Improving General Practice Sustainability Group: 2019 Report

3. Sustainability Report: 2018 Update

Following on from the Report's publication, the reformed Working Group took time to consider how to deliver the recommendations, drawing on the considerable collective skill, knowledge, experience and resources of its members.

The following sections provide an overview of the work carried out to achieve the four key recommendations.

Reccomendation 1: Enact a Sustainability Action Plan for managing sustainable General Practice workload that contains short, medium and long term actions

National Feedback
In addressing the list of actions outlined in the SLWG's Report consideration was given by the Working Group to how this work should be approached and prioritised. The action plan consists of 55 actions which were broken down into eight broad themes based on priorities identified by the Scottish General Practitioners Committee(SGPC) and Health Boards. The new GMS contract together with the contract related developments, listed the context section above, addresses more than 30 of the 55 recommendations in the action plan.^[8]

Local Feedback
In addition, it was agreed that members of the longer term sustainability Working Group would provide feedback on work being carried out locally using the listing of the 55 point action plan (Recommendation 1) as a prompt, together with details of any work generated by the three other recommendations^[9].

A total of five health boards, NHS Forth Valley, NHS Grampian, NHS Highland, NHS Lanarkshire and NHS Tayside provided local feedback on the work they have undertaken in support of the action plan.

The national and local data fed back to the Scottish Government will allow collective progress to be shared with members of the Working Group and more widely with the sector via the i-hub or within Scottish Government. This will aid knowledge-sharing, best practice and understanding. The following paragraphs highlight both local and national feedback:

1. Partnership Working with External Organisations – There is good progress on all actions, with initiatives being undertaken by the Scottish Government and other key organisations. Colleagues in Creating Health policy team are considering the introduction of an electronic referral system for fit notes that would remove the onus for GPs altogether. They are awaiting an indication from Westminster^[10] that they can begin progressing a pilot. Meanwhile, to offset their sustainability issues, health boards report measures such as embedding welfare advisers in some of their practices, to redirect the workload created by non-contractual requests e.g. welfare letters, or other examples of early adoption of the multi-disciplinary team MDT model.

2. Supporting patients to self-care – The Scottish Government is partnering with HIS^[11] and four HSCPs to deliver on the Practice Administrative Staff Collaborative, which will support the MDT by looking at the development and training need of practice receptionists for signposting patients to the most appropriate professional. Other recent developments include the '3 before GP' campaign by the RCGP, involving a three-step approach of self-care, on-line advice such as NHS Inform and advice from a pharmacist for minor ailments before booking an appointment with your GP. Locally, the 'Know Who to Turn to'^[12] campaign is cited by most boards.

3. Delivering Solutions: good working practice– To support good working practice, the Primary Care Professional Advisers Team use their expertise to provide a hands on advisory service direct to Primary Care Leads and HSPCs. The MoU was published alongside the new contract to ensure that primary care funds are solely used for primary care work. The non-clinical role of community link worker has been introduced as part of the MDT, with a focus on practices in areas of high socio-economic deprivation, to aid signposting of patients to the most appropriate services.^[13] However, on a local level, there has been variable use of the sustainability assessment tool although the vast majority of HSCPs have used it in some form.^[14]

4. Workforce – In addition to the national workforce developments listed in the context section above, the Protected Learning Time (PLT) short life working group, a subgroup of the Working Group is examining how to best deliver PLT in an expanded MDT context, including clinical and non-clinical membership to ensure learning is shared with the wider MDT. Although not contractually obliged, NHS 24 and Out Of Hours (OOH) have played a pivotal role in supporting practices to deliver PLT by providing much needed cover, In revising the terms on which this service can continue to be supplied, NHS 24 is keen to work with partners at Board level to explore options for PLT provision beyond 2018/19.

All 5 health boards responding indicated that they were proactively developing the MDT approach. They reported mixed feedback on PLT, with some struggling to deliver as a result of service pressures. However, Tayside have an established PLT programme in all 3 of their HSCPs, and Grampian and Tayside report good work being done on their returner programmes.

5. GP Contract – A number of actions listed in the sustainability action plan were covered by the contract negotiations in agreement with the BMA^[15], including elements around registration, closing lists and changing boundaries. A formal process to vary practice areas has been introduced via regulations and work is already underway with external partners on the GP retainer scheme across Scotland. Locally, Tayside reportedproactive groups, with governance processes in place that are supported by clusters and HSCP data in a review of practice boundaries. Most HSCPs are in the early stages of the Primary Care Improvement Plan process and remain positive about the intention to engage with local stakeholders and service users in their re-design.

