players including professional organisations is crucial to make a positive impact in reducing unscheduled hospital activity, enabling people to better manage their own health and keep them well in their own home for as long as possible. National level activities supporting this concept of anticipatory care include:

Change Fund for older people's services is a partnership resource for health, social care and the third and independent sectors, which is expected to act as a catalyst for more radical, innovative redesign of older people's care and support. The aim of the fund is to improve outcomes for older people and their carers through greater integrated planning, commissioning and delivery of adult health and social care and in partnership with third and independent sectors. It aims to put an end to the "cost-shunting" between the NHS and local authorities that too often ends up with older people being delayed in hospital longer than they should or being admitted to hospital due to social support at home being too difficult and bureaucratic to access quickly. The Change Fund is facilitating a shift in the locus of care from hospital and long-term residential care to primary and community settings, and shifting the focus of care upstream towards anticipatory care and preventative spend.

The Fund is influencing decisions taken with respect to the totality of Partnership spend on older people's care and support. Following the 2012 Spending review, £80m Change Fund for older people's services has been made available for Partnerships in 2012/13, with £80m committed for 2013/14 and £70m for 2014/15.

From April 2012, NHSScotland has mainstreamed the Keep Well programme of targeted health checks. The programme offers a systematic cardiovascular disease risk assessment and management programme for people aged between 40 and 64 who are at greatest risk of preventable ill health because of their life circumstances. The programme was developed as part of plans to tackle health inequalities and aims to shift primary care practice and culture towards anticipatory care. Patient experience of the Keep Well health programme is being captured as part of the ongoing work on performance indicators which will be a mix of quantitative and qualitative measures.

During 2011 NHS 24 rolled out its Life Begins at 40 service inviting all adults in Scotland over the age of 40 to complete a health check over the telephone or online. Users who complete a self-assessment questionnaire are given health information tailored to their needs and signposted to other sources of information on local and national services. The online and telephone check-ups are part of a £15m package of services devised to help people over 40 with their health.

DALLAS (Delivering Assisted Lifestyles At Scale) initiative will examine the use of new technologies to support people in their own homes and find out which innovative products, systems and services work best. The three-year programme is part of a UK-wide scheme run by the UK's innovation agency, The Technology Strategy Board.

The Technology Strategy Board will invest up to £18m over four years to establish three to five DALLAS sites across the UK, with £5m of this for a site in Scotland. The Scottish Government, Scottish Enterprise, Highlands and Islands Enterprise are investing a further £5m in the Scottish Assisted Living Programme. Within Scotland, DALLAS is phase one of the wider Scottish Assisted Living Programme, which aims to deliver effective technologies to support care for people with disabilities and or health conditions in their own homes.

Five areas of Scotland are to take part in the programme that will focus on finding innovative solutions that could improve the lives 10,000 or more older adults with long-term conditions. The work will be led by NHS 24's Scottish Centre for Telehealth and Telecare (SCTT) and will examine how new technologies can help improve the quality of life of, and support independent living for, older people and people living with long-term health and care issues.

The key objective behind the initiative is to take the next step towards integrating new healthcare and wellbeing technology and services across the public sector, the private sector and the third sector, including by charities and social enterprises. The next steps will be to work closely with the partnerships in the identified areas to scope out the specifications required for the programme which gets underway in 2012 and will run until 2015.

Childsmile adopts a multi-agency approach to improving children's oral health through dental practice, community, and education settings and has a holistic approach to healthy living and health improving life skills. The Childsmile Core Programme provides every child with a dental pack containing a toothbrush, tube of 1000ppm fluoride toothpaste and an information leaflet on at least six occasions by the age of 5 as well as a free-flow feeder cup by the age of 1. The Childsmile Practice Programme promotes oral health from birth, with families supported in the community via a network of Childsmile Oral Health Support Workers (OHSW) who work closely with Public Health Nursing Teams and encourage toothbrushing, healthy diet and registration with a dentist. Since October 2011, Childsmile is included in the statement of dental remuneration within which those General Dental Practitioners providing NHS items of treatment and the salaried dentists work, so oral health promotion and clinical preventative care can be delivered by all local dental practices. Childsmile Nursery & School Programmes provides daily, supervised toothbrushing for all children attending nursery schools and additional clinical preventative programmes such as fluoride varnish for children attending nurseries and schools in our most deprived areas.

