GMS contract: 2018

8 The Role Of The Practice

Key Points

• General practice nursing will continue to have a vital role under the proposed new contract.
• There will be new enhanced roles for practice managers and practice receptionists.
• In addition, a number of clarifications and improvements to the underpinning GMS and Primary Medical Services ( PMS) regulations will be made.

Introduction

The table below sets out how the activities of the practice team might be expected to change in the next three years. The examples given below under the heading of each professional are indicative only, not exhaustive. More information on the services mentioned in the table is set out in chapter four.

Figure 5: Services in 2017 and 2021

2017	2021
General practitioners Independent contractor – based in the practice Default primary medical service provider Undifferentiated presentations- patients who are ill/believe themselves to be ill, who require diagnosis Complex care - including patients who have more than one diagnosis or medical issue Clinical leadership of the practice team to improve patient outcomes Home visits Delivery of chronic disease monitoring Chronic disease management Delivery of some nursing services (treatment room) Repeat prescribing, serial prescribing, ‘specials’, and polypharmacy reviews. Reviewing results (large Docman activity) Leading practice team/practice management	General practitioners Independent contractor – based in the practice Default responsibly for a reduced number of primary medical services Undifferentiated presentations- patients who are ill/believe themselves to be ill, who require diagnosis and cannot choose to see other health professionals Complex care - including more time with patients who have more than one diagnosis or medical issue Clinical leadership of extended primary care team to improve patient outcomes Fewer home visits but more complex and often as part of team assessment and support Oversight of chronic disease management Reduced volumes of Docman – outpatient and self-ordered test results Leading practice team / practice management Leading clusters Influencing local system
2017	2021
General Practice nurses Employed by the practice Treatment room services Chronic disease monitoring/management Vaccinations Minor injury, dressings Practice manager Employed by the practice Contract management Contract monitoring Business planning Contract and other regulatory compliance Staff management Receptionists Employed by the practice Organising patient appointments Managing communications to/from the practice Managing prescription requests/enquires Operating call/recall systems Administration	General Practice nurses Employed by the practice Minor illness management Chronic disease management Supporting GP to deliver care planning Monitoring lab results Practice manager Employed by the practice Contract management MDT co-ordination Contract monitoring Business planning Contract and other regulatory compliance Staff management Receptionists Employed by the practice Organising patient appointments Supporting patients with information on available services Managing communications to/from the practice Managing prescription requests/enquires Operating call/recall systems Administration
New for 2021	New for 2021
Pharmacotherapy services HSCP/ NHS Board Service Repeat prescribing, serial prescribing, ‘specials’, shortages Medication and polypharmacy reviews. Medicines reconciliation Medication enquiries Monitoring lab results for high risk medicines Urgent Care Services HSCP/ NHS Board Service Assess and treat urgent and emergency care presentations Home visits Falls Additional Professional Services HSCP/ NHS Board Service Acute musculoskeletal physiotherapy services Community mental health services Community link worker services	Community Treatment and Care Services HSCP/ NHS Board Service Management of minor injuries and dressings, phlebotomy, ear syringing, suture removal Chronic disease monitoring – routine checks, and related data collection Screening test results will go directly to requesting physician Monitoring lab results to pharmacist/general practice nurse Carrying out requests from secondary care Vaccination Services HSCP/ NHS Board Service Provide all vaccinations previously provided by GP practices. Travel vaccines and travel health advice

Case Study – community treatment and care services in Lanarkshire

In Lanarkshire, most GP practices have access to a ‘Treatment Room’ ( TR) service which enables a range of procedures, many of which were previously provided by a GP or GP employed-staff. The service provides core services which includes, amongst others, wound management, venepuncture, injections and ear irrigation.

For routine needs, patients are provided with appointments at health centres. However, both GPs and Board run treatment rooms have retained flexibility in how they provide services in order to deliver the best experience for the patient. For example, some GPs will take blood samples when the patient is in their practice if they have a view that there is an urgent need or to do so or it is clinically appropriate for the patient.

