National health and social care workforce plan: part three

Chapter Six: Planning and Developing the Multidisciplinary Workforce - Wider Clinical and Non-Clinical Workforce

• We will build a sustainable pharmacotherapy service in Scotland that includes access to pharmacist and pharmacy technician support for every GP practice.
• Faster and more efficient whole system pathways will support patients with musculoskeletal conditions, led by physiotherapists.
• There will be a significantly enhanced paramedic provision in all Integration Authorities, aligned to clusters, based on local service design, and delivered via the commitment to train an additional 1,000 paramedics to work in the community.
• We will see a developed and enhanced role for allied health professionals in supporting patients' needs, including promoting prevention and self-management with improved access.
• We are committed to increasing the mental health workforce in A&Es, GP practices, police station custody suites and prisons by 800. Supported by investment of £12 million in 2018-19, with annual investment rising to £35 million by 2021-22.
• There will be 250 community links workers in place by 2021, reducing practice workload and supporting patients' holistic needs.
• We will support enhanced training and support for practice managers and practice receptionists to develop their roles, supported by continued investment.
• There will be increasing use of community pharmacy for improving population health, managing self-limiting illnesses and supporting self-management of stable long term conditions in- and out-of-hours, and an expanded workforce.
• We will work with stakeholders to consider the need for a proposed marketing campaign to attract individuals into allied health professions to ensure a sustainable workforce is available to meet Scotland's future requirements.

Introduction

The previous two chapters set out our approaches to enhancing and expanding the nursing and GP workforces. In this chapter we focus on how we will develop the wider clinical and non-clinical workforce to ensure enhanced MDT models of care will provide patients with the most appropriate treatment, as quickly as possible, by the most appropriate practitioner in the most appropriate setting. This includes models being developed for pharmacy, musculoskeletal physiotherapists, mental health workers, community links workers and paramedics as first point of contact. To ensure effective MDT working that delivers high quality person-centred care, local planners will need to give consideration to the collective mix of generalist and specialist skills within each team and service. This will be facilitated by the development of more comprehensive workforce data, as set out in the final chapter.

Physiotherapists

Neck and lower back pain generates the second highest burden of disease in Scotland ^[104] . Early intervention and self-management can have a significant impact in preventing chronicity of these conditions. Musculoskeletal ( MSK) health issues are a common cause of GP appointments but the majority of a GP's MSK caseload can be seen safely and effectively by a physiotherapist without a GP referral. However the existing patient pathway often includes an unnecessary delay while initial non-physiotherapeutic solutions are attempted prior to access to an MSK Physiotherapy service. While there is no waiting time to access advice via the Musculoskeletal Assessment and Treatment Service ( MATS), there are variable waiting times across the country for access to face to face physiotherapy. Under a new model, physiotherapist's could provide first point of contact appointments providing assessment, diagnosis (including access to diagnostics), advice and onward referral to secondary care services if appropriate. Where they have appropriate training and skill mix, MSK physiotherapists should carry out prescribing as well as treatments such as injections. This will enable a faster and more efficient whole system pathway for patients with MSK conditions.

A sustainable Physiotherapy / Advanced Practice Physiotherapy provision should be considered by all Integration Authorities in developing their Primary Care Improvement Plans, potentially aligned to GP clusters. A significant proportion of the current workforce either already has the skills required, or could be quickly up-skilled to take on these roles. However, the training of new physiotherapists will take time, with undergraduate training currently lasting two to four years, therefore a transitional phase would be required to enable a sustainable model to be achieved.

New models of MSK physiotherapy provision have been tested across Scotland as part of the Primary Care Transformation Fund. The Scottish School of Primary Care is evaluating selected models on behalf of the Scottish Government. The study will help us understand the context in which the new models of MSK physiotherapy were tested, and examine the barriers and facilitators to deployment and uptake that were met by the test sites. It will also consider how well, in early sites, the changes have been embedded as part of routine practice, and consider sustainability issues. A report setting out key findings will be published by the end of 2018.

