National health and social care workforce plan: part three

Chapter Three: The Changing Shape of Primary Care

• We have a vision of a primary care workforce that supports everyone to live longer healthier lives at home, or in a homely setting.
• Developing multidisciplinary capacity at the heart of transformed and sustainable primary care services. Multidisciplinary teams will deliver care in communities and be involved in the strategic planning of services.
• The Transforming Roles Programme is ensuring nationally consistent, sustainable and progressive roles, education and career pathways for nurses, supported by investment in additional training and continuous professional development.
• Transformed Nursing, Midwifery and Allied Health Professional community roles, will inform and support local workforce planning.
• Reform of primary care gathering pace through the transformation programme and significant investment in new models of care.
• We have made a commitment to increase funding in direct support of general practice by £250 million by 2021.
• A new GP contract has been agreed, and a co-produced Memorandum of Understanding between the Scottish Government, the Scottish General Practitioners Committee of the British Medical Association, Integration Authorities and NHS Boards will support its delivery.
• Priorities areas are being taken forward to enable service change in general practice over the next three years, to ensure that patients receive the right service at the right time from the right profession.
• The six step methodology offers an evidence based approach to workforce planning which takes into account local need.
• Reconfiguring services will bring challenges – there is a need for local flexibility in how this is done.

Introduction

The previous chapter broadly set out the shape and size of our primary care workforce, acknowledging that there are gaps in the available data. This chapter describes the shared principles underpinning our approaches to developing a sustainable and safe primary care service for Scotland's people. Improving MDT capacity in primary care, with enhanced pathways to wider health and social care services including third sector service provision, is crucial for the development of new ways of delivering continued high quality services to patients. This is in the wider context of health and social care integration and the role of Integration Authorities in planning and commissioning primary care services.

Primary care is provided by generalist health professionals, working together in multidisciplinary and multiagency networks across sectors, with access to the expertise of specialist colleagues. All primary care professionals work flexibly using local knowledge, clinical expertise and a continuously supportive and enabling relationship with the person receiving care, to make shared decisions about their care and help them to manage their own health and wellbeing every day, seven days a week.

Enabling change

The context for the reform of primary care in Scotland is Health and Social Care Integration. Integration is the most significant change to health and social care services in Scotland since the creation of the NHS in 1948. With a greater emphasis on joining up services and focussing on anticipatory and preventative care, integration aims to improve care and support for people who use services, their carers and their families. Since April 2016, Integration Authorities have been responsible for the commissioning, planning and delivery of all community and primary care services in their localities – including general practice.

The 2020 Vision ^[57] for health emphasised the drive to provide more care at home or in a homely setting, and this was further underlined in A National Clinical Strategy for Scotland ^[58] and the Health and Social Care Delivery Plan ^[59] , which embeds primary care at the heart of reform.

The vision for primary care is for enhanced and expanded multi-disciplinary community care teams delivering person-centred care and improving outcomes for individuals and local communities. The principles that underline this vision closely align with those set out by Scotland's health professional groups in The Future of Primary Care: a view from the professions ^[60] .

The principles underpinning the approach to general practice in Scotland were set out in General Practice: Contract and Context – Principles of the Scottish Approach ^[61] published by the Scottish General Practitioners Committee of the British Medical Association and the Scottish Government in October 2016. These provide a vision for general practice where:

• General practice and primary care at the heart of the healthcare system;
• People who need care are more informed and empowered than ever, with access to the right person at the right time, and remaining at or near home wherever possible;
• Multi-disciplinary teams in every locality, both in and out of hours, are involved in the strategic planning and delivery of services.

Following the agreement by GPs to the new contract, and as set out in the landmark Letter of Intent published in November 2017 ^[62] , Chief Officers and Chief Executives are recommending to their respective Boards the approach set out in the co-produced Memorandum of Understanding.

The Memorandum of Understanding ^[63] between the Scottish Government, Integration Authorities, the British Medical Association, and NHS Boards, sets out respective roles and responsibilities including the development of Primary Care Improvement Plans. The Plans will set out how additional funding will be used and the timescales for the reconfiguration of the services set out in the MOU and the new GMS contract (see below). Health and Social Care Partnerships will ensure that local stakeholders are appropriately informed and involved in the process and in the development (and where appropriate, the approval) of the plans.

