Delivering quality in primary care: progress report

3. Overarching considerations, priorities and challenges ahead

Overarching considerations

This report takes stock of progress of which we are aware in the key areas identified. In almost every case this is being taken forward by others and many of the developments had their genesis before we started our work. However, we hope this report helps to highlight what is being achieved across the country by dint of active engagement with practitioners and a firm focus on quality.

Progress so far

The Steering Group is pleased to note that good progress is being made in each of the areas identified by practitioners and others who contributed to the DQPC process.

The fuller story is told in section 4. While it might seem unfair to pick out particular examples – we would draw particular attention to the excellent work on patient safety
in primary care ^[5], developing and making widely available the productive general practice ^[6] tool, leadership ^[7], integrating eye care ^[8], rolling out Childsmile ^[9], the emergency care and key information summaries ^[10] and on steps such as the Links project ^[11] aiming to help tackle Scotland's health inequalities.

The combination of new national actions and effective local activity throughout the country is gratifying and reflects a renewed sense of energy and purpose in primary care. Moreover the group has had the sense that the 11 areas of national activity and indeed the two overarching themes (the central role of primary care and the need for strong, productive relations with independent contractors) remain entirely appropriate.

Challenges ahead

The task is, however, far from over. Since the creation of the Action Plan, and the establishment of the Steering Group, the challenges which both were intended to meet have undoubtedly grown. We are clearer than ever before about the scale of the challenges facing the NHS in Scotland, and its partners in local government and the third and independent sectors, in terms of public health, demographic change and financial challenge.

We welcome the articulation by the Scottish Government of a "20:20 Vision" ^[12] for sustainable high quality healthcare and in particular its straightforward recognition that healthcare cannot carry on being provided as it always has been. We strongly support the vision's emphasis on anticipation, prevention and a shift towards more care at home or closer to home. These are also the priorities articulated in the Scottish Government's proposals for integration of adult health and social care.

Keeping our eyes on the medium-term goal – the 20:20 Vision – is vital. But in doing so we must also act with urgency. Patients, practitioners, families and carers are already feeling today the impact of the challenges articulated.

The DQPC approach has been characterised by a focus on coming together to agree on practical actions which will make a difference. Faced with the enormity of the challenge, both in scale and complexity, we have sought to try to make sense of a crowded landscape and to tease out tangible actions to take us forward. In that same spirit, the DQPC steering group has set out below those areas we believe to be the most pressing to continue to address. Whilst it will be for the Scottish Government National Quality Strategy Delivery Groups to fine-tune, prioritise and progress the actions needed to move forward these challenges, in our view these priorities should include an immediate focus on person-centred care, telehealth and telecare developments and access to meaningful primary care data.

High-level priorities

People at the centre

In all our efforts to provide focus and to make sense of the complex system we work in, we have returned time and again to the fundamental point that it is not inputs and activity which matter most, nor indeed progress on particular conditions or systems, but rather the overall outcomes for individuals and for their family and carers. In all our activity we must never lose sight of the need to nurture, value and develop the essential patient facing role of clinicians. It is also about only pursuing particular "improvements" if, taken in the round, they are of net benefit to the individual.

We welcome the endorsement of supported self-management and person-centred care. It is important that these values, attitudes and behaviours continue to be articulated and demonstrated at all levels. In many senses they are as old as the professions we represent. But if pursued vigorously and resolutely they will represent a significant paradigm shift. It is important that we continue to engage patients, carers and practitioners about what this will mean for them on a day-by-day basis.

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Giving priority, pace and energy to the newly-launched person-centred programme;
• Ensuring that accountability frameworks and the quality measurement framework focus on the meaningful as well as the measurable, taking forward work to develop and spread approaches and tools that facilitate holistic care and shared decision making;
• Sense checking other interventions – policies, guidelines, improvements, publications etc. – to ensure they enhance and do not cut across this approach. This should be the key litmus test for steps to integrate health and social care.

NHS Boards –

• Creating the conditions and a culture that empowers patients and staff and puts patients and carers at the centre;
• Giving priority and building local leadership and improvement capacity and capability to drive improvement in person-centred care.

The Professions –

• Ensuring curricula for undergraduate and postgraduate education and training give sufficient attention to this area;
• Embedding person-centred practice within the professional development and regulatory frameworks for all primary care contractors.

Telehealth and telecare developments

Faced with new challenges we need to be quicker to adopt new solutions. We consider that the pace and determination with which we adopt innovation will go a long way to determining the success of our response to the challenges we face. This is true for both clinical innovation and technological advances. Technology itself will not deliver better quality, it is an enabler for service redesign and quality improvement. Targeted appropriately and with the right safeguards in place the use of technology such as telehealth and telecare solutions may liberate capacity to target resources to other priority areas of the system. Used creatively, it should maximise vital face-to-face care, and enable greater choice and access for individuals.