7. Help the professions with their workforce planning.

It will be important for NHS Boards and primary care services to modernise and further develop their models of delivery by reconfiguring the existing workforce and introducing a new mix of skills and competencies to meet the challenges faced by the changing population demographics, service delivery imperatives, future workforce profiles and the subsequent change in the needs of patients. National activities in this area include:

The Modernising Nursing in the Community (MNiC) Programme Board was set up to support NHS Boards in their workforce planning and development by developing and testing a framework which will assist NHS Boards to carry out this work in a Scotland-wide co-ordinated approach, while enabling local solutions. The online interactive toolkit resource that was launched in January 2012 assists NHS Boards in service redesign and workforce planning/configuration. The site consists of three platforms:

• Children, Young People and Families
• Work and Wellbeing
• Adults and Older People

Each platform illustrates the 12 elements of the framework and will support the delivery of safe, effective and person-centred care in the community. From April 2012 the programme will transition to the Delivering Modernised Community Nursing Action Plan which will support Boards in a number of areas including the sustainability of the website and the future direction of education provision.

The Allied Health Professional (AHP) National Delivery Plan will help Boards to plan future AHP services and determine priorities including where AHPs can contribute to best effect in achieving national and local targets. The AHP workforce has an essential role to play in implementing the Reshaping Care for Older People strategy; they effectively help to keep people well and independent at home, and prevent hospital admissions. In particular, The Change Fund Plans submitted for 2011/12 were reviewed with respect to AHP contribution. Analysis showed that most Partnerships plan to use the rehabilitation and reablement skills of AHPs to help reshape services for older people. AHPs can also support GPs to achieve the new Quality and Outcomes Framework (QOF) indicators by providing alternative pathways for some hospital outpatient referrals and providing services to prevent hospital admissions. To maximise their contribution, the AHP workforce may need to redesign how and where services are delivered, including a shift from acute to community focus, integration across health and social care, better links with GPs and more preventative/anticipatory work.

NES Delivering Quality in Primary Care Co-ordinating Group has been formed to help share information on educational support for primary care. Much of the NES primary care activity is part of a general educational approach to improving quality which often cuts across the specific areas of work in the Action Plan. Examples of how NES is supporting the primary care workforce include Practice–based Small Group Learning – an approach to continuing professional development originally developed for general practitioners in Canada. It is now a core NES activity and well established in primary care. It has been shown to reduce professional isolation, plays an important part in developing Communities of Practice and more recently in fostering Faculty Development. Groups were initially established for GPs, then Practice Nurses, and now also for doctors from across primary and secondary care. The aim of the primary and secondary care mixed groups was to enable joint working on educational topics with the wider aim of encouraging productive dialogue between primary and secondary care.

NHSScotland and the NHS Institute for Innovation and Improvement, in partnership with general practices designed and tested a new innovative programme, The Productive General Practice, which is now being used in practices across Scotland. It's a practical, flexible programme designed to help practices reduce waste and streamline services for the benefit of partners, staff and their patients. It takes proven approaches used in other areas of healthcare and the worlds of engineering and design and adapts them to the primary care environment.

The programme enables general practices to dramatically improve internal efficiencies whilst increasing support for clinicians, enhancing quality of care, increasing safety and working to better meet the needs of the local population. As well as releasing time there are other gains for practice staff, such as the development of improvement and change management capability.

Productive General Practice is aligned with the Primary Care Patient Safety Programme in Scotland and the RCGP P3 patient involvement work. It can be used by practices in improving pathways, access and working with partners in primary and secondary care.

8. Take steps to ensure more effective partnership between the different primary care professionals.

The establishment and effective operation of the DQPC steering group itself has provided a powerful context for more collaborative working and joint endeavour to address shared problems. The impact continues to be felt both nationally and at the local level, with for example the establishment of similar groupings in some Board areas.

The RCGP and NES have begun a collaborative project on developing and implementing a leadership programme for primary care practitioners. This is being carefully designed to ensure that all primary care professions can benefit in their own right and from collaborative learning. This leadership capacity within primary care will be essential in the context of the commitment to ensure that there is clear and effective clinical leadership in and of the new bodies to be created in the context of the integration of health and social care.

There have been a number of specific collaborative endeavours including an innovative joint venture between Community Pharmacy Scotland and Optometry Scotland to ensure each profession can draw more effectively on the skills of the other for the benefit of patients.

The framework, Breaking Down the Barriers, produced jointly by the Royal Pharmaceutical Society and the RCGP has provided opportunities for discussion on closer collaboration between general practice and community pharmacy, both in terms of practical linkages and, going forward, in respect of the ongoing review of pharmaceutical services and the GMS contract. The Productive General Practice Programme also provides excellent materials and opportunities to enhance partnership working at local level.