6. Effective Primary/Secondary Care Interface Working – The primary/secondary care interface is a key issue and as parallel work was being carried out by the Scottish Government team managing the Modern Outpatient Programme, Scottish Government colleagues have led on this work. This has also been a priority area of work for RCGP Scotland for the last 4 years. As a result of collaborative working with the Scottish Government, a well-received interface programme, funded by Scottish Government is now being delivered by RCGP Scotland.^[16]

Nearly all health boards that responded stated that they either have an existing group that looks at interface issues or a specific dedicated interface group. Some also advised they have an interface review process in place. Some Boards have also advised that they had successfully moved to 'specialist to specialist' referrals within secondary care, removing GPs from unnecessary involvement in the process. More than one health board have advised they have processes in place to allow fit notes to be completed by secondary care professionals rather than GPs when appropriate.

The new RCGP Scotland clinical lead, recruited in May 2018, will work across all Scottish health boards, supporting each board to establish dedicated high-functioning primary-secondary care interface group. This work will run over a three year period.

7. Effective Working Between GP & Pharmacy Services – The majority of actions on pharmacy services are underway or completed. Of note is the interim solution to allow pharmacists independent prescribers to prescribe electronically using GP clinical systems which were rolled out nationally in April 2017. A full national solution will become available through the GP IT re-provisioning process. In most cases, clinical pharmacists can already prescribe on practice software systems (EMIS and Vision) when working in practices.

8. Strategic Sustainability Issues – This section is the largest of all eight themes and most closely reflects on-going Scottish Government primary care policy initiatives such as to the workforce plan, the premises strategy and elements of the contract covered in the MoU. Notable work includes the GP IT work where NHS Boards have commissioned a procurement competition to provide the next generation of GP clinical IT systems for GPs in Scotland. This is being undertaken by NHS National Services Scotland.

Through the investment in GP recruitment and retention and working with NES, two schemes have been introduced that will help improve GP numbers in the form of a returner scheme and an enhanced induction scheme targeting international GPs. In addition, SG Policy continue to produce a standing report on spend for the Working Group on practice improvement projects such as the General Practice Improvement Programme - GPIP, which is applicable to the whole practice.

All responding health boards are actively involved in the Working Group with 'action learning set' meetings in the first half of 2018 being held in Tayside and Highland Board areas. All responding Board areas also have proactive local practice sustainability groups.

Conclusion
Although the sustainability action plan may have initially been seen as aspirational, at a national and local level more than 50 of the 55 action points have already been addressed. On-going review of the action plan remains central to the Working Group; the Working Group continues to discuss and address these issues alongside new issues as they arise.^[17]

The vast majority of recommendations in the action plan have already been or are being actioned as part of the implementation of the 2018 GMS contract, or are an integral part of the service redesign. There are, however, one or two pieces of work that are still under discussion e.g. two elements relating to care homes.^[18] Some local work has been undertaken to address requests for care home GP visits^[19] and at a national level an outline plan is in place for test of change working together with the Care Inspectorate. Further detail is expected to be provided at the next Working Group meeting in September 2018. Although translation services^[20] are listed on the national action plan, resolution is thought to best take place at a local level and again progress on this is reflected in local feedback.^[21]

The new GMS contract rightly focuses on undifferentiated presentations, complex care in the community and whole system quality improvement and clinical leadership as key elements of the GP role as an expert medical generalist supported by an enhanced, wider MDT. The sustainability action plan closely reflects this shift. As new actions come into play as the GMS contract is implemented and benefits of the contract related developments are realised, this may be an opportune moment to revisit how we use the action plan. It is proposed however that not further work is done on the plan in its current format at this time.

Recommendation 2: Develop a Practice Sustainability Network that both shares and supports current and future learning on practice sustainability across Scotland.

Following initial discussions on networking, the Working Group identified that it would be difficult to progress the recommendations set out in the Report unless there was increased visibility and awareness of their work. Members agreed that the Knowledge Hub pages^[22] offered an opportunity as a repository and to create an Improving General Practice Sustainability Network profile. Using the already established pages for primary care, two new sections were created: one an open practice sustainability page for anyone to join and share and the other a private group for members of Primary Care (PC) Leads. However, uptake to date has been limited and members of the Working Group are assessing how they can refresh this in the short term.

In an effort to improve utilisation and value of shared sustainability learning, the Working Group are also considering whether the management of the communications and networking processes should be devolved to Healthcare Improvement Scotland (HIS). HIS are members of the Working Group, who are already working collaboratively with healthcare providers and Scottish Government. They also operate an i-hub and in developing and extending this resource, HIS will be able to provide a one-stop-shop for primary care improvement, including GP practice sustainability.