The service is also helpful in allowing a range of patients, where appropriate, who would previously have required a domicillary visit from a District Nurse to now receive such treatment in a more appropriate clinical setting. This is also more efficient than a domiciliary service with attendant travel time between visits.

TR services are staffed, where possible, with an appropriate skill-mix to reflect the range and quantity of interventions.

General Practice Nursing

General practice nursing is an integral part of the core general practice team. The profession provides primary care services, mainly through GP independent contractor employment, including general nursing skills as well as extended roles in health protection, urgent care and support for people with long term conditions.

General practice nurses had a key role in the achievement of QOF points as part of the 2004 GMS contract. However, many in the profession felt that QOF greatly increased bureaucratic workload and had a negative impact on consultations, supporting “box ticking” rather than facilitating holistic and person-centred consultations. The new general practice landscape in Scotland will enable general practice nurses to have more meaningful person-centred consultations.

With dedicated community treatment and care services delivered through HSCPs the 2018 GMS contract will support GPNs to focus on a refreshed role in general practice as expert nursing generalists. They will provide acute and chronic disease management, enabling people to live safely and confidently at home and in their communities, supporting them and their carers to manage their own conditions whenever possible.

To fulfil the challenges associated with the increasing complexity and demand of primary care in Scotland the role and career pathway of general practice nursing will need to adapt and evolve. A ‘one size fits all’ approach may not be appropriate for all posts, but there will be a common pathway to lead general practice nurse or advanced nurse practitioner careers. At the present time variation in terms of both job titles and training is evident within general practice nursing.

To support an enhanced role safely integrated into general practice it is critical that there are agreed role definitions supported by a robust career and educational framework. The Transforming Roles: General Practice Nursing Group was established by the Scottish Government in 2017 to refresh the role and educational requirements of general practice nurses. This work will be taken forward jointly by the Scottish Government’s primary care and Chief Nursing Officer Directorates in 2017/18.

GPNs require a significant breadth of knowledge and need to access appropriate structured education and training. Investing in general practice nurses provides a valuable opportunity to deliver a highly skilled ‘fit for purpose’ profession. The Scottish Government has invested £2 million in 2017/18 for additional training for general practice nurses in recognition of the importance of this role in the future delivery of care to patients in the primary care setting. This training will enhance the skills of general practice nurses so that they are better equipped to meet the increasingly complex needs of patients. This training enhancement will also make it easier for patients to access the right person at the right time.

The Transforming Roles: General Practice Nursing Group will oversee the continued funding of training for general practice nursing to enable the on-going development of this critical workforce during the three year transition period as outlined in the MoU.

Given the changes in service redesign in primary care, demand for nursing staff in the community will increase. We anticipate continued employment of the nursing workforce in primary care by both NHS Boards and Independent Contractors. There will also be opportunities, if individuals wish, to change roles to take on new opportunities in the community treatment and care services; in general practice nursing, and in advanced nursing practice.

Practice Managers And Practice Receptionists

Practice Managers play a key role ensuring the smooth and efficient day-to-day running of practices and the long term strategic management and co-ordination of primary care, including supporting the development of the multi-disciplinary team.

The role of the primary care manager was introduced in the 1980s as a senior receptionist/office Manager role. With the introduction of the Red Book contract in 1990, which coincided with the introduction of the first IT systems into general practice including automated call and recall systems and electronic appointment systems, the role began to evolve and become more commonplace.

The 2004 GMS Contract formally recognised the contribution effective practice management has on reducing the administrative burden on clinical staff and included a core competency framework for practice management.

Since 2004 the role of practice managers has adapted to meet a number of new challenges such as the development of practice IT systems; larger practice employed clinical and administrative teams; the increasing complexity of the GMS contract; and payment processes including the management of regularly changing QOF criteria and Enhanced Services. Practice managers have had a key role as facilitators of many of these changes. Indeed, many practice managers are now in senior management roles, however there nevertheless remains large variation in practice managers’ roles, responsibilities and skills from practice to practice.