May 2010 saw the beginning of the roll out of the Chronic Medication Service (CMS). CMS provides personalised pharmaceutical care by a pharmacist to people with long-term conditions. It is underpinned by a systematic approach to pharmaceutical care of people with long-term conditions. CMS formalises the role of community pharmacists in supporting people with long-term conditions by making better use of their skills and expertise to improve an individual's understanding of their medicines and to help to maximise the clinical outcomes from their therapy. It promotes the ethos of therapeutic partnerships between patients, pharmacists in the community, hospital pharmacists and GPs so that patients receive optimum benefit from the care and medicines they receive.

Importantly, the CMS involves collaborative working between patients, community pharmacists and general practitioners, subject to patient consent. It is based on three stages, registration, pharmaceutical care planning under a generic framework and shared care allowing an eligible person's GP to produce a serial prescription for 24 or 48 weeks which can be dispensed at appropriate time intervals determined by that person's GP.

Patients are registered for the service electronically and the patient's GP practice is notified via the electronic registration. In relation to serial prescriptions eCMS will be capable of delivering electronic feedback on both items dispensed and clinical activities thereby facilitating regular feedback and communication between the participating GP and the community pharmacist.

Over 60 GP practices and 137 community pharmacies are currently participating in the early adopter phase of CMS roll out. These early adopters are being used to ensure the supporting IT infrastructure is tested, using one uncomplicated medical condition, prior to national roll out. The roll out process will be informed by lessons learned during the early adopter phase.

By mid May 2012, 157,000 patients had been registered for CMS across all community pharmacies in Scotland. Over 138,000 Pharmacy Care Records (PCRs) had been created for individual patients and over 14,000 care issues recorded.

The introduction of CMS is central to the longer-term vision of sustainable, high quality NHS pharmaceutical care in Scotland and is consistent with the principles of the 20:20 Vision. Indeed. Scottish Ministers are committed to … further enhance the role of pharmacists, building on the introduction of the Chronic Medication Service, and encourage even closer joint working between GPs, pharmacists and other community services.

Over the past 18 months the Scottish Government has been working with Community Pharmacy Scotland so that remuneration arrangements are better shaped towards the delivery of CMS and its contribution to person-centred, safe and clinically effective care. Work will continue in this area and to identify opportunities for pharmacy contract funding arrangements to best deliver these ambitions.

In October 2011, the Cabinet Secretary for Health, Wellbeing and Cities Strategy announced a Review of NHS Pharmaceutical Care of Patients in the Community. The review is well underway. Central to the review is how NHS pharmaceutical care can best contribute to care that is person-centred, safe and clinically effective to every patient every time.

The review is taking evidence from a wide range of stakeholders to enhance the role which pharmacists play in contributing to the healthcare of patients in the NHS, and encourage closer working with GPs and other community-based services and the associated challenges.

The outputs from the review will form the basis of the biggest work programme on NHS pharmaceutical care since The Right Medicine. A report setting out the review's conclusions and recommendations is expected in Autumn 2012 and will provide a significant contribution to delivering the Quality Strategy and the 20:20 Vision for achieving sustainable, high quality healthcare in Scotland.

There has been particular focus on the need to achieve effective partnership between primary and secondary care, the new quality and productivity indicators of the GP contract have provided a mechanism (and resource) or improved and productive dialogue throughout the country. There is evidence of the face-to-face dialogue between clinicians leading both to service change and improvement and to enhanced partnership working more generally.

9. Continue to attach priority to, and implement, cost-effective solutions to improve communications within primary care and between primary and secondary care.

The national eyecare integration project aims to have 95% of referrals from optometrists/OMPs to hospital eye services made electronically by April 2014 and provide for electronic submission of payment claims from optometrists/OMPs to Practitioner Services Division (PSD). The first tranche of funding to support the project was issued to Boards in October 2011 (£0.75m), with second tranche anticipated in Summer 2012. Planning is underway within Boards, supported by the eHealth Leads forum, and the Eyecare Integration Steering Group. Proposals are in place to raise public awareness of optometrists/OMPs as the first port of call for patients with eye problems are in the early stages of development. The project will bring benefits by:

• A reduction in time from referral to treatment;
• The allocation of the patient to the correct clinic at first hospital visit;
• A reduction in unscheduled attendances; and
• Identification of patients suitable for community care.

