Main Report of the National Review of Primary Care Out of Hours Services

7 Workforce and Training

Aim

The prime objective of the Workforce and Training Task Group was to develop options for recommendations, particularly in relation to the key aim of the Review to deliver the right skill mix of professional support for patients during the OOH period.

The full report of the Workforce and Training Task Group is available on the Review website.

Recommendations 8-19 primarily relate to workforce and training.

Background

As described elsewhere in the Review , OOH services are coming under increased pressure from insufficient workforce capacity largely due to insufficient availability of GPs to fill rotas. While there is variability throughout Scotland, all Boards face significant challenges and the service is fragile and unsustainable in its current form. This is exemplified by significant recent increases in Health Board expenditures on locum and agency costs as highlighted in Key NHS Financial Data (Annex C).

Methodology

• The shared work of the Models of Care Task Group was fully taken into account when working up workforce proposals. .

• A questionnaire was issued and analysed survey to primary care OOH service managers and undertook telephone interviews. Specific questions recognised the vital role played by non-clinical administrative support staff in keeping OOH services delivery infrastructure viable and consistent.
• In conjunction with RCGP Scotland a survey questionnaire was distributed to all 514 GP members within five years of completing their GP training (First 5s) to seek their views about OOH services and participation therein.
• As part of the academic support commissioned by the Review, qualitative research with two focus groups took place - one was with GPs who had recently completed their training and another with more experienced GPs.
• ISD provided analysis of OOH relevant workforce survey data from the Primary Care Workforce Survey 2013 available. A further 2015 Workforce Survey is underway, at the time of publication, but was too late to contribute latest data for the Review
• The work of the Workforce and Training Task Group was also informed by the Short Life Working Group established to provide guidance on terms and conditions for GPs working in OOH services.

Future Contribution of the GP Workforce - Recommendation 11

Evidence

Shape of Training: Securing the future of Excellent Patient Care. (The Greenaway Report) and: The future of primary care: Creating teams for tomorrow. (Report by the Primary Care Workforce Commission, Health Education England Joint principles submitted by the RCGP Scotland and the Scottish General Practitioners Committee (SGPC) of the BMA and Position statement from the National OOH Operations group, summarised in Annex D and available on the Review website.

GP Workforce Profiles

Figure 7.1 below shows the age-sex profile of all GPs (known as GP Performers) in the Scottish NHS workforce at 2014 - excluding GPs in training. This demonstrates the increasing numbers of female general practitioners (a percentage that has changed from 45% to 55% Female, over the past ten years).

Figure 7.1 GP Performers in post by ageand gender in 2014

Figure 7.1 also shows that there are significantly more GPs in the 50-54 years age cohort (826), compared to the 45-49 cohort (749), the 40-44 cohort (650) and the 35-39 cohort (687). These figures herald the potential of serious shortages in the future GP workforce. This re-emphasises the urgency of comprehensive primary care workforce planning for both daytime and OOH services, including systematic data collection of workforce numbers (Recommendation 8). The recruitment and retention of GPs appears to be UK wide rather than specific to Scotland.

Figure 7.2 below shows the age-sex-profile of all GPs working in OOH services in 2013. Whereas there are more females than males in the whole GP workforce a smaller number of females contribute to working in OOH services. The age profile of GPs working in the OOH service is younger than the general workforce.

Figure 7.2 GP Performers working in OOH Services in 2013 by age and gender

Figure 7.3 below shows the time commitment of GPs working in OOH services by age group. There is an inverse linear relationship with age in relation to hours of GP commitment per week, with a significantly smaller number of hours worked by the youngest GP cohort, aged under 35 years. The exact explanation for this remains unclear and is likely to be multi-factorial. GPs in the youngest cohort were recruited into the specialty, following the introduction of the 2004 GMS Contract, which no longer required GPs to be responsible for, and to work in OOH services. Recent research (Fay et al), suggests that today's young doctors value both work-life balance and personal fulfilment more highly than their predecessors. Of all specialties, GP recruits rated hours/working conditions significantly higher than all other specialty recruits (93.9% of GP recruits v 46.7% of all specialty recruits) and did likewise for domestic circumstances (69.9% v 32.5%).