Leadership

The need for good collaborative leadership is essential in promoting and driving change, with leadership in primary care being the responsibility of all professions. The continued development of the skills and attributes of leadership should be supported and visible across all organisations. The Scottish Government recently funded the Leadership for Integration development programme delivered in partnership by NHS Education for Scotland, RCGP and the Scottish Social Services Council ( SSSC). The aim of the programme was to build capacity and capabilities of primary care and social care professionals to work effectively at locality level and within integrated partnerships to deliver integrated models of care. The principal target audience was those with leadership roles in health and social care contexts, including GPs and other health professionals, and social care leaders from local authority, third sector and independent care organisations.

Leadership capability and capacity amongst our workforce needs to be developed and grown in tandem with service development. As part of the development of the primary care multidisciplinary workforce, NES will support GP practices to provide the necessary clinical leadership and supervision to the wider team of professionals as required. NES will work with Integration Authorities to align this support with the priority areas as set out in the GMS contract.

Investment

As part of its commitment to increase funding in direct support of general practice by £250 million by 2021, the Scottish Government is investing £110 million in 2018-19 to support implementation of the new GP contract and wider primary care development, in line with the priorities set out in The 2018 General Medical Services Contract in Scotland ("the Contract offer") ^[64] . There will be new investment in expanded teams of health professionals in practices and communities, which may include pharmacists, nurses, physiotherapists, paramedics, community mental health workers and non- clinical support workers such as community links workers.

We outline our approaches to developing MDT capacity across primary care in Chapters four to six. Shifting the balance of care will require investment to grow the community nursing workforce, which includes District Nurses, General Practice Nurses, ANPs and others over the next three to five year period. A total investment of £6.9 million over three years will be allocated between general practice nurses and district nurses to help meet the training and education needs of a sustainable 24/7 community nursing workforce.

A modernised General Practice

General Practice has a long history of innovation to meet the changing need of its patient population. The new Scottish GMS contract will help accelerate the pace of change, with an enhanced opportunity for GPs to work as Expert Medical Generalists and senior clinical decision makers within multidisciplinary teams (described in Chapter five). To enable GPs to more fully deliver this role, strong and well-connected multidisciplinary teams are needed with workload appropriately redistributed to ensure that patients have the benefit of the range of expert advice needed and available for the delivery of high quality care.

As set out in the MoU, we have agreed to focus on a number of specific priorities for service change at scale over a three year period. Table 5 briefly describes these services and the associated workforce.

Table 5: Workforce needed to deliver service reconfiguration in Primary Care

Service	Description of service	Workforce
Pharmacotherapy	By April 2021, every practice will benefit from the pharmacotherapy service delivering the core elements of the service including acute and repeat prescribing, medicines reconciliation and monitoring of high risk medicines. Additional elements of the service include medication and poly pharmacy reviews and specialist clinics. This will form part of a three-tiered approach to developing pharmacy services to support GP practices.	Pharmacists and pharmacy technicians
Vaccinations	Responsibility for vaccination and immunisation services will move from general practices to IAs and NHS Boards through the transforming vaccination programme.	Nurses, other appropriate clinical professionals and healthcare assistants
Urgent care services (advance practitioner)	Providing sustainable advanced practitioner support for unscheduled care, based on appropriate local service design. Advance practitioners such as a nurse or paramedic for GP clusters and practices as first response for home visits, and responding to urgent call outs for patients, working with practices to provide appropriate care to patients.	Paramedics, nurses where appropriate
Community Treatment and Care Service	These services include, but are not limited to: basic disease data collection and biometrics (such as blood pressure) chronic disease monitoring the management of minor injuries and dressings phlebotomy ear syringing suture removal; and some types of minor surgery as locally determined as being appropriate. Phlebotomy will be delivered as a priority	Nurses, and healthcare assistants
Additional Professional Roles	Additional professional roles will provide services for groups of patients with specific needs that can be delivered by other professionals as first point of contact in the practice and/or community setting. For example, but not limited to: Musculoskeletal focused physiotherapy services Community clinical mental health professionals ( e.g. nurses, occupational therapists psychologists) directly working in general practice	Musculoskeletal Physiotherapists and community mental health practitioners.
Community links workers	A generalist practitioner based in or aligned to a GP practice or cluster who works directly with patients to help them navigate and engage with wider services, often serving a socio-economically deprived community or assisting patients who need support because of (for example) the complexity of their conditions or rurality. As part of the Primary Care Improvement Plans, IAs will develop CLW roles in line with the Scottish Government's manifesto commitment to deliver 250 CLWs over the life of the Parliament. The roles of the CLWs will be consistent with assessed local need and priorities and function as part of the local models/systems of care and support.	Non-clinical staff providing support and connection, based in practices or groups of practices