Recommendation 3: Promote the use of, and share learning from a Practice Sustainability Assessment Tool (SAT).

The Report suggests that Boards will be supported to identify vulnerable practices, including any with premises issues, by developing and promoting the use of a SAT and a practice risk register. There is at present no one single, assessment tool to provide comprehensive feedback on all the possible sustainability issues. However, the Working Group developed a Scottish version of the Sustainability AssessmentFramework Tool, adapted from an earlier NHS Wales version, which takes into account pressures being experienced in NHS Scotland.

The Tool was initially tested across Scotland by three Health Boards - NHS Tayside, NHS Forth Valley and NHS Lanarkshire. This test and subsequent roll out to all health boards allowed Boards and practices to adapt this tool for local use.

On behalf of the Working Group, colleagues from NHS Forth Valley Health Board led on a country-wide assessment of usage of the tool, which generated responses from six of the 14 Health Boards. Findings indicate that if used, the tool could aid greater collaboration between individual practices and Health Boards in dealing with sustainability issues and was a helpful indicator for forward planning.

However, many felt that, in isolation, the tool provided only part of the picture and that it needed to be used in collaboration with other local intelligence measures. As it was used in a different way in different areas the tool could also not support an accurate assessment of sustainability challenges across different HSCP/Board areas. For those practices already experiencing difficultly the tool was perceived as offering too little or no new information. Some local experiences with the tool were;

• NHS Tayside - while providing an objective measure, the SAT is only considered to be one piece of the jigsaw that requires marrying up with local knowledge, circumstances and context.

• NHS Lanarkshire - need for tool to highlight practices in early stages of difficulty and SAT on its own may not provide that sensitivity. The score can change rapidly over 48 hours with a change in one or two inter-dependent factors.
• NHS Orkney - some qualitative areas like adaptability, innovation and flexibility are hard to score and the SAT does not always take practice culture into account. There is limited recognition of rural issues and health inequalities.
• NHS Highland - the tool did not shed any additional light on practices in difficulty or about to be so.
• NHS Dumfries and Galloway – that the information gathered allowed the Health Board to quantify local need.
• NHS Forth Valley - completion was best carried out as a joint process by the Practice and Board

Anecdotally, HSCPs and Boards have indicated that they see the tool as best used in combination with other local intelligence/measures of practice sustainability.

Since the tool was reviewed, the 2018 GMS contract will ensure that local systems receive a standard dataset (details as yet to be agreed) on practice activity and demand that should complement use of the tool locally. (See Annex E)

Recommendation 4: Creating a long term Sustainability Working Group

The reformed multi-partner Working Group has focussed on delivering the four key Report recommendations. The Working Group has met several times over the past 18 months and has effectively engaged on a range of perspectives, largely drawn from its member organisations. This has included sustainability challenges associated with delivering safe and sustainable OOH services across Scotland, improving primary/secondary care interface working, proposals to free up GP time and extend the multidisciplinary team through the development of pharmacotherapy and other MDT services.

The initial phase of work was highly successful; however, in response to feedback from Primary Care Leads, a new 'action learning set' format was successfully tested at the Working Group meeting in Dundee, February 2018. This meeting gave members the opportunity to present and 'troubleshoot' live sustainability issues and to consider innovative ways of working, using workshop and feedback sessions. It is intended, subject to regular review that this format continue for the short to medium term until changes under the new contract start to be felt.

At the first meeting using the new format, presentations were made by Tayside and Forth Valley Health Boards, on Protected Learning Time (PLT) by NES and on NHS 24 support to practices in difficulty. Key issues included workforce, working hours, premises & infrastructure and 2C practices. Follow up actions included establishing a PLT sub-group.

This change was accompanied by a review of the Working Group’s attendance and a broadening out of their membership together with greater engagement from health boards and supporting organisations. This reflects changes to the Working Group’s terms of reference and a desire to locate and hold meetings outside the central belt (e.g., Tayside and Highland Health Board areas) to encourage the increased attendance of those representing rural and remote locations.

The Working Group last met in May 2018, when live sustainability issues were presented by Highland and Grampian. Meeting the desire to innovate and importantly addressing the rural theme, presentations were given on the work of the Scottish Rural Medicine Collaborate and on rural aspects of the Community Link Workers programme. The next meeting will be held in Glasgow in September 2018 and will include consideration of live sustainability challenges in Greater Glasgow and Clyde and the Islands (Orkneys, Shetland and the Western Isles)

(See Annex F, pages 17&18)