Figure 7.3 Commitment of GPs working in OOH Services by Age Group

Older GPs working in OOH services contribute on average, a greater contribution of working hours than younger GPs. This is counterbalanced by the workforce age profile which is biased towards younger GPs. However, as older GPs withdraw or retire from OOH services, this could have disproportionately adverse effects on service delivery, unless younger GPs work more in OOH services, as they become more experienced.

To inform this further, survey work undertaken by the Workforce Task Group, revealed that although the majority of first 5s GPs thought their training had prepared them well, a significant minority were unsure and a small number that training had not prepared them well. In this survey, improved OOH shift flexibility was seen as important as was improved multidisciplinary team working and administrative support. It was felt that senior clinical GP support/mentoring was important but lacking, and aggravated by limited access to patient electronic records. Pay and conditions were seen as unsatisfactory by many and flexibility regarding superannuated/non-superannuated contracts was sought. Day time general practice working was seen to be increasingly demanding and stressful and unless conditions improved, then this would inhibit participation by GPs in OOH services. The key and increasing importance of work/life balance was again raised in this survey.

This survey of GPs was reinforced by the commissioned focus group research which reached similar conclusions. The limited sample interviewed in this research study, suggested that more senior GPs may possibly have a greater sense of 'professional duty' than younger GPs, but this is a preliminary view and requires further elucidation. One unequivocal finding was that all GPs felt that patients were confused by the increasingly fragmented approach to daytime and OOH care and that such services were about delivering urgent (not convenience) care and that there had to be clear messages and support of the public to know how best to access and use urgent care services.

Short Life Working Group on GP OOH Terms and Conditions

The emerging findings from these surveys and from the engagement programme gave a consistent message that many GPs working in, or who have recently withdrawn from OOH services, are discouraged and confused by existing terms and conditions. Rather than delaying some weeks until the Review was published, a Short Life Working Group (SLWG) on GP OOH Terms and Conditions established and produced a report which is available on the Review website.

As anticipated, a large array of terms and conditions throughout Scotland, was uncovered by the SLWG for GPs working in OOH service. The findings of the SLWG report have been shared with Scottish Government and discussed with NHS Board Chief Executives and Workforce/Human Resources Directors. The SLWG concluded:

• There are a variety of arrangements which are now in existence to engage GPs in OOH work. The importance of these arrangements was recognised to reflect local circumstances, which suit both employers and GPs.
• This variation is impacting on services to attract and retain GPs to work out of hours. Employment or engagement packages to encourage working in OOH services should be more attractive. There was a mixed view on engagement packages for sessional GPs, about including employment rights which are in place for other staff, such as annual leave and study leave. Including such rights would come with a cost in both financial and human resources, but should be considered as part of future implementation of the recommendations of the Review.
• Extending indemnity cover to all GPs providing OOH services and introducing an opt out on superannuation should have a greater impact on attracting and retaining GPs working in OOH services than effecting changes in terms and conditions.
• The Scottish Government, employers and GP representatives should engage in a discussion about the balance between local determination of pay and conditions of service for this group of staff, compared to a national approach which is now in place for all other staff groups.
• At the moment GPs working in OOH services need to apply separately to each territorial NHS Board they wish to work in, to be registered on that Board's Performer's List. This was felt by many GPs to be a barrier to flexibility and overly bureaucratic. Moving to one National Performer's List would be beneficial, in terms of both clinical governance (with a consequential impact on patient safety) avoiding duplication of effort and unnecessary expense for doctors who wish to provide services to more than one Board. That has been translated as a recommendation by the Review and work is underway to achieve that objective.