Further detail on the new GP contract and reconfiguration of services can be found at: http://www.gov.scot/Topics/Health/Services/Primary-Care/GP-Contract

Safe and Effective Staffing in Health and Social Care

Taking a rigorous, evidence based approach to workload and workforce planning is important to ensure safe and effective staffing in primary care that reflects patients' care needs and promotes a safe environment for service users and staff. The Scottish Government's Programme for Government 2017-18 ^[65] includes a commitment to introduce a Safe Staffing Bill to enshrine NHS staffing in law, starting with nursing and midwifery.

The Nursing and Midwifery Workload and Workforce Planning Programme has been in use since 2004. In October 2012 the application of the tools was mandated by the Scottish Government to be used as part of NHS Boards' annual nursing and midwifery workforce projections from April 2013. This is referenced in Local Delivery Plans and Workforce plans ^[66] . There is now a suite of 12 tools covering 98% of all service areas, including a Community Nursing Tool.

In summary, the overarching intention is for the legislation to:

• Be a further enabler of high quality care and improved outcomes for individuals by helping ensure appropriate staffing for high quality care.
• Strengthen and enhance arrangements already in place to support continuous improvements and transparency in workforce planning and employment practice across Scotland.
• Support consideration of service delivery models and service redesign.
• Actively foster an open and honest culture where all staff feel safe to raise concerns regarding safe and effective staffing.
• Provide assurance – including for service users and staff – that appropriate staffing is in place to enable the provision of high quality care.

Given the importance of ensuring the right people, in the right place at the right time to deliver sustainable and high quality services with improved outcomes for service users, irrespective of setting, and of enabling integrated workforce planning, the intention is that the legislation will – in an appropriate and proportionate way – span the health and social care landscape. However, in taking this broader approach, the legislation will not be restrictive or prescriptive. Rather it will seek to be appropriate and enabling for the social care sector, and in particular support the recommendations in the co-produced Part 2 of the National Health and Social Care Workforce Plan to develop multidisciplinary workload and workforce planning tools where this is considered appropriate.

We consulted on initial proposals for safe staffing in 2017, and published a discussion document in January 2018 setting out refreshed legislative proposals, taking account of further engagement with stakeholders. Currently, the intention is that this legislation will:

• place a duty on Health Boards and care service providers to ensure appropriate numbers of suitably qualified staff, similar to and learning from the current requirement for care service providers set out in existing regulations
• enshrine overarching principles which will apply to NHS Boards and care service providers who will be required to take them into account in carrying out their general duty
• include more specific requirements where a validated workload planning tool and methodology exists – in the first instance this will only be applicable to nursing and midwifery services and to medical services in emergency medicine settings.

We continue to work closely with stakeholders to refine proposals and will introduce legislation later this year.

National Oversight Group

New oversight arrangements for the implementation of the GMS contract in the context of wider primary care transformation in Scotland have been developed including:

• A national oversight group with representatives from the Scottish Government, the SGPC, IAs and NHS Boards which will oversee implementation of the GMS contract in Scotland and the Integration Authorities' Primary Care Improvement Plans, including clear milestones for the redistribution of GP workload and the development of effective MDT working.
• National issue specific groups – a range of national issue specific groups with members drawn from a range of stakeholders will support and provide policy and professional advice to the national oversight group on a range of national policy areas relevant to the delivery of primary care transformation.

Implementing the changes described in Table 5 relies on robust workforce planning, appropriate utilisation of the workforce, expansion where necessary or appropriate of MDTs and effective MDT working. This will be determined locally and set out in local improvement plans but in practice this will include a mix of the nursing, pharmacy, mental health, allied health professional, paramedic and non-clinical workforces. Delivering this change will require investment at national level to ensure workforce supply in future years. This is discussed further below.

The extent and pace of change over the next three years will be determined locally but will be affected by a number of factors including workforce availability, degree of skills enhancement and the needs of individual practices or practice clusters. In a small number of cases it may be locally determined that GPs and their staff continue to provide some of these services, for example in some very small remote and rural practices. Patient safety will also be a determining factor in local implementation in that the changes will only be made when it is safe to do so. These changes will require investment in the skills of the workforce so that these match the service needs.