This is not primarily about resources for telehealth. It will ultimately require a cultural shift – both professional and public acceptance that this technology should be part of the bigger picture of healthcare delivery enabling greater participation and wellbeing. This will not be straightforward. It will require consistent messaging, explanation and powerful examples of stories that illustrate the transformative potential of technology on outcomes for all.

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Systematically considering telehealth and telecare solutions to enable progress in each of our quality programmes in order to deliver safe, effective and person-centred care in a way that is both sustainable and value for money;
• Giving priority to the appropriate use of this technology as an enabler in anticipatory care planning.

NHS Boards –

• Continuing to engage and work collaboratively with NHS 24 and Scottish Centre for Telehealth and Telecare (SCTT);
• Systematically considering telehealth and telecare solutions in local service redesign;
• Engaging with health professionals on barriers to deploying this technology including issues of data security and confidentiality;
• Ensuring that eHealth leads work closely with NHS 24 and the Scottish Government to explore and spread more widely the use of telecare/telehealth solutions in the primary care setting.

The Professions –

• Engaging constructively with colleagues to identify the opportunities from telehealth and telecare for each of the professions;
• Involving professional champions to help others understand and seek to overcome the barriers to adoption and spread of the technology.

Access to and intelligent use of data

Quality data are central to providing quality care for patients. Best use of data supports clinical care, and promotes excellence in quality improvement at all levels. Such data are essential to underpin clinical governance, for the planning and commissioning of new services and to inform research and development activities. Research provides the essential new knowledge required to improve health outcomes and reduce inequalities. It is vital – particularly when resources are under pressure – in helping our health systems to identify new and better ways of preventing, diagnosing and managing diseases in a clinically and cost-effective way. Relevant research can also make an important contribution in meeting the challenges of Delivering Quality in Primary Care.

In the past, whilst there are rich sources of data in primary care, NHSScotland national datasets have predominately been used in secondary care and public health. This has been changing in recent years, most notably with the creation of PRISMS ^[13] to make prescribing data more accessible, and with the quality data derived from the Quality and Outcomes Framework (QOF) ^[14] payment system. However, the uses of these datasets are constrained, since they are typically aggregated data at practice level, whereas assessing the quality of care beyond the current QOF measures reported usually requires patient level data.

General Practice clinical IT systems are the single largest, richest and most consistently recorded source of electronic clinical data at patient level anywhere in NHSScotland but the data are fragmented across more than one thousand general practice systems. The potential of these data will therefore only be realised when a robust national mechanism is established, allowing appropriate access for a range of users and uses. This will require clinical leadership, clarity about how data will be used and for what purposes and, crucially, evidence that practices and patients will benefit from data sharing. The data we use must be meaningful, proportionate and designed to drive quality improvement and sharing of good practice.

In the context of adult health and social care integration it is even more important that we are clear about the purpose, process and governance mechanisms for data sharing and that we make significant progress in this area during 2012 and beyond.

To make progress in this area we expect to see:

The Scottish Government –

• Developing and implementing over the next year a strategic approach to primary care data extraction and uses;
• Ensuring the approach simplifies the information landscape and avoids proliferation
  of datasets;
• Chief Scientist Office continuing to encourage and support primary care research via
  the Scottish School of Primary Care and the Scottish Primary Care Research Network
  to support the ambitions of Delivering Quality in Primary Care.

NHS Boards –

• Engaging proactively in this process, resisting the temptation to add complexity at local levels;
• Developing in collaboration national datasets which will allow Boards to compare key performance indicators helping to share good practice and reduce unwarranted variation.

The Professions –

• Engaging constructively with each of the professions on the use of data;
• Using professional champions to help others understand and seek to overcome the barriers to primary care data extraction and use;
• Agreeing the parameters and use of common data sets for each profession;
• Agreeing the governance principles to be applied in any data extraction process.

Other priorities

Partnerships/relationships

To sustain quality and reliably deliver good outcomes we need to be innovative about how we organise ourselves and, crucially, how we develop and nurture new relationships. This is most clearly relevant to integrating health and social care; but it is also about finding new, tangible and sustainable ways of achieving the elusive integration of the whole health system. The Scottish Government's proposals for integrating health and social care acknowledge the need to make progress on integration within health, as well as between health and social care and working more collaboratively with partners from the third and independent sectors.

Within primary care itself, we acknowledge the ongoing task of finding fresh ways of achieving well-integrated primary care teams. Systems as they stand, including the arrangements for the governance and reward of staff, in part mitigate against the teamwork that is required to deliver the 20:20 Vision and to improve health and reduce inequalities. The complexity of interactions required to deliver high quality care will always require continuous nurturing of relationships, close collaboration and co-operation.

In our view there is a particular urgency to address the interface between community nursing and general practice ensuring that structural boundaries are not barriers to collaborative working. ^[15]

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Developing explicit plans for engaging primary care practitioners in the new arrangements designed to deliver adult health and social care integration;
• Continuing to put every effort into ensuring that interventions in the service both support collaboration and are themselves well coordinated;
• Considering how to promote optimal collaboration in any new developments, including contractual change.

