GMS contract: 2018

6 Better Care For Patients

Key Points

• The principles of contact, comprehensiveness, continuity and co-ordination of care for patients underpin the proposals.
• GP time will be freed up for longer consultations where needed – improving access for patients.
• There will be a wider range of professionals available in practices and the community for patient care.

Introduction

The joint Scottish Government/ SGPC Memorandum published in November 2016, described the aim of the negotiations to develop a contract that helps to reinvigorate the core principles of general practice in primary care, and frees up more time for the role of the GP as expert medical generalist. The four C’s of primary care, discussed in chapter one, are: contact, comprehensiveness, continuity, co-ordination.

GPs recognise these attributes as the qualities patients value most in general practice; they are the key strengths of general practice and the guiding values underpinning the negotiations.

This is why the focus of the transition over the next three years is to move away from the over-specification of services as described in chapter two – to progressively, though not entirely, move away from Additional and Enhanced Services – and to focus on the core role of the GP as expert medical generalist.

In order to ensure that the provision of any new or reconfigured service has a patient-centred approach to care, based on an understanding of patient’s needs, life circumstances and experiences, it is important that patients, carers and communities are engaged as key stakeholders in the planning and delivery of new services. It is equally important that other health care professionals are part of the redesign process. We will therefore ensure that engagement with patients, and professionals delivering primary care, is a key part of the development and delivery of any service redesign.

This chapter is structured around the four Cs. The first section addresses how we will maintain and improve accessible contact.

The second section addresses comprehensiveness of care in the context of the multi-disciplinary team. The third and fourth sections address how patients will have continuity of care and how that care will be co-ordinated.

Contact – Maintaining And Improving Access

Improving patient access to primary care and general practice is multi-faceted. Access in general practice is influenced by a range of issues: the location of the practice; when it is open; how easy it is to make appointments; and the speed of access to appropriate care.

Speed is not the only aspect of access that matters to people. Convenience – how easily people can make appointments; who those appointments are with; and when those appointments are – also matters. Being able to see a practitioner of choice also matters to some groups. The importance of these different aspects of access – ease of making appointment; time to appointment; time of appointment and choice – varies among different groups.

We have agreed that practice core hours will be maintained at 8am to 6.30pm (or as previously agreed through local negotiation), and that practices will continue to be required to provide routine services to patients during this period as appropriate to meet the reasonable needs of their patients.

More accessible information on surgery times within these practice core hours will be available to help patients easily identify when they can see a GP and/or other healthcare professionals.

The Extended Hours Directed Enhanced Service will be maintained. It will be clearer to patients when their local GP practice offers care in Extended Hours and when appointments with GPs and other practice staff are available within the Extended Hours period. Services provided by healthcare assistants may also be available during Extended Hours periods.

There will be improved convenience for patients in how they can access their local practice. Under the proposed new contract, GP practices will be required to provide online services to patients such as appointment booking and repeat prescription ordering, where the practice already has the existing computer systems and software required to implement online services safely.

Comprehensiveness – A Wider Range Of Health Professionals Within The Expert Medical Generalist Context

Ensuring patients have sufficient time with their GP when it is needed means recognising that not all patient needs at all times require the expertise of a doctor. The agreement on service redesign reflected in the Memorandum of Understanding will underpin the contract and allow GPs to have more time to deliver the type of care that only their skills and training can provide. At the same time, comprehensive patient care will be maintained within an expanded primary and community care team, with GPs having a more prominent clinical leadership role.

The discontinuation in Scotland of the single disease-focused approach to quality represented by the Quality and Outcomes Framework, has been a major step in creating a renewed focus on whole person and whole community health. This renewed commitment to a more holistic approach to quality and outcomes is being supported by the development of peer-led GP quality clusters. Clusters, in addition to improving quality and patient outcomes across GP practices, will have a leading role in advising on quality, patient experiences, and patient outcomes across the wider primary, community and social care landscape.

Significant new investment in expanded teams of clinical and non-clinical professionals working in practices and localities will widen patient choice and ensure that GPs are able to focus on their expert medical generalist role. As set out in chapter four, additional professionals will include pharmacy; nursing; allied health professionals (physiotherapy, and paramedics and other urgent care practitioners); and non clinical support workers (e.g. links workers).