Future AHP workforce

NHS Boards across Scotland have indicated challenges around recruitment across all of the AHP workforce, but particularly affecting physiotherapy. The numbers entering the Allied Health Professions are not currently controlled, and are largely determined by supply and demand factors. The potential for a more managed approach to workforce planning for those training to become AHPs is being explored. Consideration is also being given to the potential for other, faster, routes into the professions such as return to practice and post graduate training.

In addition, we will work with a range of stakeholders to consider how best to attract and retain people into AHP careers – particularly for those professions where it is already difficult to recruit to such as physiotherapy. As part of this wider work, we will consider the potential need for a marketing and recruitment campaign.

Pharmacists and pharmacy technicians

A three-tiered pharmacotherapy service is to be implemented in a phased approach with the aim of introducing a sustainable service that includes access to pharmacist and pharmacy technician support in every GP practice by 2021 as set out in the Memorandum of Understanding. Level one is a core service that will be made available to all GP practices, with activities at a generalist level of pharmacy practice focused on acute, repeat and serial prescribing, medication management and prescribing efficiencies (technical and basic clinical roles). Levels two (intermediate) and level three (advanced) are additional services and describe a progressively evolving stage of clinical pharmacy practice and experience which includes medication and polypharmacy reviews. The levels of support will take into account the needs of individual practices and practice clusters by planners at local level.

The Inverclyde New Ways of Working pilot provided an average of 0.5 WTE pharmacist per practice alongside some pharmacy technician involvement. Another model, which better accommodates the needs of remote and rural practices is 1 pharmacist per 10,000 list size.

The pharmacotherapy service will be led by the Directors of Pharmacy for the three year trajectory period to allow workforce planning to be supported, appropriate governance arrangements embedded and the successful initial momentum to be maintained. This will also allow the service to reach a level of maturity before being reviewed with the view to a handover to Integrated Authorities. A national implementation group has been established to support the delivery of the service.

Approximately one third of GP practices currently have pharmacy input supported by Primary Care Funding. Boards have adopted a number of different delivery models, including sessional input from hospital and community pharmacists, and split posts between practices and locality approaches. We will continue to work closely with NHS Boards to monitor progress against the Programme for Government commitment and to ensure that recruitment to the new pharmacotherapy service is delivered in a sustainable way so as to minimise any risk of destabilising other parts of the system. That is why a phased approach to the recruitment of pharmacists and pharmacy technicians into general practice has been essential.

The commitment that every GP practice will receive pharmacist and pharmacy technician support by 2021, through the Pharmacotherapy Service, is being supported through the Primary Care Fund. The funding available in 2017-18 for general practice pharmacy support was increased by a further £4.2 million. Based on this additional funding over and above the original three year figure of £16.2 million, by the end of March 2018, NHS Boards planned to have appointed over 200 whole time equivalent pharmacists and over 50 whole time equivalent pharmacy technicians working with or within GP practices. Outturn figures up to the end of March 2018 are currently being gathered.

As part of their Primary Care Improvement Plans ( PCIPs) Integration Authorities and Health Boards will be updating their plans for 2018-19 up to the end of 2021 and this will be reflected in future iterations of the workforce plan.

An evaluation of the workforce aspects of the GP practice-based pharmacists and pharmacy technicians should be available by the end of 2018 and the early findings, alongside the Inverclyde evaluation, will be used to inform detailed workforce planning work to identify how many additional pharmacists will be required to deliver full roll-out of the pharmacotherapy service.

Developing the future pharmacist workforce

Community Pharmacy

Community pharmacy already plays an important role in the provision of NHS pharmaceutical care, providing highly accessible services for people both in-hours and out-of-hours. We want more people to use their community pharmacy as a first port of call, not only for the treatment of self-limiting illnesses and medicine-related matters, but for the on-going self-management support for people with long term conditions. Enhancing these services also expands the clinical role of community pharmacists .