Planning Multidisciplinary Teams

A clear and consistent approach to effective workforce planning at national, regional and local levels that involves appropriate engagement between service commissioners and employers is key to high quality service provision.

There is recognition that the multidisciplinary approach needs to grow. To develop an understanding of future requirements and how this approach should be taken forward, Scottish Executive Nurse Directors are leading work, together with the Chief Nursing Officer and partners, with the aim of profiling what an integrated Nursing, Midwifery and Allied Health Professional ( NMaHP) community team for adults would look like in a cluster context. This will support local workforce planning and inform the need for national undergraduate and postgraduate education provision to support a growing workforce.

To manage and plan the workforce effectively, local workforce planning agencies need up to date information on:

• The healthcare needs of the population both now and in the future
• The number of people employed and what they do
• Current deployment of staff, past trends and anticipated changes
• What skills the workforce has and where there are gaps
• What skills and staff will be needed to deliver future services and priorities.

In the future, primary care services will increasingly be delivered through multidisciplinary teams including General Practitioners (partners and salaried), other health professionals and social care partners working across clusters of practices, integrated into Health and Social Care Partnerships.

MDTs can be organised at different levels – typically at practice level, but potentially also at cluster or wider primary care level depending on local circumstances. They can therefore be small or large in size and can vary in the composition of their membership. There is no fixed or defined structure for an MDT but instead a significant degree of flexibility to ensure that the services provided meet local needs.

Integration Authorities working with NHS Boards have, over the course of the last two years, identified priorities for local improvement. In 2015 a £20.5 million Primary Care Transformation Fund was announced aimed at supporting the redesign of primary care services across Scotland. A further £10 million was invested in primary care mental health services to encourage the development of new models of care. With investment from the fund, 24 tests of change in 10 NHS Boards focussed on the expansion of the multidisciplinary clinical team and these tests of change have supported the direction of travel set out in the GP contract. As an example, in Inverclyde, Advanced Practice Physiotherapists ( APP) have been embedded in three general practices resulting in over 1,000 consultations being provided by APPs which would have otherwise been GP appointments.

Already we are seeing significant change happening through the primary care transformation programme. In particular, there is growing evidence to demonstrate that a sizeable proportion of current GP consultations can be safely and appropriately delivered by other professionals, freeing up GP time for the more focused Expert Medical Generalist ( EMG) role. The Scottish School of Primary Care has been commissioned by the Scottish Government to capture key learning from the transformation fund tests of change and we anticipate a final report in late 2018.

GP Clusters

In January 2017, the Scottish Government published Improving Together, a National Framework for Quality and GP Clusters in Scotland ^[67] . GP clusters are typically groups of between 5 to 8 GP practices in a close geographical location. The purpose of clusters is to encourage GPs to engage in quality improvement activity with their peers, and to contribute to the oversight and development of their local healthcare system. Each GP practice has a nominated Practice Quality Lead ( PQL) and each cluster will have a Cluster Quality Lead ( CQL). Healthcare Improvement Scotland ( HIS) is developing the required educational and quality improvement support to embed continuous quality improvement in primary care. The aim of this work is to:

• Support GPs to care for their patients and to better address the health needs of their local communities;
• Reduce primary care health inequalities and contribute to improving people's health;
• Improve patient experience of primary care through the local delivery of care by a range of health professionals ( e.g. GPs, nurses, AHPs, pharmacists, dentists);
• To develop a network of Quality Improvement leads to support and embed continuous quality improvement in primary care.

Where appropriate it is expected that integrated multidisciplinary teams will support and be shared across GP clusters, depending on priorities identified by local planners including cluster leads. The role of Local Intelligence Support Team ( LIST) analysts has been expanded to support GP Clusters with the data, evidence and intelligence required to drive quality improvement (more detail on LIST is provided in Chapter seven). Public health professionals also have a clear role to play in advising on approaches to addressing local need and providing evidence on effective population health initiatives.

Approaches to planning the primary care workforce

There are a variety of approaches to identifying local population need and planning the primary care workforce to best address local circumstances. This requires good communication between planners and health and social care professionals. Employers across different sectors frequently use a variety of approaches in undertaking their workforce planning, including case management tools, Indicator of Relative Need ( IORN), and the NHS Scotland 6-step workforce planning methodology ^[68] .