The potential of a common national aggregated approach for primary care datasets for supporting local clinical care, local and national quality and safety improvement, clinical governance, NHS planning and supporting research and development is one which has been agreed and discussed in many forums. Two short-life working groups have been convened to look, in discussion with the profession, at data extraction requirements from GP IT clinical systems and the common set of data that could potentially be made available as practice profiles.

These groups will report and provide recommendations on:

• Governance and support structures which can support the extraction and use of patient data whilst adhering to a common set of information governance and confidentiality principles;
• Common data sets and quality requirements;
• Objective benchmarking, both between practices and over time, on particular parameters so as to identify variation and areas for improvement, in whatever part of the system they need to occur;
• Objective benchmarking between and within Board areas so as to identify any
  geographical variation;
• The collection of national data sets to inform national policy and practice; and
• Ensuring that Information Services Division (ISD), NHS Board IT and other colleagues prioritise to ensure that there are effective processes for collecting and using robust, reliable data.

The HEAT performance targets are intended to set out the accelerated improvements that will be delivered specifically by NHSScotland in support of the quality outcomes and quality indicators. It is therefore essential to have a shared agreement on these key areas for HEAT target setting, and an understanding of how these targets will contribute to the Quality Outcomes. As a result, work is underway to develop proposals for new HEAT targets in 2012/13 one of which seeks to improve the timeliness and accuracy of communication at the interface between primary and secondary care to support the delivery of safe and effective care. The purpose of the communication is to highlight the key information to clinicians, improve patient safety and reduce readmission.

The Key Information Summary (KIS) is a summary of medical history and patient wishes which will replace paper-based faxing of patient information between GP practices and Out of Hours. It is intended to be a replacement for the "special notes" sent to Out of Hours and for anticipatory care forms for patients with long-term conditions.

The KIS builds on patient information already contained within the patient's Emergency Care Summary (ECS) and will be pre-populated from the GP system as much as possible. In addition to the basic medication, demographic and adverse reaction information on ECS, the KIS will hold the following information:

• Medical History
• Diagnoses
• Patient Wishes
• Special Alert Messages
• Future Care Plans
• Resuscitation Status
• Emergency Contacts and Next of Kin Details
• Legal Information such as Power of Attorney
• Preferred Place of Care

The benefits of the KIS include:

• Reduction of errors in the transcription of data from paper-based records, as all patient data will be automatically downloaded from GP Practices to the ECS;
• Reduction of the risk that inappropriate care is given by displaying patient information on one easy to access user interface;
• The KIS is patient-centred: the patient and/or the patient's carer will be directly involved in the creation of the KIS;
• The KIS information will be available quickly for Out of Hours and Emergency users; and
• The KIS will contain up-to-date patient information, which will save time for clinicians,
  as they will not have to phone GP Practices to obtain critical information.

A GP will create a KIS for the patient if required. It will be the responsibility of the GP to explain to the patient how the KIS works, how it will be updated, and who will have access to it. If the patient is happy for their information to be shared with other NHS staff and gives consent, the GP can then set up the KIS for the patient. Patient information leaflets and posters about KIS are available for practices.

KIS will be rolled out to all Health Boards in Scotland during 2012/13 in line with the eHealth Strategy. All patients, where appropriate to do so, will be offered a KIS by 2014.

10. Ensure primary care practitioners contribute to a clearer understanding between patients and practitioners on what it will mean to be a fully mutual NHS in the decade ahead.

The Quality Strategy's person-centred ambition will be achieved through the delivery of a healthcare experience that recognises and responds flexibly to each person as a unique individual, builds trust and empathy, and engages them in decisions that affect their healthcare and wellbeing. Actions to achieve improvements in person-centredness are system wide and will be led and delivered locally, by staff in partnership with patients and the public. These actions will be focused on:

• Enabling our systems to deliver person-centred care, through clear leadership and values
  of how we care;
• Improving services based on patient experiences and outcomes;
• Improving staff experience; and
• Improving communication and effective collaboration between patients and staff.

In support of this a number of national activities are underway or have already been delivered these include:

The Patient Rights (Scotland) Act 2011 which gained Royal Assent on 31 March 2011. The Act aims to improve patients' experiences of using health services and to support people to become more involved in their health and healthcare. It will help the Scottish Government's aspiration for an NHS which respects the rights of both patients and staff. The Act also provides for the publication of a Charter of Patient Rights and Responsibilities. This will summarise the rights and responsibilities people have when accessing NHS healthcare in Scotland. The intention is that it will be published by 1 October 2012.