General practice in Scotland has a highly skilled and experienced practice manager workforce. These managers have skills and experience which will be vital to ensure the success of the proposed new contract.

Practice managers already have a wide range of skills which will be essential for the future including financial management, IT management, HR management, contract management, leadership and facilitation, quality improvement skills, change management, communication and patient engagement skills. Work is ongoing with NHS Education for Scotland to identify and meet practice managers’ training needs. Career development and succession planning will also be important considerations going forward.

The introduction of the proposed 2018 contract will increase the need for highly skilled practice managers with wide ranging, adaptable and versatile skills. In addition to continuing to manage the practice employed team, they will work more with the wider primary care system including GP clusters, NHS Boards, HSCPs, and emerging new services.

Alongside the changing role of practice managers, the roles of receptionists and other non-clinical staff in the practice have also evolved.

Practice receptionists have an important role supporting patients and enabling practices to run smoothly.

Opportunities to develop the skills of practice receptionists to support patients with information on the range of primary care multi-disciplinary team services available, or to increase their role in the management of practice documentation and work optimisation, are currently being explored with Healthcare Improvement Scotland ( HIS). HIS will be working with GP clusters to develop training and resources to support these staff.

There is also a wide range of practice administrative staff carrying out a diverse number of tasks from prescription management, medical secretarial skills and IT management including call and recall, to documentation management, health and safety monitoring, and finance management. These staff are a highly skilled and adaptable workforce who will continue to have an important role in general practice in the future.

Strong leadership by practice managers supported by their teams, and by the practice GPs will be hugely important to the success of the proposed new contract and new ways of working.

Improvements To Regulations And Other Issues

In addition to the proposals set out in previous chapters, a range of clarifications and improvements will be made to the underpinning regulations for General Medical Services contracts and Primary Medical Services contracts. These, and other issues not contained in underpinning regulations but pertinent to general practice, are set out below.

Indemnity

In the spirit of reducing risk for GPs, the Scottish Government and the SGPC are working collaboratively with Medical Defence Organisations to seek the best solution for indemnity in Scotland, following the announcement of changes to the discount rate in February 2017 and subsequent announcement by the UK Department of Health of its intention to introduce a state-backed scheme. The solution will take into account the indemnity needs of partners, locums and sessional GPs.

Temporary Residents

Practices are currently paid to treat Temporary Residents under the Temporary Patient Adjustment provisions of the Statement of Financial Entitlements. Before the 2004 contract this treatment was paid for by the temporary residents’ fees, emergency treatment fees and immediately necessary treatment fees under the Red Book. All contractors currently receive a payment for unregistered patients as an element in their global sum allocation. The amount each contractor receives is generally based on the average amount that, historically, the contractor’s practice claimed for treating such patients each year under the Red Book prior to 1 April 2003.

The Temporary Patient Adjustment leaves practices exposed to the risk of their number of Temporary Residents fluctuating while the resources to treat them remains constant. Under the new contract, practices will be required to report on numbers of Temporary Residents in 2018/19 to allow the Temporary Patient Adjustment to be reformed and uplifted on the basis that funding will follow activity as soon as practicable and by 2020/21.

Data also will be collected on activity around care homes to ensure that funding follows activity on a similar basis to Temporary Residents.

Dispensing

The current arrangements for dispensing in Scotland will not change under the proposed new contract. As part of the preparation for a Phase 2, we will establish a short-life working group to consider the current dispensing arrangements and look for any mutually beneficial improvements. Relevant interest groups will be consulted to ensure their views are incorporated.

Challenging Behaviour Scheme

All NHS Boards are required to establish a Violent Patients Scheme, the underlying purpose of which is to ensure that there are sufficient arrangements in place to provide general medical services to patients who have been subject to immediate removal from a GP’s patient list of a general medical services contractor because of an act or threat of violence.

Under the new contract, this Directed Enhanced Service will be revised to introduce a greater degree of consistency across NHS Boards ensuring that practices and staff are protected from patients who have been violent or threatening.

