Delivering Quality in Primary Care National Action Plan: implementing the Healthcare Quality Strategy for NHSScotland

3. National Actions -what we will 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

We will do this by sharing best practice across the professions. This will build on, but not be limited by, the principles behind the Quality and Outcomes Framework ( QOF), including the systematic capturing and use of patient feedback. In particular, we will:

• In the light of the aims of the Quality Strategy take a radical look at the
  GP Enhanced Services in place in Scotland. We will aim to ensure not only that the substance of the enhanced services align closely with Scottish Government health priorities and are fit for purpose but also that the processes in place are as transparent and simple as possible. We will do this through continued engagement with all interested parties so that by Spring 2011 we will be in a position to propose changes to the enhanced services programme.
• Prepare well for any consequences in Scotland of the UK Government's White Paper which, for example proposes significant changes to the UKGeneral Medical Services Contract. We will seek to make realistic changes which would do the most to make the contract fit for the purposes of the Quality Strategy and for improving Scotland's health and reducing health inequalities.

Engage with:

• The British Dental Association ( BDA) and others on defining and measuring quality in dentistry including re-visiting the role of the dental reference officers, developing a measure of patients' experience, revising the dental practice inspection document and reviewing clinical audit and ensuring best educational techniques are in place to maintain and develop standards in clinical practice;
• Community Pharmacy Scotland ( CPS) and others on introducing a quality framework to underpin the new community pharmacy contract; and
• Optometry Scotland ( OS) and others on further developing quality outcomes through refinement of the new ophthalmic arrangements.

2. Improve access for patients

Access to primary medical services is a key consideration in improving the delivery of services and ensuring patients are at the heart of how these are designed and provided. The national survey results as part of the Better Together patient experience programme give a picture of patients' perception of access. It will be crucial to use these results to focus actions and give priority to helping all Primary Care contractors improve access for patients. This will include:

• Drawing clear lessons from the excellent results demonstrated by the Better Together programme;
• Rolling out throughout the country a new fit for purpose package of material on best practice in General Medical Practice;
• Working with NHS Boards and the profession to deliver support to those practices which experience the most difficulties; and
• Examining the role of community hospitals as a valuable resource to be utilised more widely and play a key role in delivering services that have been traditionally based at Secondary Care sites.

3. Develop and implement the Scottish Patient Safety Programme in Primary Care

Patients should have increased confidence that the care delivered by all parts of Primary Care in NHSScotland is safe, effective and person centred. This requires a culture of ongoing review of decisions taken, and interventions made, as well as encouraging comment and input from patients and the wider public. It also requires confidence that the identification and sharing of concerns and near misses will lead to learning and change for improvement.

The Patient Safety in Primary Care ( PSPC) Advisory Group will look at the key challenges which occur both at the interface between Primary and Secondary Care and within Primary Care itself and set and monitor progress against clear targets for reductions in harm. This work will build on the achievements of the NHS Quality Improvement Scotland ( QIS) funded pilots in NHS Forth Valley and NHS Tayside which led work on risk management in General Medical Practice, managing high risk medication, and communication between Primary and Secondary Care. Future targets will also be guided by outputs from the Closing the Gap project funded by The Health Foundation, and involving practices in NHS Forth Valley, Tayside, Fife and Lothian.

The PSPC Advisory Group intends to publish its work plan and possible targets for improving safety in Primary Care for consultation in Autumn 2010.

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

Agreed care pathways assist both heathcare staff and patients understand and achieve the best approaches for care which is safe, person centred and clinically and cost effective. It is recognised that the combination of targeted action within Primary Care, and both informing and empowering the individual with a condition, will improve their sense of wellbeing and avoid repeated admission to hospital.

In the first instance, we will focus on pathways where the behaviour of Primary Care has the greatest impact on Secondary Care and on the health service as a whole. These are likely to include a number of long term conditions which have an impact on an individual's quality of life, and which depend on input from the person with the condition (self care), the Primary Care team and, where necessary, from Secondary Care providers.

Examples will include:

• Care of diabetes;
• Asthma;
• Chronic obstructive pulmonary disease ( COPD);
• Dementia;
• Congestive heart failure; and
• Support to older people (both at home and in care homes) who are frail and have multiple long term conditions which combine to reduce their ability to function independently.

NHS Boards will further develop local pathways (many of which have been agreed through existing managed clinical network arrangements) and facilitate structured dialogue on local implementation, and ensure shared learning between clinical disciplines and across NHSScotland. Central to that dialogue will be the close and ongoing involvement of representatives of GPs and Secondary Care as well as input from patients and service users. QIS and GP representative organisations will provide support for this local dialogue.

5. Develop, as part of the Quality Measurement Framework, national quality indicators for the delivery of primary medical services out of hours

QIS will work in partnership with NHS Boards to develop national out of hours quality standards with a view to piloting in Summer 2011. This will ensure consistent care throughout the country and to drive continuous service improvement. We will also further develop a framework to monitor the patient journey in the out of hours emergency dental service.