GP Specialty Training

The Shape of Training: Securing the Future of Excellent Patient Care. (The Greenaway Report) recommended in 2013 that GP specialty training in the UK should be extended to four years instead of the usual three years and been adopted as official policy by the Royal College of General Practitioners. There has as yet, been no UK wide agreement to implement this recommendation. !n Scotland at January 2015, the total headcount of trainees was 1053 of which approximately 60% were in four year training posts compared to 40% in three year posts. The four year posts are not seen to be as attractive as three year posts, because the additional time is spent in hospital posts rather than more training experience in general practice. Survey work and informal views suggested that after three year speciality training, newly qualified GPs are competent but may not feel sufficiently experienced or confident to participate in OOH services. This needs to be remedied as a matter of urgency with increased exposure to OOH experience - existing four year posts should be reviewed to determine fitness for purpose and post certificate of Certificate of Completion of Training (CCT) new one year salaried clinical development posts should be offered which will include OOH work, with enhanced support and continuing professional development (CPD) in OOH medical care.

The fill rate for GP specialty training posts has been declining over the past few years throughout the UK and urgent measures are required to raise the profile and importance of the GP role in a number of ways. Medical Schools have a key role to play in this matter.

Recognising the seriousness of the situation the Scottish Government recently moved to increase the number of training places by opening an additional 100 GP training places on top of the 305 already allocated for 2015. If successfully recruited to, this should bolster GP recruitment for both daytime and OOH services, in due course.

OOH Commitment from GPs

One of the RCGP and SGPC joint principles submitted was:

" It is a core professional value that GP care in the community is available at anytime and it is essential that GPs remain a central part of OOH services to ensure holistic, coordinated patient care".

This is endorsed by the Review and resolute efforts should be made, as a matter of urgency, to recruit and retain GPs to work in OOH services, as they remain core and essential to OOH service provision.

This imperative is not GP specific, but about comprehensive skill mix and workforce planning - for all staff working in OOH services (Recommendation 8).

Summary

The evidence considered here provided a clear and compelling case for urgent measures to be taking to enhance GP capacity in OOH services but also for daytime care (Recommendation 11). This is also reflected in other recommendations related to workforce and training and holds good for all other workforce groups considered by the Review.

Future Contribution of the Nursing Workforce - Recommendation 12

Evidence

Submission by the Chief Nursing Officer endorsed by Scottish Executive Nursing Directors (SEND) and the Royal College of Nursing (RCN) Scotland available on the Review website. Three recent publications from the RCN informed deliberations:

1 Nurse Innovators: Clinical Decision Makers in Action (2015)

2 Going the Extra Mile: Improving access to Community Healthcare for Older People in Remote and Rural Health Care in Scotland (2015)

3 The nursing contribution to seven day care: community nursing and advanced nursing practice(2014)

A systematic literature review: Substitution of doctors by nurses in primary care (Laurant et al, Cochrane Database of Systematic Reviews, 2005) which suggested that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. Other reviews of advanced nursing roles have been similarly positive. An evaluation of advanced nursing practice in Ireland (Nursing Council for the Professional Development of Nursing and Midwifery, 2010) showed strong evidence that such roles improve patient outcomes by, for example, providing earlier diagnosis and intervention, timely access to care, promoting self-management and increasing patient satisfaction. Similarly, an evaluation in primary care trusts in England (Action Shapiro, 2009) , showed that nurses with advanced training, carried out more holistic assessment of patients and increased patient satisfaction; resulted in better engagement of patients in 'hard-to-reach' groups; improved continuity of care; reduced waiting times; and shortened length of stay for hospital patients.

Advanced Nurse Practitioners

Advanced Nurse Practitioners (ANPs) have a significant and growing contribution to make in delivering sustainable and consistently high quality OOH care. The term Advanced Nurse Practitioner (ANP) used by RCN Scotland refers to any nurse who is working at an advanced level of nursing practice, irrespective of their official role or job title. There is no single definition or terminology which collectively describes all those nurses who work at an advanced level of practice and the variety and lack of consistency of roles and terminology can be confusing

RCN has identified key characteristics of advanced nursing practise including:

• Making professionally autonomous decisions for which they are accountable
• Receiving, assessing and diagnosing patients with undifferentiated and undiagnosed problems
• Having the authority to admit, discharge and refer patients
• Ordering investigations and providing treatment individually or as part of a team
• Supporting patients to self-care, manage and live with illness
• Working collaboratively across professions and disciplines
• Providing clinical leadership

In her submission, the CNO noted that modern health care system in Scotland is waking up to the potential of clinicians from across professions to deliver robust clinical decision making and manage high levels of risk in a truly joined up way that improves patient outcomes and experience. Advanced Nurse Practitioners (ANPs), as autonomous decision makers, are already proving their worth in leading and delivering high quality, cost effective services across acute, intermediate and community care, including in the out of hours period.

