General Practice: Contract and Context - Principles of the Scottish Approach

3. Scottish Government Primary Care Vision and Outcomes

3.1 The vision puts general practice and primary care genuinely at the centre of a community health service, improving outcomes for local communities. Effective, sustainable and accessible general practice is needed by everyone - so we all start well, live well, age well and indeed die well. We share a vision of the future role of the GP as the Expert Medical Generalist in the community; focussed on complex care, undifferentiated presentation and local clinical leadership. This is exactly what is needed to focus GP time on those patients who need them most, including those with palliative and end of life care needs.

3.2 The context in Scotland for general practice is Health and Social Care Integration - the single biggest public service reform in Health and Care in Scotland. HSCPs are, since April 2016, responsible for the commissioning, planning and delivery of all community and primary care services in their localities - including general practice. The nine Health and Wellbeing Outcomes (' HSCP outcomes') set out in the integration legislation are depicted in the centre of the figure above. The specific contribution of primary care (and general practice within this) is set out in the six Primary Care outcomes. These are:

Outcome 1: We are more informed and empowered when using primary care

Outcome 2: Our primary care services better contribute to improving population health

Outcome 3: Our experience as patients in primary care is enhanced

Outcome 4: Our primary care workforce is expanded, more integrated and better co-ordinated with community and secondary care

Outcome 5: Our primary care infrastructure - physical and digital - is improved

Outcome 6: Primary care better addresses health inequalities

3.3 The first three outcomes are concerned with the nature and culture of demand for services. More empowerment and better information will enable more self-care, for both routine and chronic conditions. Improving population health and enhanced experience - including better access to wider primary care services - will contribute to overall lower demand on the health and care system.

3.4 The second three outcomes are enabling outcomes. They describe the nature and characteristics of the underpinning interventions required to deliver the vision. They include an expanding workforce - both in primary care in general and in general practice specifically - and improved infrastructure including GP premises and IT.

3.5 General practice already requires a team approach. It relies on clinical and non-clinical staff in medicine, nursing, healthcare assistance, and practice management. Our approach is to extend this core practice based team to include other professionals - initially pharmacy, with enhanced pharmacists available to every general practice in Scotland.

3.6 Depending on local population need, the practice based multi-disciplinary team will also include allied health professionals (including paramedics playing a larger role in the community in and out of hours) and non-clinical professionals whose roles are to help people navigate the wider health and care system, such as practice receptionists, links workers and community connectors.

3.7 GP practices, clusters, and localities will know what is needed to make improvements to services in their areas. The Primary Care Transformation Fund is enabling a wide programme of tests right across Scotland, built on suggestions by local partners. At its heart is testing the multidisciplinary approach to patient care. This involves primary care professionals - pharmacists, physiotherapists, mental health professionals, advanced nurse practitioners and others - meeting the needs of patients, freeing up GPs to focus appropriately on undifferentiated presentations, complex care and provide clinical leadership.

3.8 How to ensure we have the right long term spaces for this team based general practice in the future is under active consideration by the Premises Short Life Working Group.

3.9 Better addressing health inequalities through our primary care services will require action primarily beyond the GP contract. In addition within the contract, the Scottish Allocation Formula weights practice funding by various factors that affect workload, including deprivation, rurality and age. The formula has been reviewed, and we are currently considering the impact at practice level as part of any overall changes to how GPs are funded. We need to look beyond the contract to other interventions and ways of supporting general practice in areas of high deprivation.

3.10 We understand and agree that delivery of the primary care outcomes is not possible solely through the GP contract. And we are clear that delivery requires additional investment. The Government's manifesto committed to shifting the balance of funding to primary, community, social care and mental health in each year of this Parliament. On 15 October 2016 the First Minister made a landmark announcement, committing to increase annual investment in primary care by £500 million by 2021/22. This will see the share of NHS frontline spending dedicated to primary care increase to 11%. This increased investment will help deliver our shared vision for general practice in the short and long term.

3.11 The principle - that delivering the outcomes needed requires three levels of intervention - contractual, primary care policy and investment and wider government policy and investment - is an important element of our agreed approach in Scotland. It is depicted below.