Achieving Excellence in Pharmaceutical Care ^[105] committed to working in collaboration with NHS Education for Scotland and other key stakeholders to understand and address future pharmacy workforce requirements. It describes the need to further build the clinical capacity within community pharmacy and our commitment to target resources to expand the number of community pharmacists undertaking independent prescribing and advanced clinical skills training. This includes exploring how resources to cover back-fill for the residential training and period of learning in practice can be provided in order to build clinical capacity to deliver an extended Minor Ailment Service and enhanced Chronic Medication Service.

Given the importance of community pharmacy in helping transform our primary care services, in Chapter 7 we describe how for the first time we have undertaken a national community pharmacy workforce survey to provide the necessary insights into staff numbers and skill mix to meet the challenges of delivering new models of primary care. Crucially this will inform national workforce planning and the educational needs of the profession in this sector.

The Pharmacotherapy Service

With regard to the pharmacotherapy service in GP practices, there are a number of additional implementation factors that need to be considered alongside the number of pharmacists and pharmacy technicians required to deliver it. This includes their education and development and importantly securing the pipeline of new pharmacists.

Depending on the experience of the pharmacists and pharmacy technicians working in GP practices there can be a need for additional training, this includes advanced clinical and independent prescribing skills. This will also require appropriate levels of clinical mentorship. Resources have been identified and allocated to Boards to support this. Additionally, the new NES vocational training programme for pharmacists in primary care and community pharmacy will contribute towards ensuring early career pharmacists build skills and capability. A General Practice Clinical Pharmacist Competency and Capability Framework ^[106] has been developed to underpin the education and training needs of pharmacists supporting GPs going forward.

As a first step, and in order to increase the pool of qualified pharmacists available to provide the pharmacotherapy service, additional funding has been secured to increase the number of NES pre-registration pharmacist training posts from 170 to 200 per year from 2018/19 onwards.

Paramedics

A number of tests of change in Scotland over the last two years have focused on the role of paramedics in primary care. Evidence from pilots in Inverclyde, Hawick and Kelso shows that support (such as responding to urgent call out to patients) allows GPs to provide more appropriate patient care. The Inverclyde Pilot, for example, found that in the first three months following paramedic support to practices being put in place, the percentages of home visits carried out by GPs reduced by over 60% ^[107] . Paramedics are equipped to consult with unscheduled urgent care presentations, making them an ideal fit to work with primary care colleagues. This model will free up GPs' time to focus on their EMG role by reducing appointments and home visit requests for unscheduled and urgent care presentations.

This model also supports paramedics to practice their skills at the highest level of their professional competence, consolidate their learning, gain exposure to and experience of patients with acute illness and injury and develop closer relationships with primary care colleagues, becoming part of a wider multi-disciplinary team. It helps support the Memorandum of Understanding, which specifies that advanced practitioners, such as paramedics, should be used to respond to urgent care appointments, such as home visits, in place of the GP. These practitioners will be aligned to clusters as appropriate and be based on local service design and working during core general practice hours, as well as out of hours. These paramedics will assess and treat patients in a range of settings, including urgent and emergency care presentations, home visits and Heath Centre attendees.

As autonomous practitioners, paramedics will not require regular supervision by the GP within a cluster, but will need access to support when issues outwith their scope of practice arise. While this will be provided by a clinician, this may not necessarily be the GP. Supervision for paramedics working within a practice will always be agreed under the GPs clinical oversight. Peer supervision with clinical oversight and leadership from the GP will be encouraged under this new model.

Paramedics and advanced paramedics will continue to be employed by the Scottish Ambulance Service ( SAS). As part of the Primary Care Improvement Plans, we expect the SAS to work with Integration Authorities to set out what support is required at a local level, using evidence gathered from current tests of change, such as in Inverclyde. This will include developing robust clinical governance frameworks and evaluating practice data.