Practice Areas

The current regulations provide limited information and guidance on practice areas beyond the need for practices to refer to their area by reference to a sketch diagram, plan or postcode in their practice leaflet. The new contract will clarify how practice areas should be agreed as part of the contract between NHS Boards and practices. The regulations will introduce processes for the formal variation of practice areas to ensure that NHS Boards do not make unilateral decisions and patient wishes are respected. This will enable practices to make changes in a timely fashion whilst ensuring that the interests of other practices in the vicinity are taken into account by NHS Boards.

Patients will retain the right to remain on the list of a practice if they live outwith a boundary which has been reduced. Not all patients will wish to remain on the list of a practice which no longer covers their area, and NHS Boards will be empowered to help practices rationalise their lists where patients are willing, even to the extent of assigning patients to practice lists which are otherwise closed where practices agree.

Practice List Closures

Under the current regulations practices must apply to their NHS Board to submit a notice to close their patient list. Closing a practice list is a last resort for a practice and the process for closing lists is intended to function as a failsafe to ensure that NHS Boards work with their contractors to keep lists open for patients wherever possible.

Under the new regulations, if NHS Boards have not completed discussions concerning support with practices within three months, a closure notice will be considered as accepted. Where assessment panels do not accept applications to close practice lists they should nonetheless agree the increase in terms of either a percentage of the current number of patients or an actual number of patients which would trigger a closure of the list.

Contract Disputes

The NHS Dispute Resolution procedure provides an inexpensive way for parties to the GMS contract to hold each other to account. Under the new contract the Local Dispute Resolution procedure will be formalised giving practices confidence that their disputes are recognised and are being taken forward within specified timescales. Local dispute processes will address practice boundary and list closures.

The constitution of local resolution panels will include: a representative from the NHS Board;
a representative from the LMC; and an independent chair.

Certificates fees and charges

GPs are not always the best or only person to provide the various certificates prescribed in current regulations and this will be reflected in new regulations which will make alternative and routine providers clear.

The new regulations will provide a list of certificates which, through primary legislation, GPs are entitled to charge for providing. The regulations will be clear that other work falls outwith the GMS contract.

Emergency Responders

GPs have a professional duty to provide immediate and necessary treatment due to accident or emergency in their practice areas. However GPs should be understood as a last resort for these situations and the new regulations will reflect that.

Patient checks

The new regulations will clarify that while new patient checks will still be required, they can be conducted by members of the wider multi-disciplinary team.

All practices are currently required to offer patients who have not been seen within 3 years and patients aged 75 years and over (on an annual basis) appointments. Patients are not obliged to take up the offer. As all patients are entitled to request an appointment with their GP regardless of when they last attended, these specific provisions will be removed from the existing regulations.

New practices

The arrangements for Phase 2 will include developing proposals for creating new practices. This will usually be in areas where the population is growing rapidly and established practices are unable to expand their patient list further. The proposals will include specific financial support for new practices while their list size is growing, and a mechanism for establishing new premises. Additional funding for supporting new practices will not affect the funding of other practices as funding in Phase 2 will be practice specific.

Community hospitals

The current local arrangements for community hospitals in Scotland rest with HSCP and are unaffected by the proposed new contract. As part of the preparation for Phase 2, consideration will be given to reviewing the current arrangements and how they align with the proposed new contract and the role of the GP as expert medical generalist. Relevant interest groups will be invited to contribute to such a review process.

Primary Medical Services (“17C”)

Alongside updating the NHS (General Medical Services Contracts) (Scotland) Regulations 2004 (17J), the Scottish Government and the SGPC have also agreed to update the NHS (Primary Medical Services Section 17C Agreements) (Scotland) Regulations 2004. This will ensure that both contracts will support the transformation of primary care services and deliver significant benefits to patients, GPs and practice staff. The proposed changes outlined in this document will apply equally to both GMS contracts and 17C agreements. The intention is that practices in 17C and 17J will, in future, have equity of access to funding.

The revised sets of Regulations will not remove the right for any practice which currently operates under a 17C agreement to choose to revert to a 17J contractual status.