6. Continue to give priority to anticipatory care

The Quality Strategy stresses the importance of primary prevention and anticipatory care in helping to reduce health inequalities and tackling the causes of poor health. Primary Care will work with a new Primary Prevention Steering Group to identify how it can best contribute to the prevention of ill health, building on the lessons learnt under Keep Well and Well North, and continuing to improve Primary Care's identification of and response to dementia and anxiety.

7. Help the professions with their workforce planning

Traditionally, workforce planning has been about ensuring that we are able to maintain the supply of nurses, doctors, and AHPs etc to meet demand. However, changing population demographics, service delivery imperatives and future workforce profiles and the subsequent change in the needs of patients, means the need to support appropriate care models for role flexibility becomes ever greater.

It will be important for NHS Boards and Primary Care services to modernise
and further develop their models of delivery and community nursing services and allied health profession services by reconfiguring the existing workforce and introducing a new mix of skills and competencies to meet these challenges.

To facilitate this we will:

• Support NHS Boards through the Modernising Nursing in the Community Board to address these drivers 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. This will include development of an online toolkit resource to assist NHS Boards in service redesign and workforce planning/configuration. We expect the planning toolkit to be available to NHS Boards by Spring 2011.
• Support independent contractors with relevant survey and other data and by facilitating debate on different models of delivery.
• Support NHS Boards to maximise the contribution of AHPs in Primary Care and
  the community.

8. Take steps to ensure more effective partnership between the different Primary Care professionals

This will include:

• Taking forward the care pathways work in such a way that we maximise the opportunities for productive dialogue between Primary and Secondary Care and other partners (this is closely linked with action 4);
• Exploring the scope for more joint development activities relevant to Primary Care practitioners, including the promotion of clinical leadership, and for incentives that reward for shared care;
• Ensuring that there is an effective strategic forum for taking forward Primary Care issues with and between NHS Boards; and
• Establishing a small steering group of external stakeholders, with a clear link to the Quality Alliance, to oversee the implementation of this action plan. Whilst the group will draw up its own work programme, we would expect it to:
• • Monitor the implementation of national actions and in particular ensure alignment with the Quality Ambitions;
  • Recommend in due course new actions which would help deliver the vision; and
  • Contribute substantively to a number of the national actions, in particular the development of measures within the Quality Measurement Framework described at 11 below.

One task for the group, whose initial term will be a year, will be to explore whether such a group should continue to operate on a standing basis.

9. Continue to attach priority to and implement cost effective solutions to improve communications within Primary Care and between Primary and Secondary Care

Past investment in Primary Care IT and telecommunications, including links with Secondary Care has resulted in real benefits. Continuing this effort and taking a more strategic approach to IT connectivity in Primary Care will result in further benefit, with the key ones being patient safety and quality improvement as the baton of care is passed.

Key work under way in this area includes:

• Migration of GP practices from the GPASS electronic patient record system to modern alternatives, by a completion target date of April 2012;
• The ePharmacy Programme, where the Electronic Transfer of Prescriptions already supports over 85-90 per cent of all GP prescribing. We will continue to build on this success with a view to increasing the electronic claims generated and sent by community pharmacies. Additionally we will further develop the implementation of the Chronic Medication Service which aims to improve patient care through a systematic approach to the provision of pharmaceutical care underpinned by electronic infrastructure;
• With a focus on patients with long term conditions, developing and testing the Key Information Summary proposal as a means of sharing high quality information with the agreement of the patient, by a completion target date of October 2010;
• Testing the case for making the Emergency Care Summary available in scheduled care to support medicines reconciliation and patient safety, by a completion target date of October 2010; and
• Complete the business case for introducing electronic links between the NHS and optometry practices by end September 2010.

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

This will involve ensuring full engagement by Primary Care practitioners in the ongoing dialogue brought about by the Quality Strategy on patients' rights, responsibilities and expectations. In particular, the Patients Rights Bill and supported self management which encourage people to be more involved in their own health and healthcare, and respects the rights of both patients and staff will be a key mechanism to do this.

NHS 24 will develop NHS Inform - a national health information service to provide a single shared health information online resource. This will bring together quality assured local and national information from NHSScotland and other sectors to provide; a national health information helpline and a network of branded health information support centres, embedded in local communities. This has been developed to inform and support patients. Additionally we will use the lessons learned from the Grampian pilot Know who to turn to on signposting and information sharing and from Better Together on the collection and use of patient experience data to inform improvement based on what they tell us is important
to them.

11. Ensure that NHS performance management and accountability structures reflect the central importance of Primary Care

Scottish Government Health Directorates are developing the Quality Measurement Framework and setting out how HEAT targets will relate to that framework. As part of that we want to ensure that full account is taken of Primary Care. We will work with NHS Boards and independent contractors towards that aim and ensure that the steering group overseeing this action plan feeds into that process.