SAS will integrate all existing pilot activity, such as the work being carried out in Inverclyde, into a single national programme of work to transform primary care in a 'Once for Scotland' approach. This will include developing robust clinical governance frameworks and evaluating practice data. As part of the Primary Care Improvement Plans, we expect the Scottish Ambulance Service to work with local Health and Social Care Partnerships to set out what support is required at a local level.

Patient safety will be fundamental in delivering this workforce at scale. At all stages of the roll-out, we will ensure the available workforce is appropriate to ensure the safety of patients requiring urgent unscheduled care is assured, and core ambulance services are not negatively impacted. This will require consistent and reliable provision of paramedic staff working in primary care teams, appropriate training and education, supervision and support arrangements, and, crucially, positive relationships between colleagues in the MDT.

Future paramedics workforce

There will be an increase in paramedics and advanced paramedics in the coming years. The Scottish Government has committed to training 1,000 additional paramedics during this Parliament to work in Scotland's communities to deliver more care at home. This is also in alignment with the Scottish Ambulance Service's strategy Towards 2020: Taking Care to the Patient ^[108] – focusing on increasing the Service's capacity for care at home or in the community. This role could be further enhanced as plans are now underway to allow paramedics to become independent prescribers.

Current paramedic training is carried out through a two year diploma in higher education and Scotland's first undergraduate BSc in Paramedic Science commenced in September 2017. Following publication of the Paramedic Evidence Based Education Report ( PEEP) ^[109] in 2013, a consultation is now underway to explore changing the training to be undertaken as a degree. This may impact on the availability of workforce due to longer training times and we will work with SAS and other stakeholders to ensure suitable transitional arrangements are in place.

Mental health workers

Mental health issues are a common feature of primary care consultations. For instance, Scottish research in primary care showed that depression is associated with a wide range of physical health conditions and is a significant burden on primary care ^[110] . Across a range of conditions, each patient with co-morbid depression costs health services between 30% and 140% more than equivalent patients without depression ^[111] .

Appropriately skilling our primary care workforce to ensure they are confident in dealing with mental health problems is crucial. Mental health expertise therefore needs to be embedded in multi-disciplinary primary care teams through a mixture of specialist mental health workers and by ensuring that other professionals are mental health trained / aware.

A £10 million Primary Care Mental Health Fund ( PCMHF) has allowed different services to try different approaches to improving mental health provision. The Scottish School of Primary Care is undertaking an evaluation of a range of projects funded by the Primary Care Transformation Fund and the PCMHF. The evaluation will comprise case studies with a geographic and thematic focus and will be published in Autumn 2018.

Future mental health workforce

The Mental Health Strategy for 2017-2027 ^[112] recognises the importance of primary care transformation and sees it as an opportunity to improve services for people with mental health problems with parity of esteem between physical and mental health. This includes Action 23 which is a commitment to test and evaluate the most effective and sustainable models of supporting mental health in primary care, by 2019.

In addition, Action 15 states that we will increase the workforce to give access to dedicated mental health professionals to all A&Es, all GP practices, every police station custody suite, and to our prisons. It commits to increasing additional investment to £35 million per annum by 2021-22 (including £12 million in 2018-19) for 800 additional mental health workers in those key settings.

There are a number of implementation factors which need to be considered in respect of the delivery of this commitment. These include the commissioning arrangements of each Integration Authority and how to align the roles of services from both a national and local perspective in order to balance the skills and capacity for this additional workforce.

The Scottish Government has asked the Health and Justice Collaboration Improvement Board (which includes senior public sector leaders who, amongst other responsibilities, identify and address organisational and systemic barriers to working collaboratively) to develop recommendations on how to achieve Action 15 from 2018-19.

Wider Clinical Roles

There are a range of other roles as part of the MDT that can offer high quality care as part of a comprehensive and person-centred service.