Applying the six step methodology provides the opportunity to take into account local population needs and assess potential impact on other services. Using the guide across workforce planning will assist in ensuring that decisions made around service design and recruitment of staff and MDTs are sustainable, realistic and support the delivery of high quality patient care.

The six steps in this tool are briefly outlined:

1. Defining the plan – This could include measures to improve practice sustainability, improve integration of health and social care services, develop MDT capacity and strengthen workforce planning.

2. Mapping service change – This step is about being clear on what services need re-configured to meet the aim(s) of the workforce plan. A strong vision of what an expanded and / or enhanced service can look like sets the appropriate parameters for workforce planning.

3. Establishing workforce needed to meet service demand – Population needs analysis, as well as additional information on the current number and types of services provided is an important first step here. When assessing population need, consideration should be given the specific circumstances in terms of rural, remote or island communities (further detailed below), an increasing elderly population in many areas and/or the needs of areas of high socio-economic deprivation. The expansion of LIST analysts into primary care is an important facilitator in this respect, as is the role of Public Health professionals.

4. Mapping workforce skills and competencies – Competency-based planning to help distribute work more efficiently, and skill mix initiatives should be utilised to determine the most appropriate use and redeployment of available workforce. Determining what type of skill mix is needed to meet future demand will help support succession planning. In order to support enhanced MDT roles in primary care it is critical that there are agreed roles supported by defined competencies and a robust career / educational and support framework irrespective of employer.

5. Understanding workforce availability – The next step is to profile the existing primary care workforce, including vacancies, and the demographic profile of the workforce. Workforce demographics for certain staff groups may pose particular challenges which should be considered and addressed. We have already highlighted, for example, the older profile of our General Practice and District Nurses. These demographics may of course vary across local areas. This enables an understanding on whether current resources are in the right place, are being utilised effectively and whether the workforce has the right skills to deliver safe and effective patient care. Regional as well as local planning will help in the appropriate distribution of the workforce across Scotland.

6. Implementing, monitoring and refreshing –It is essential to measure the impact of any change including outcomes for patients, services and the wider organisation or local community. Scotland is fortunate to have a range of national organisations whose role it is to provide data, improvement support and evaluation advice to local partners. We set our approaches to monitoring and evaluation in Chapter seven.

Additional factors that should be considered when planning MDTs, include:

The employment of staff will be an important consideration when redesigning services. The expectation is that there will be a mixed model of employment, with Practice Managers, administrative staff and General Practice Nurses generally remaining directly employed by the practice as independent contractors, and the new expanded workforce typically being employed outwith the practice by the Health Board or Scottish Ambulance Service but embedded within practice teams. This provides continuity of care to people, whilst supporting practice sustainability and professional governance.

One area which faces particular challenges is the sustainability of GP Out of Hours ( OoH) services. Sir Lewis Ritchie's report – Pulling together – transforming urgent care for the people of Scotland ^[69] identified a number of key recommendations for service redesign, including workforce planning focussing on the development of MDTs, and the need for robust inter-relationships between daytime and OoH care to ensure a sustainable service for the future. Whilst OoH and in-hours will remain GP-led services, it may increasingly be the case that some patients' needs are best met by another member of the MDT, whether that be an advanced nurse practitioner, a pharmacist or a paramedical practitioner. Improving Health and Social Care Service Resilience over Public Holidays ^[70] focused on what can be done to ensure that good working practices and processes are rapidly put in place to ensure that appropriate levels of service are available throughout public holiday periods.

Where patients have high levels of non-clinical need, this may lead to consideration of whether provision of non-clinical support such as community links workers or welfare rights advisers would be a suitable intervention.

Local Examples of MDT approaches

Govan ' SHIP' was launched in 2015 by four practices working in Govan Health Centre who are within the top 100 most deprived practices in Scotland ('Deep End'). The practices are increasingly working with expanded and integrated network of partners from statutory and third sector agencies, which includes attached physiotherapy, pharmacy, housing, link workers, social work, education and are currently developing teamwork with secondary care. In a short period of time for a project of this complexity, it has managed to innovate, change patient behaviour and reduce use of health services across all patient groups ^[71] .

In Ayrshire and Arran some physiotherapists have been redeployed from acute into community settings to offer a better 'first point of contact' service for patients and fewer avoidable referrals into secondary care.