However, the evolution of ANP roles has been local and organic, resulting in inconsistencies of role and education, as well as significant gaps in the availability of services which have progressed piecemeal across Scotland. Capitalising on the contribution of ANPs will mean a radical reconfiguration of teams and this may well challenge traditional expectations. In this context, the public, professional colleagues and nurses themselves need to have greater confidence in, and better understanding of, the ANP role in Scotland. This must be addressed in the short term to support the refreshed workforce needed to improve OOH care.

In order to achieve that objective, the CNO has also instigated a Review of Advanced Nurse Practitioners. This is due to report in April 2016. The RCN Report: Nurse Innovators: Clinical Decision Makers in Action provides an excellent description of current ANP activities and innovation across Scotland and further examples of good practice of physical and mental health collaborative projects can be found in: The nursing contribution to seven day care: community nursing and advanced nursing practice. The CNO cites two models of good practice in her submission to the Review, at NHS Grampian and NHS Ayrshire & Arran, covering the island of Cumbrae, available on the Review website.

The NHS Grampian OOH model employs a significant number of ANPs. In the main centre in Aberdeen, ANPs work alongside GPs, with team members from SAS, community psychiatric and district nurses, Marie Curie nurses and on-site pharmacy service. In the rural care centres some have GPs and ANPs on duty; others are staffed solely by ANPs who rely on video and telephone links to the main centre. Every ANP in NHS Grampian service is either an independent prescriber or preparing to become one. Recruits must have a minimum five years post-registration experience at senior staff nurse or charge nurse level, and most come in from A&E, surgical, intensive care and general practice. They must complete a master's programme at Robert Gordon University (accredited by the RCN), as well as successfully completing the British Association of Immediate Care (BASICS) training and passing Objective Structured Clinical Examination (OSCE) appraisal of their skills.

In NHS Ayrshire and Arran, on the Isle of Cumbrae, OOH services are provided by an ANP-led team operating from a base at the island's Lady Margaret Hospital. The highly experienced ANPs commute from the mainland and maintain their critical clinical skills by continuing to work in other NHS Ayrshire & Arran hospitals. They work alongside locally based nursing staff to provide urgent and emergency health care, supported by ambulance technicians and a paramedic. They also provide cover for patients in the community hospital's ward, where local people are typically admitted for palliative care, rehabilitation or treatment for infections. They also make OOH home visits, usually to tend to the needs of frail older people

During the national engagement programme a number of examples of nursing innovation in OOH care were seen and discussed, including Community Unscheduled Care Nurses (CUCNs), in NHS Western Isles.

Figure 7.4 Community nursing staff by specialty and age group 2015

Figure 7.4 above shows the age profile of the community nursing staff working for the NHS in Scotland in 2015. The picture shows very significant challenges of an aging workforce, where the 50-54 years age group is the largest cohort for all community nurse categories. In particular for district nursing, this varies by Health Board area and is worse in some rural areas.

The Chief Nursing Officer's (CNO's) submission to the Review recognises these workforce challenges and she has also instigated a Review of district nursing contributions, including a specific focus on their role in OOH services. The role of district nurses is essential to support 24/7 community healthcare. The CNO review is seeking to underpin a nationally consistent district nursing role, where nurses have the capacity, capability infrastructural support and access to resources, enabling to meet patient need. The CNO's review of district nursing is expected to report in April 2016.

Summary

Recommendations underpin the CNO Reviews of Advanced Nurse Practitioners and District Nursing which should help to support future OOH and urgent care services. Agreed definitions, standards for training and career development, recruitment and retention, and comprehensive workforce planning are proposed (Recommendations 8 and 12).

Future Contribution of the Pharmacy Workforce - Recommendation 13

Evidence

Joint submission by Community Pharmacy Scotland, NHS Scotland Directors of Pharmacy and the Royal Pharmaceutical Society Scotland - available on the Review website.