Healthcare Scientists are the fourth largest clinical group, who collectively are responsible for over 80% of all clinical diagnoses ^[113] . This workforce covers over 50 different scientific specialities and is the specialist workforce in the health system that responds directly and uniquely to advancing scientific and technological changes.

A more holistic approach to treatment pathways could see scientists integrated into patient pathways, and working in multi-disciplinary teams as part of a whole systems approach. The ability to support patients with complex needs at home will increasingly rely on the use of networked medical technology supported by Medical Physics and Clinical Engineering services in collaboration with eHealth. Clinical Engineering services are already experienced in supporting equipment, such as portable ventilators and assistive technology, in the community and this expertise can be utilised to allow the roll out of other medical equipment for use in the non-hospital settings in a safe, controlled manner.

Healthcare Scientists can contribute to reducing out-patient attendance such as for Audiology, Cardiac Physiology and Respiratory Physiology where what are typically "routine" out-patient attendances for investigations and rehabilitation can be delivered in local setting e.g. community hospital type setting. Pharmacists and healthcare scientists are working together to develop models of point of care testing in community treatment centres.

Dieticians can now train as supplementary prescribers and have the skills and knowledge to help manage conditions such as irritable bowel syndrome, reducing referral to secondary care and improving symptoms for 70% of people, type 2 diabetes and food intolerance conditions ^[114] .

Mental health problems and presentations of distress are common in primary care. Early intervention can prevent later mental ill health and improves outcomes for the person. The prevalence of mental illness also has a profound effect upon our success in treating physical illness. Mental health presentations can be seen in the first instance by a primary care mental health practitioner ( PCMHP). Occupational Therapists ( OTs), working as a first point of contact practitioners in general practice, are providing quick access to early assessment and intervention for people with emerging mental health problems. When required the therapist can signpost and refer to third sector and other healthcare professionals as appropriate.

OTs have particular expertise in helping people who are frail or have long term conditions. The benefits of this role include enabling independence and social inclusion; preventing deterioration; and minimising crisis situations, thus reducing demand on GP practices and acute admissions.

A fully integrated primary care podiatry service can safely diagnose, manage, rehabilitate and prevent disease related complications of the feet, ankles and lower limbs, particularly around MSK, diabetes, rheumatoid conditions and peripheral arterial disease. They also have a significant role in the public health and prevention agenda specifically around falls prevention, cardiovascular risk reduction, medicines management and reconciliation, antibiotic stewardship and keeping people mobile and active.

Podiatrists have the ability to utilise advanced diagnostic techniques including imaging and can prescribe independently, for a range of lower limb conditions. As the experts in lower limb health and disease, podiatrists have the requisite knowledge, skills and training to work as first point of contact practitioners in primary care

Speech and language therapists have the specialist knowledge and skills to diagnose, directly assess and support problems in relation to communication, safe eating, drinking and swallowing. The assessment and management of eating, drinking and swallowing problems has an important role in to prevent malnutrition and dehydration, reduction the risk of repeated chest infections, urinary tract infections and falls.

Dentists

The 2016 dental workforce report ^[115] is the latest in a series of biennial dental workforce reports that aim to inform workforce planning for dental services in Scotland. The report examines supply and demand for services based on several contributory factors including uptake of services, population projections, changes in demography, country of qualification of the dentists and the years spent in the service post qualification.

On the current trajectory our dentist workforce will exceed the needs of the projected Scottish population by 2026. To help counter this potential future over-supply of dentists we have reduced the dental school in-take of Scottish, Rest of the UK and EU dental students to 135 per year. The impact of this reduction will begin from June 2018 onwards.

However, when planning the dentist workforce it is necessary to consider the make-up of the workforce going forward, in particular the number of EU dentists and the possible impact Brexit may have. Primary Care dental services in remote and rural area have a higher non- UK dentist workforce, made up of EU and international dentists, and would potentially feel the effects of any Brexit impact more acutely than other parts of the country.