The Headroom initiative involved 23 GP practices across South East Edinburgh in areas with concentrated economic disadvantage. It recognised the distinct challenge and opportunities for more effective intervention by primary care through working in partnership, including with the local authority, voluntary and other community organisations. In particular Headroom delivered improvements aimed at the critical `life-wrecking` dimensions of inequality; mental health, alcohol, drugs, severe parenting problems, housing, employability, chronic disease and social isolation. While Headroom came to an end March 2017, a number of strands of learning have gone on to inform and/or support general practice including the implementation of a Community Link Worker Network across Edinburgh and the continuation of small 'Total Place' groups delivering responsive, local outcomes through collaborative working.

Remote and Rural

There can be particular challenges in recruiting and retaining GPs, nurses, pharmacists, AHPs (particularly paramedics) and other clinical staff in remote and rural areas. Working in rural areas, especially very remote areas or islands, can be significantly different from working in more urban areas – e.g. relatively limited options to develop careers, access to updating professional skills, difficulty in meeting employment needs of spouses and partners, etc. This is coupled with the often dispersed nature of the practice population, the potential difficulty in recruiting locum cover, wider expectations of the role of health and social care professionals, and the (lack of) availability of other support services such as Care Homes, palliative care, etc.

Clinical staff working in these remote areas often need to have a wider or different range of skills to meet the needs of the local population. We must therefore ensure that we develop a workforce that has the appropriate skills and experience to work in our remote and rural areas. This includes supporting professionals working in these areas and ensuring such roles are attractive and rewarding.

These recruitment and retention challenges should be reflected in the Primary Care Improvement Plans of rural Health Boards/ Integration Authorities, as the role of the MDT and the skills required of the team will be different in each area depending on local need.

In addition, the Scottish Government and BMA have committed to setting up a Rural Short Life Working Group which will support the implementation of the new GP Contract in rural areas, both in the short and longer term, and support the sustainability of remote and rural practices, in particular for very small practices in remote areas.

This will work alongside a Dispensing Short Life Working Group which will look at the needs of dispensing practices in Scotland, including workforce development and training needs especially for non-clinical dispensing staff, and the role of Pharmacists to support dispensing practices.

The Scottish Government will also continue to fund the Scottish Rural Medical Collaborative to take forward work looking at the recruitment, retention and training needs of primary care staff working in rural Scotland (further details are provided in Chapter five).

The Chief Nursing Officer's Commission on Widening Participation in Nursing and Midwifery, Education and Careers ^[72] , published in December 2017, sets out a number of recommendations and will provide a platform for further targeted work to attract and retain individuals into careers in nursing and midwifery, including remote and rural areas.

Health Inequalities

Health inequalities are linked to a range of factors that are complex and interrelated. For example, genetic factors and poor housing can have a major effect on an individual's health over time, and issues can be exacerbated by behaviours such as poor diet, smoking, sedentary behaviour and alcohol misuse. Public services in Scotland can address some of these factors, for example by improving social housing or access to sports and community facilities. Broader UK and global factors, such as levels of economic growth also play a significant role.

Better addressing health inequalities therefore requires continued action beyond primary care but, as set out in Chapter one, the primary care workforce also has a significant role in focusing activity on prevention, anticipatory care planning, and managing complex care to improve patient outcomes. A key aim of the new GMS contract is to focus GP time on complex care as an Expert Medical Generalist, whilst we continue to build capacity in the wider MDT. As patients living in our most deprived areas experience higher levels of ill health earlier in their lives, enabling GPs to address complex care will benefit those patients with greatest clinical need. All Integration Authorities will develop Primary Care Improvement Plans which will show how they intend to address inequalities locally.

The new Scottish Allocation Formula ( SAF) is a methodological improvement on the previous formula. It more accurately captures the determinants of the workload of GPs, giving greater weight to older patients and to deprivation. It uses smaller geographies than the previous formula, ensuring that both deprivation in urban areas and isolated pockets of rural deprivation are better addressed by the new formula. The formula provides about 25% more funding to support the care of patients living in the most deprived areas compared to the least deprived. With the introduction of the new formula, all GP practices in Scotland will be protected from any potential funding losses. To this end, the Scottish Government has committed to invest an additional £23 million to fund the additional care needs recognised by the new formula. This additional investment has been provided to practices to improve services for patients in areas where workload is highest.