Seeing the right person at the right place at the right time will sometimes mean not seeing a GP first, if this is appropriate. This might represent a significant change over time, both to how work is carried out and patients’ experience. Emerging evidence from the testing of new models of care in Inverclyde indicates patients can adapt quickly and respond positively to improvements brought by this model. For example, high levels of patient satisfaction have been recorded among those people who have accessed new first point of contact acute musculoskeletal physiotherapy care in a group of practices in Inverclyde.

Realistic Medicine, Person Centred Care and Expert Medical Generalists

Scotland’s Chief Medical Officer ( CMO), Catherine Calderwood, published her first annual report Realistic Medicine ^[17] in 2016. The report explores whether improved healthcare can be achieved by combining the expertise of patients and professionals in a more equal relationship; through building a personalised approach to care; increasing shared decision making; reducing unnecessary variation in practice and outcomes; reducing harm and waste; managing risk better; and improving innovation. The CMO’s second annual report, Realising Realistic Medicine ^[18] , continued the debate – with widespread support and contributions from national and international clinicians, leaders in medicine and public health and stakeholders representing the public and patient voice.

The values of Realistic Medicine are wholly aligned with the values of general practice supported decision making; holistic care that focuses on the person – mind and body – not the disease; care that skilfully manages clinical risk with every encounter – these attributes of realistic medicine are already the hallmarks of general practice. Moreover general practice has a strong history of innovation, learning and collaboration and GP clusters offer an opportunity to revitalise and strengthen these traits over time.

Refocusing the GP role as expert medical generalist enables GPs to further pioneer the practice of realistic medicine among their medical colleagues. General practice provides just the right amount of medicine for the best possible outcome to individuals and populations. The principle of shared decision making extends to genuine discussion and engagement with the public about how care is best delivered. All four parties to the MOU are committed to public engagement in the development of Primary Care Improvement Plans.

Continuity – Time With A GP When It Is Really Needed

Continuity of care – the development of lifelong therapeutic relationships between doctor and patient – is a distinctive hallmark of general practice. The aim of the workload reduction measures described in chapter four is to free up GP capacity for those times when only the expertise of a doctor is sufficient.

Scottish Government and SGPC agree it is not appropriate to contractually define consultation lengths, as that will continue to be a matter for clinical judgement. Freeing up capacity, through the redesign of services over the next three years, will allow for longer GP consultations when required by patients, particularly for complex care.

We agree that the independent contractor model of general practice is a benefit to continuity of care as it encourages a strong and enduring commitment from GPs to their community of patients.

The new proposed contract reduces current risks to practice stability and sustainability, for example, by addressing some of the key risk factors relating to rising workload, premises ownership and employment of staff. This in turn will make the partnership model more attractive to newer generations of GPs.

Co-Ordination – Including More Information And Better Help To Navigate The System

The 2004 GMS contract requires each practice to make a practice leaflet available to patients. This requirement will remain and the practice leaflet will continue to include important information for patients about the practice and how they can access available healthcare services in their local surgery. This includes: the name of the contractor; partners and all healthcare professionals who deliver services; how to register with the practice; the practice area; and the opening time of the practice premises; as well as how to access services in core hours of 8am to 6.30pm.

The Scottish Government and SGPC have agreed to modernise access to, and provide a consistent platform for, the supply of this key information for patients. This will involve better use of NHS 24 - the national agency for health advice and information in Scotland.

NHS24 will develop a national standardised website for each practice in Scotland that will contain all the key information required in the practice information leaflet. It will also consistently signpost practice patients to reliable self-care information and to wider health and care services in the community. This website will be made available at no cost to individual GP practices. Once available, practices will be able to choose whether to use this service or another service, but all practices will be required to make practice information available to patients digitally.

In summary, ensuring continuity, comprehensiveness, accessible contact and co-ordination for patients lies at the heart of the proposed new contract. As well as treating the individual, the proposed new contract offers a better contribution by general practice to local population health and ensuring the needs of the community are met.

The next chapter will cover the wider role of GPs and GP Clusters in population health, planning of local services, quality planning, quality improvement and quality assurance, and supporting information for quality and sustainability at local, regional and national levels.