Dentists wishing to provide NHS General Dental Services in Scotland, unless otherwise exempt, have to complete a vocational training ( VT) period of one year duration. Three-quarters of dentists who started working in Scotland after finishing VT in the UK were still in NHS Scotland six years later. If, however, they entered NHS Scotland from the EEA only 46% remained after six years. After 10 years more than half of vocational dental practitioners stayed in NHS Scotland. Currently approximately 10% of GDPs in Scotland qualified in the EEA but in recent years there is the beginning of a trend of these numbers reducing. Since the distribution of EEA dentists is skewed towards remote and rural areas, this is a concern for the future. We will continue to monitor trends in the profile of dentists via the biennial workforce plans.

Dental Care Professionals

The role of dental care professionals ( DCPs), also has to be taken into account when planning the dental workforce. Approximately 40 new dental therapists qualify every year. As the emphasis on care moves towards prevention and there is an increasing need to consider the on-going care of older people the more potential there is for greater involvement of DCPs particularly therapists. Direct Access to DCPs (instead of patients visiting a dentist first) may enable them to contribute significantly more than at present but legal challenges to introduce this arrangement will first have to be overcome.

Optometry

Optometry plays a key role in the provision of community care. This has developed since the introduction of free NHS funded eye examinations in 2006, to the service being the first port of call for people with eye problems, helping to detect eye diseases early. More integrated care is being provided in local practices, with community optometry supporting pharmacy, GP, nursing, social care and third sector colleagues to help patients remain within primary care. The development of General Ophthalmic Services ( GOS) to support community eye care has reduced the burden on GPs and has allowed more patients to be discharged from the hospital eye service. Age is the greatest risk factor for developing eye conditions, and training is being developed to enable safe and high quality community care for patients with long-term ophthalmic conditions.

The Community Eyecare Services Review ^[116] was commissioned by the Cabinet Secretary for Health and Sport in 2016 to consider and evaluate community eyecare services currently provided across Scotland, and identify examples of good practice that could be replicated on a national basis. The Review also forms part of the Health and Social Care Delivery Plan. The Review made a number of recommendations, including schemes to reduce geographical differences in services, more tailored arrangements for patients with specific complex needs to support care closer to home, and suggested that some eye services traditionally offered in hospitals (such as post-cataract surgery appointments and managing stable glaucoma patients) should be made available locally. The Scottish Government is in the process of implementing the recommendations of the Review, including the development of new GOS regulations, and is engaging with a range of stakeholders, including health professionals and patients.

Non-clinical staff

Community Links Workers ( CLW)

Community links workers ( CLW) have a specialist or generic non-clinical role in the primary care workforce. Their purpose is to improve patient health and well-being, reduce pressure on general practice and tackle health inequalities. To be most effective a CLW should be integrated or embedded in general practice, provide a non-clinical intervention which meets the needs and demands of the practice and practice population and is employed by a local authority or third sector organisation.

They provide an essential role in tackling deprivation, and the needs of those who have complex conditions, are socially isolated, or live far from other support. Following successful piloting in areas of high socio-economic deprivation, there are now CLWs in place in several areas. There are also numerous staff fulfilling comparable roles across the country with a range of job titles. Many CLWs are generalists, but staff providing specialist non-clinical support specifically with, for example, welfare issues or supporting mental health are providing equally valid services to patients who need it, and form part of our overall approach to CLWs.

CLWs are one of the six key services that, in future, will be provided to patients in GP practices or clusters of GP practices by Health Boards under the new GP contract. Their roles will be designed, commissioned and planned by Health and Social Care Partnerships, based on assessment of local need, working hand in hand with local GPs, patients and the third sector. This will be a locally-determined and delivered service, built up across the country to deliver our overall national commitment to at least 250 staff as per the Scottish Government's commitment. The new GMS contract National Oversight Group will ensure that the service is being rolled out at pace nationwide over the next three years.