A significant proportion of consultations with GPs in areas of very high deprivation are due to experiences of social adversity, especially poverty and financial problems. This can place additional pressures on practices, whose primary aim is to address the clinical needs of their patient population. We have therefore committed to recruiting 250 community links workers by the end of this Parliament. CLWs are one of six key services that, in future, will be provided to patients in GP practices by Health Boards under the new GP contract. The roles of the CLWs will be consistent with assessed local need and priorities. CLWs are one of the ways in which local systems can tackle health inequalities, and therefore our expectation is that the first priority for CLWs will be more deprived areas.

Promoting workforce health and wellbeing

The health and social care workforce is our greatest asset, they have a vital role in delivering Everyone Matters - the 2020 vision ^[73] , to drive improvements in health, patient care and reducing inequalities. It has been recognised that improvements to staff health and wellbeing have major benefits to the economy, society as a whole, and to reducing disease and illness ^[74] , with staff themselves benefiting from improved morale, job satisfaction and improved health and wellbeing ^[75] . Crucially, a workforce that is healthy, valued and treated well improves patient care and overall performance ^[76] . The Boorman Review found that over 85% of staff reported their health and wellbeing impacts upon patient care, while a recent influential study found a direct relationship between staff health and wellbeing and staff reported performance ^[77] .

There are key challenges in this area. The workforce is ageing; some staff require support with management of their weight; musculoskeletal disorders and mental health problems can lead to staff absences; and issues with working cultures and shift patterns can also cause staff ill-health. Some of the issues are already being addressed through current policies and programmes including: Workforce 2020 Vision, Healthy Working Lives, iMatters, Partnership Information Network ( PIN) policies, and our public health policies. The Nursing Vision 2030: Promoting Confident, Competent and Collaborative Nursing for Scotland's Future recognises the need to put in place measures to protect and promote nurses' physical and mental health and wellbeing. The Nursing Vision 2030 recognises that all environments in which nurses work, whether in communities, hospitals, care homes or elsewhere, are hugely influential in fostering – or inhibiting – professional practice and behaviours. A positive culture can help support the workforce to feel valued, and share their experiences and insights honestly and openly, leading to a healthier workforce that feels more valued.

In addition, in October 2016, the Scottish Government and the BMA launched the General Practice Occupational Health Service to provide a range of occupational health services to GP's, GP Locums, Administration, nursing and other practice staff. This service can be accessed through local NHS Board Occupational Health Services, which is available to all NHS staff. The Occupational Health Service for General Practice provides a range of services including pre-placement assessments, management and self-referrals, Immunisation and BBV exposure follow up, Health Surveillance, Physiotherapy and Mental Health advice and support.

NHS Scotland has transformed its approach to measuring staff experience ^[78] . The national staff survey has been replaced by the iMatter Continuous Improvement Model complemented by a short additional Dignity at Work Survey to provide a full overview of national staff experience. The iMatter Continuous Improvement Model ^[79] was developed by NHSScotland staff for staff and provides a team-based tool offering individual teams and managers the facility to measure, understand, improve and evidence staff experience. The Dignity at Work Survey addresses questions about discrimination, bullying and harassment, violence and abuse from patients and members of the public, resourcing and whistleblowing.

These new arrangements have been developed in full partnership and through focussed engagement with the HR community and local and national staff side representatives. It comes with the full support of these communities and has been endorsed by the Scottish Workforce and Staff Governance Committee ( SWAG), and approved by the Cabinet Secretary for Health and Sport. This has enabled NHS Scotland to obtain a comprehensive picture of staff experience indicating areas of success and those which require improvement both nationally and locally. A number of Integration Authorities have been involved in this new transformational approach, and more staff than ever before have used their employee voice to engage in the new approach across health and social care.

Conclusion

Primary care is embarked on a process of reform to place it on a more sustainable and resilient footing and to address the increasing and changing needs of Scotland's population. The Memorandum of Understanding sets out the principles underpinning primary care in Scotland, including respective roles and responsibilities going forward. We are investing significantly (including £250 million in direct support of general practice by 2021) to enable the reshaping of primary care to be delivered.

Shifting the balance of care from hospitals to community and primary care settings presents significant challenges and will require collaborative working across many partners. What is clear though is that to deliver our vision of a modernised and reformed primary care, we must develop multidisciplinary capacity across Scotland and the following chapters begin to set our approaches to increasing workforce capacity.