Prescription for Excellence, A Vision and Action Plan for Pharmaceutical Care in Scotland (2013). Recent publications by Fielding et al, Watson et al and Paudyal et al, found similar outcomes for treating minor ailments in GP, emergency department and community pharmacy settings but at substantially lower costs for pharmacy consultations.. Greater awareness and use of community pharmacies for treating minor ailments could shift substantial demand away from daytime/OOH urgent care and A&E services towards community pharmacies.

Community pharmacies throughout Scotland make an essential contribution to care both in daytime and during the OOH period. There has recently been a major funding initiative as part of the 2015 Primary Care Transformation Fund to attach clinical pharmacists to general practices for daytime medicines management support. As this adds capacity to daytime GP services it is possible that that may release clinical capacity to support OOH services. Pharmacists also play a key role in patient care within NHS 24 and with additional prescribing capability would enhance the multidisciplinary urgent care team working OOH hours.

The joint pharmacy submission contained a number of short/medium and long term recommendations about:

Enabling best electronic access to community pharmacies

• Extending the use of national community pharmacy patient group directions (PGDs)
• Maximising the use of the Minor Ailment Service (MAS)
• Strengthening use of the urgent care PGD for repeat medicines/appliance; pharmacists with additional skills to provide enhanced services in community pharmacies and the OOH services
• Engagement by pharmacists in anticipatory care planning
• Exploring extended hours opening, including weekend; develop a national direct referral and clinical handover framework
• Encouraging pharmacist prescriber input to GP practices daytime services reducing pressure on OOH services
• Examining potential roles for pharmacist prescribers in both OOH and A&E services
• Expanding pharmacist input into NHS 24
• Reducing negative impact of medicines shortages on patients, pharmacists and GPs
• Enhancing pharmacist assessment and management skills for common clinical conditions
• Ensuring robust workforce planning for the entire pharmacy workforce, to ensure future fitness for purpose

Summary

Recommendations have been provided which support greater prominence for community pharmacies for urgent care both in daytime and OOH services, enabling electronic patient record access, promoting greater awareness and use of the minor ailments service (MAS), extending community pharmacy patient group directives (PGDs) and enhancing clinical skills including prescribing capability are consolidated in Recommendation 13.

Future Contribution of the Paramedical Workforce - Recommendation 14

Evidence

The five year strategic framework of the Scottish Ambulance Service (SAS),Towards 2020: Taking Care to the Patient. Publications notably by Snook et al and by Mason et al, have shown that paramedical practitioners (paramedics) with extended skills can provide clinically effective alternative treatment in the community for elderly patients with acute minor conditions, instead of ambulance transfer to an emergency department. This includes a significant role in the management of older people who fall (SAS attends more than 45000 older people who fall each year). There is a growing literature underpinning extended roles for paramedics 'seeing and treating' in the community which is applicable throughout Scotland, but may be particularly relevant for remote and rural areas. This role might be reinforced by increasing use of mobile technology/ video-linking , with professional to professional clinical decision support provided remotely. A modern ambulance fully equipped, including information technology and robust digital communications, could be regarded as a mobile Urgent Care Centre.

In their five year strategy, SAS indicated priorities including: improving access for health care; improving outcomes for patients (specifically cardiac, trauma, mental health, respiratory, frailty and falls); evidence a shift in the balance of care, by taking more care to the patient; enhanced clinical skills as a key and integral partner working with primary and secondary care; more collaboration with other partners including the voluntary sector and other blue light services; improving emergency services; strengthening community resilience; expanding diagnostic capability and use of technology. All of these priorities fit well with the needs of future OOH and urgent care services.

Specific example of SAS innovation include the specialist paramedic model in NHS Western Isles, where such paramedics 'see and treat' patients, both as part of the OOH community team and working within the minor injuries unit at the local hospital. The enhanced skills of specialist paramedics allows them to operate more autonomously and they are able to access alternative care pathways directly resulting in fewer avoidable A&E attendances They are are able to access decision support from GPs and request follow up visits to the patient from the GP - and by so doing, they can 'treat and refer'.