Practice manager and receptionists

Primary care transformation presents an opportunity to consider how non-clinical staff (practice managers and receptionists) can be up-skilled to help coordinate care as part of a wider MDT.

Practice Managers have a key role in ensuring the smooth and efficient day to day running of General Practices and the long term strategic management and co-ordination of primary care, including supporting the development of the multi-disciplinary team as set out in the new 2018 GP Contract.

With the introduction of the 2018 contract the need for Practice Managers with wide ranging, adaptable and versatile skills is going to increase as General Practice and Primary Care becomes a more complex landscape. In addition to continuing to manage the practice employed practice team and dealing with other practice based issues, their role working with external stakeholders including GP Clusters, Health Boards and HSCPs is going to develop and expand. Working closely with the developing services such as Vaccinations and Community Care and Treatment Services and other members of the multi-disciplinary teams that will be working in the practice or with the practice team will be vital. Coordination and communication with these new services will be crucially important across a range of issues including access to IT systems and supporting patients to access services.

Practice Managers therefore require a wide range of skills including financial management, IT management, HR management, contract management, leadership and facilitation, Quality Improvement skills, change management, communication and patient engagement skills. Following the announcement in May 2017 of £500,000 investment in the development of Practice Managers and Practice Receptionists, work is on-going with NES to work with Practice Managers to identify their training needs for the future, and make sure those needs are met over the next few years. Career development and succession planning is also going to be important for the profession going forward and is also being considered.

Alongside the changing role of Practice Managers, the role of receptionists and other non-clinical staff in the practice has also changed and developed and will continue to do so.

Practice Receptionists have a challenging role, managing patients' requests and expectations, often in difficult circumstances. They play a vital role both now and in the future which needs to be recognised, valued, supported and developed. In some practices the title of Practice Receptionist is now considered to be outdated and does not fully reflect their role and there should be consideration of a revised job title in future. Opportunities such as developing and up skilling practice receptionists to carry out care navigation of patients in this increasingly complex primary care landscape or to increase their role in the management of practice documentation , is currently being developed with NHS Healthcare Improvement Scotland who will be working with GP Clusters to develop training and resources to support this group of staff.

There is also a wide range of other practice administrative staff who carry out a variety of tasks depending on the needs of the practice from prescription management, medical secretarial skills, IT management including call and recall, documentation management, health and safety, finance management, and healthcare assistant roles. These staff are a highly skilled and adaptable workforce, who will continue to have an important role in the delivery of care by general practices. Strong leadership by Practice Managers supported by their teams and by the practice GPs is vital.

NHS 24

NHS 24's 111 service is at the forefront of delivering safe and effective urgent care and support to the public when GP practices are closed. As a national organisation NHS 24 has a unique opportunity through its infrastructure to align itself more closely with primary care, social care, and voluntary and independent sectors, in response to key drivers including Health and Social Care Integration, Primary Care Transformation, and national strategies such as the National Clinical Strategy. It is anticipated that over the next five years, to support the programme of development, an additional 371 WTE staff will require to be recruited. This represents an increase of approximately 40% of NHS 24's existing workforce. The majority of the resource requirements, approximately 65%, are for non-clinical staff, call handlers in particular, however, there will also be a requirement for NHS 24 to grow its requirement for clinical staff, including more nurse practitioners, advanced nurse practitioners, mental health nurses, general practitioners, and allied health professionals. With these additional staff in place, we would expect NHS 24 to work with Health and Social Care Partnerships to set out what support NHS 24 can offer at a local level, including the triage of patients to general practice or to self-management pathways as part of the Primary Care Improvement Plans

Conclusion

This chapter set out new models of care that will ensure quality service provision and build MDT capacity in local communities. To service these models we are re-configuring services both at a national and local level with associated investment. Nationally we are beginning to ensure through better workforce planning across all primary care professions the education and supply pipeline is adequately resourced and planned to ensure a sustainable workforce that takes account of changing trends.