The national patient experience surveys form the backbone of the information that is used to evidence progress for the national patient experience quality outcome indicator. The Better Together Programme has now led delivery of two national surveys focusing on primary care including GP services as well as three national inpatient surveys. In general, most GP practices report that patients experience good or excellent care. However, there is variation in the quality of healthcare experience between Boards and across practices that needs addressed. The most recent survey relevant to primary care published results in late May 2012. It is hoped that Boards will support their GPs to engage with the data and use it to inform improvement activities at practice and Board level. The results this year, for the first time, include questions relating to other community healthcare services including Out of Hours. It will also include questions on the outcomes reported by patients as a consequence of accessing these and other services.

Most communities have a network of hubs which connect people and offer useful support, such as libraries, churches, schools, voluntary groups and community associations. However, they may be unconnected and poorly understood. The Links Project was a six-month project, to allow 10 GP teams, time and support to explore the nature of connections between primary care and communities. During the course of the project, teams gathered data and met to explore aspects of linking with communities which influence signposting to non-medical resources.

Key observations included:

• A significant number of people were willing to accept a recommendation from a GP to attend a community resource and were still attending four to six weeks later;
• The importance of personalised, relationship-based approaches, online up-to-date local information and experiential learning;
• To support community connections is essential; and
• Staff were interested in using local resources if they had opportunity to become familiar with them.

Adopting an organised approach to linking resources may have significant mutual benefits for citizens, primary care teams and providers of support. An emerging vision for improving links in communities is personalised, relationship-based supported by robust technology.

The Links Project is now being further developed in a partnership between RCGP and Long Term Conditions Alliance Scotland (LTCAS) with the aim of producing evidence that the detailed approaches and recommendations that have emerged are operationally sustainable for GP practices and community health partnerships.

The Links project drew in part on volunteers from the Deep End general practices, a grouping of those practices serving Scotland's 100 most deprived communities. This initiative has, for the first time, given a voice to practitioners working day by day to address the multiple health and other issues encountered in Scotland's areas of blanket deprivation. Together with the RCGP's Time to Care publication it has given renewed focus to the pressing issue of health inequalities.

About 40% of the Scottish population live with a long-term health condition. An important part of helping people to live well with their condition is enabling them to manage their own health. To be confident and successful self-managers, people require support and advice. self-management support is usually provided close to home, sometimes by people who have been through similar experiences. The ALISS (Access to Local Information to Support self-management) project aims to make information about self-management support more findable. A key part of the ALISS project has been the development of the ALISS Engine which will link up current data and new contributions to make a richer set of information about local self-management support, openly available to all. The Engine manages an online index of links. It is the one place that information about self management resources can be brought together. At the moment this information lives inside separate databases around Scotland. To find them we have to know where they are held in order to search for them. Once the Engine holds links to them, they will be in a single, open, searchable national collection of data. ALISS is working with those who already develop directory services to explore ways in which it can incorporate their data. Tools are being developed which will allow a wide of individuals to contribute ideas and suggestions. In this way ALISS can learn from and share the experiences of those who live with long-term conditions.

11. Ensure that NHS performance management and accountability structures reflect the central importance of primary care.

Recognising the key role of primary care has been a crucial element of the DQPC Action Plan. Combining the progress that NHS Boards are making in implementing the plan along with NHS Boards' annual review process, have provided the first steps in integration between performance management of primary care and the rest of the health system. Furthermore, there is a need to achieve agreement between the Scottish Government Health Directorates and NHS Boards on strategic issues which will enable primary care in general and the independent contractors in particular, to play a full part in delivering the ambitions of the Quality Strategy. The Primary Care Strategic Forum has been created to provide an environment for structured engagement between the Scottish Government Health Directorates and NHS Boards on strategic primary care issues, encouraging joint working and identifying areas for further development. The forum will encourage integration by taking decisions on how primary care should be incorporated into whole system solutions in NHS Boards, partner organisations, SGHD and more widely. In order to maximise primary care's contribution to delivering the aims of the Quality Strategy the forum will ensure that Chief Executives and others are aware of the opportunities offered and challenges faced as well as ensure the most effective primary care input into other parts of the National Quality Strategy Delivery Group infrastructure.

Steps have been taken to ensure that, in exercising its performance management function in respect of Boards, the Scottish Government gives appropriate prominence to primary care issues. This includes closer working between the relevant Scottish Government divisions and joint work in developing a fit-for-purpose national data set.