SAS have committed to developing and re-profiling their workforce and investment in new roles and enhanced skill sets, an recognises that different approaches may be required in urban compared to remote and rural areas..

This translates as:

• All staff working to their full scope of practice, skills knowledge and experience supported by personal development plans
• Increased levels of specialist medical paramedics operating in the community as part of integrated health and social care teams
• Appropriate numbers of specialist critical care paramedics to respond to critically ill patients and providing support to specialist retrieval teams.

Summary

Recommendations have been provided about paramedic practitioners, which support an increasing role in the community for urgent care. Development of a competency framework for specialist paramedics is advocated, consistent standards and a clear career development pathway for paramedics (Recommendation 13).

Future Contribution of Allied Health Professionals and Physician Associates - Recommendation 15

Allied Health Professionals

Evidence

Submission by the National Allied Health Professions Advisory Committee , Driving Improvement, Delivering Results, the Scottish Healthcare Science National Delivery Plan 2015-2020 and a systematic review of evidence about extended roles for Allied Health Professionals (McPherson et al). This section deals with Allied Health Professionals (AHPs) other than paramedics.

The roles of AHPs are diverse and they will play increasingly important roles for OOH and urgent care services including:

• Maximising the potential of planned care to pre-empt avoidable urgent care and hospital admission, including anticipatory care planning
• Consolidation and leadership of integrated community rehabilitation teams
• Securing flexible access to AHP services on an urgent basis according to individual need
• Optimisation of skills and expertise with individual practitioners working to maximise use of their skills and the full scope of their practice. This should include independent prescribing capability
• Individuals who fall, requiring urgent assistance and future prevention are a key priority group. AHPs should play a leading role in the implementation spread and sustainability of the Falls Up and About pathway, to aid early identification of triggers for repeat falls/attendees (see Recommendation 6 - Frail and Older People).
• As urgent care develops it is likely that point-of-care testing (POCT) will increasingly be deployed. AHPs will have an important role in cost-effective implementation and governance.

A specific example of the contribution of AHPs is provided by NHS Lanarkshire's Age Specialist Service Emergency Team (ASSET). This a pilot project allowing older people in North Lanarkshire to remain at home rather than being admitted to hospital. The ASSET team is made up of consultants, nurses, rehabilitation staff, occupational therapists, physiotherapists and a trained psychiatric nurse working closely with the North Lanarkshire Social Work Department to enable patients to receive immediate additional home care if needed.

Summary

The extended roles of AHPs in OOH and urgent care services should be recognised In order to achieve optimal contributions they will require timely and secure access to electronic patient records, like other members of multidisciplinary urgent care teams. Their future contribution should be recognised in integrated workforce planning.

Physician Associates

Evidence

The role of physician associates (also known as physician assistants) is relatively new to the NHS. These practitioners have the education and training to diagnose, treat and refer autonomously within defined practice boundaries, working for and with doctors. Physician associates (PAs) have been deployed in the US for more than 40 years and further expansion is underway for primary care roles, in particular. They have also been introduced in other countries such as Canada, Australia the Netherland and India. PA educational programmes have been underway in Scotland for several years (University of Aberdeen) and follow a detailed national UK curriculum, with most recruits to date assimilated into secondary care settings, when qualified. They must already have a first degree in life-sciences or health and the course itself is a two year full-time, highly intensive postgraduate diploma. Recent research by Drennan et al, comparing the process and outcomes of GP and PA same-day or urgent appointments, found that outcomes were similar at lower cost. They concluded that PAs offer a potentially acceptable and efficient addition to the primary care workforce.

Summary

Given serious recruitment difficulties for GPs, as described earlier in this Report, PAs should also be considered for early inclusion in the required skill mix going forward. Their shorter duration of training, will allow earlier reinforcement of urgent care teams.

Future Contribution of Social Services - Recommendation 16

Evidence

The Workforce and Training Task Group is very aware that the greater balance of the Review has dealt extensively with clinical requirement, skill sets and expertise in future OOH service development. Social services and their workforce are equally important and crucial to the successful future development of OOH services and urgent care - they must be valued and supported, accordingly.