NHS Boards –

• Working with partners to strengthen links in their area between community nursing and general practice to ensure that primary care teams operate to the benefit of patient care;
• Building on the learning and relationships from whole system working facilitated through the quality and productivity indicators introduced into the QOF in 2011/1215;
• Fully involving primary care professionals and staff working in community hospital settings in the arrangements to implement locality planning.

The Professions –

• Maintaining local planning, quality improvement, learning forums and other mechanisms whereby all four independent contractors can continue to share good practice and reach joint decisions;
• Testing action learning approaches to promote collaborative practice;
• Building leadership capacity and capability through national and local leadership development.

Sharing good practice and reducing unwarranted variation

As we break new ground in how we deliver healthcare in Scotland we need to be more systematic about identifying what is good, sharing it amongst ourselves and spreading the activity to scale. Of course we need to promote local solutions that meet local needs and are locally owned and adopted, but we are not such a large nation that we cannot spread quickly and effectively good approaches and interventions that will work throughout Scotland. ^[16]

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Identifying solutions which have been tested and refined and are ready to spread with speed to scale. These include the patient safety in primary care programme, ALISS16 (access to local information to support self management), anticipatory care planning
  and medication reviews for polypharmacy;
• Mapping and aligning quality improvement activity in primary care to optimise a cohesive approach, release capacity and maximise impact of improvement;
• Promoting dialogue which provides opportunity for shared learning;
• Commissioning a database designed to capture and promote excellence in primary care.

NHS Boards –

• Prioritising improvement resources to support primary care teams to deliver high quality safe, effective and person-centred care that takes us towards the 20:20 Vision.

The Professions –

• Thinking creatively to establish and maintain processes for peer to peer support and challenge and share good practice.

Workforce

Throughout, the DQPC Action Plan has sought to engage and mobilise the workforce around quality. A key aim has always been to release the energy, creativity and dedication of primary care practitioners. We need a comprehensive workforce development strategy and a set of actions, enabling supports and measures, including education, practice development, career paths and succession planning which ensure that we continue to have the right capacity and skill mix of high quality effective, and capable, practitioners.

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Ensuring that both the Workforce Development Strategy and the Leadership Strategy take full account of current primary care issues and responds to the challenges of the 20:20 Vision. We believe the vision points to the urgent need both for increased capacity, in a variety of forms, in primary and community care and for better use of existing capacity;
• Ensuring robust datasets are in place to inform such strategies.

NHS Boards –

• Engage appropriately with NHS Education for Scotland (NES) primary care educational activities both at regional and national level;
• Creating a culture that fosters innovation, recognises commitment, and nurtures
  team working;
• Being innovative in use of technology, shared learning opportunities and clinical skills development to build an integrated workforce that is fit for the future;
• Maximising opportunities for dialogue with staff and seeking feedback to continuously improve both the quality of care and the staff experience.

The Professions –

• Working constructively to ensure that with the right safeguards in place comprehensive data are available to inform workforce discussions and decisions in order to optimise quality and productivity;
• Promoting professionalism, excellence and leadership development within all our contractor professions.

Whole system working

The sense of urgency – that things cannot carry on as before – is relevant throughout the health and social care system. This has particular implications for primary care. It remains our belief that primary care occupies a pivotal role, at the interface between different parts of the health system and between health and social care. We welcome the moves towards a more whole system approach to healthcare, working collectively to deliver the best quality outcomes for the people of Scotland. However, we believe more needs to be done including in NHS Boards. There are many different practical ways in which this needs to be articulated. The proposals for locality planning that form part of the Scottish Government's consultation on integration of adult health and social care offer an opportunity to build upon, discuss and develop this important strand of improvement.

It is our hope that, going forward, there will be a greater focus on effective integration of care among all elements of health and social care services. ^[17]

To make progress in this area we expect to see:

National Quality Delivery Groups –

• Developing mechanisms within the NHS Board annual accountability process which ensures that the themes in the DQPC Action Plan and highlighted within this document feature in Boards' local development plans and improvement activity;
• Enabling the Primary Care Strategic Forum to make a key contribution to achieving whole system working;
• Ensuring the Quality Measurement Framework17 reflects in full the role of primary care, including through appropriate HEAT targets (for example those being developed on discharge data and the outcomes for integration) and in other ways.

NHS Boards –

• Strengthening links between primary care and secondary care and whole system Managed Clinical Networks to ensure a whole pathway approach to service planning, delivery and quality improvement;
• Building on the learning and relationships from whole system working facilitated through the quality and productivity indicators introduced into the QOF in 2011/12;
• Fully involving primary care professionals and staff working in community hospital settings in the arrangements to implement locality planning for health and social care.

The Professions –

• Contributing constructively to opportunities for shared learning, interdisciplinary practice and integrated team working;
• Seeking opportunities to engage with, and better understand, the contribution of local community and third-sector resources to support health and wellbeing.