The traditional view of primary care is that it is principally a NHS activity, delivered by clinical practitioners, along with support staff. In the context of Health and Social Care Integration that view is narrow, restrictive and should be extended. The Review therefore has used the following definition of primary care:

Primary care provides access to care at the right time when it is required and secures ongoing care in the community and continuity of relationships, where this is important. In addition to GP practices, primary care services covers: community services - including: district and community nursing, mental health and dental services, community pharmacies, optometrists - and for effective health and social care integration - social care services, third and independent sector provision

The Task Group considered evidence including workshop activities, submissions by Social Work Scotland, Social Care and Chief Officers of Integrated Joint Boards which are available in Annex D in summarised form and available in full, on the Review website. Strong support for a more inclusive definition of primary care came from all of these bodies, from representatives of the third sector and during the national engagement programme. Key Facts on Social Services are summarised in Annex D.

This inclusive theme is summarised by key messages from Social Work Scotland:

• Current primary care OOH provision and local authority OOH (emergency) social work provision should be better connected.
• Through integration of health and social care and the establishment of Health and Social Care Partnerships there is an opportunity to consider, how in the future, social work and primary care OOH may be better integrated.
• All health and social care services need to focus on building resilience and self care management. This should include contingency arrangements for extraordinary circumstances, which may mitigate the number of crisis interventions required.
• Service users, carers and the broad workforce need to be clear what constitutes urgent care, which may require attention by OOH services. There is a need to establish frameworks for use of these services where the detail of the provision of services needs to be clearly laid out and understood -including roles, responsibilities and functions of each agency.
• The future needs of the service should support roles to be developed to ensure better patient services, user outcomes and a more flexible service. This has to be considered in the context of multi-disciplinary team - with social work and social service workers as key partners.
• Focusing on supporting staff to integrate cultures and ways of working and increase mutual respect between professions. Only by improving this, will integrated working come to fruition.

The submissions from Social Work and Social Care on behalf of the independent sector both placed emphasis on the importance of the relationship between social care and clinical OOH services and the need for mutual awareness and of valuing staff and supporting their contribution their contribution. Both recognised that integrated and effective urgent care needs to be delivered 24/7 and not just on an OOH basis.

Co-location of health and services would be helpful but not in itself sufficient - co-working and co-production would be key for success. The Urgent Care Resource Hub and Urgent Care Centre model proposed by the Review should provide options for team-based integrated care in environments that are configured for both service delivery and training.

Other examples of integrated working include hospital-at-home schemes which are presently patchy and do not necessarily operate on a 24/7 basis. These schemes appear to be effective at reducing admissions. The ASSET model described earlier in relation to the future AHP workforce contribution, is another example of encouraging multi-sectoral co-working.

Summary

Two specific social service workforce recommendations were offered by Social Work Scotland regarding key roles supporting individual and have been incorporated into Recommendation 16:

• The Social Service workforce will have key and developing roles in supporting individuals to ensure they receive the most appropriate support in a community setting.
• Along with other members of inter-sectoral teams, they will continue to play key and developing role in the prevention of, and response to falls in the community and other urgent care needs - for example via the community alarm system. In the future this should include other forms of innovative remote monitoring via telecare, video-linking and mobile applications
• Learning and development programmes should be inter-professional for all practitioners and be embedded within formal Performance and Development plans

Generic Recommendations for Workforce Development and Support

The following additional generic recommendations are made:

Recommendation 8 - Effective Workforce Planning

Recommendation 9 - Interdependent Linkages between Daytime and

OOH Services

Recommendation 10 - The Importance of the Working and Educational Environment

Recommendation 17 - Working and Learning in Professional Partnership

Recommendation 18 - Valuing Support Staff

Recommendation 19 - Leadership

Regarding Recommendation 18 - Valuing Support Staff, the national engagement programme and commissioned survey work by the Workforce and Training Task Group clearly demonstrated the essential roles undertaken by dedicated administrative and support staff. They play a vital role in keeping OOH services viable and consistent in a high stress environment. They should be valued and supported, accordingly.

Primary care multidisciplinary out of hours team, drivers, GP, OOH nurse and receptionist, co-located with Emergency Department at Borders General Hospital