Primary and Community Health Steering Group minutes: June 2024

Attendees and apologies

• Co-Chair and Director of Primary Care, Scottish Government
• Co-Chair and Deputy Chief Medical Officer, Scottish Government
• Chief Pharmaceutical Officer, Scottish Government
• Chief Dental Officer, Scottish Government
• Delivery Director, Preventative and Proactive Care Programme, Scottish Government
• Professional Nurse Adviser for Primary Care and Chief Nursing Officer representative, Scottish Government
• Director of Dentistry, NHS Shetland
• Director of Allied Health Professionals, NHS Fife
• Deputy Medical Director for Primary Care, NHS Greater Glasgow and Clyde
• Associate Medical Director Primary and Community Services, NHS Borders
• Director of Pharmacy, NHS Borders
• Scottish Executive Nurse Directors (SEND) Representative and Executive Nurse Director NHS Ayrshire and Arran
• Director of Midwifery, NHS Western Isles
• NHS 24 representative
• Board Optometric Advisor, NHS Greater Glasgow and Clyde
• Head of Audiology Services, NHS Tayside and Board Member of the British Academy of Audiology
• NHS Board Digital Leads Group representative
• Chief Officer South Lanarkshire HSCP and HSCP Chief Officers Representative
• National Strategic Lead for Primary Care, Health and Social Care Scotland
• Operations Director, National Services Scotland
• Healthcare Improvement Scotland (HIS) representative
• Chief Executive, National Education for Scotland (NES)
• Director of Place and Wellbeing, Public Health Scotland (PHS)
• Out of Hours (OOH) Oversight Group Representative
• Deputy Chair, Scottish General Practitioners Committee of the British Medical Association (SGPC BMA)
• Chair, Royal College of General Practitioners Scotland (RCGP Scotland)
• National Director, British Dental Association Scotland
• Chair, Optometry Scotland
• Director for Scotland, Royal Pharmaceutical Society
• National Co-Ordinator, Scottish Practice Management Development Network
• Senior Clinical University Lecturer (General Practice & Primary Care), University of Glasgow
• Queen's Nursing Institute Scotland (QNIS)
• Senior Officer of Development, The ALLIANCE
• Chief Executive, Voluntary Health Scotland 
• Primary Care Strategy Unit, Scottish Government
• Primary and Community Health Steering Group Secretariat

Apologies

• Chief Allied Health Professions Officer, Scottish Government
• Director of National Centre for Remote and Rural Health and Care
• Chief Executive, Scottish Ambulance Service
• Director of Psychology (NHS Fife Psychology Service) and Vice Chair of Heads of Psychology Scotland (HOPS)
• Nurse Director, Angus Health and Social Care Partnership
• Director of Digital, National Education for Scotland (NES)
• Associate Director, Royal College of Nurses (RCN)
• CEO, Community Pharmacy Scotland

Items and actions

Please note: views expressed during the meeting include working positions under development, which are not reflective of current Scottish Government policy.

Introduction from the Co-Chairs 

The co-chairs welcomed attendees and thanked all for their engagement and contributions so far. The following points were noted:

• the diversity of this group was reflected upon as one of its key beneficial characteristics
• the Cabinet Secretary for Health and Social Care’s emphasis on the vital contribution of primary care within the wider health and social care (HSC) system in the recent Parliamentary Debate on Health and Social Care (HSC) reform on 4 June 2024 was highlighted, and the vision outlined in his speech noted as an important steer for this group’s work to refresh the vision and outcomes for primary care as part of the route map development
• the aim of this meeting was to build on the outputs of the recent vision focus group session and reach a broad consensus on the elements of primary care that are critical to shaping its future vision and state and which must be protected and promoted. A refreshed vision is fundamental: a “north star” to align policy direction, funding decisions and delivery, at all levels
• a range of recent engagements with service providers, service users and the third sector were also highlighted as further opportunities for discussion around the route map work

Apologies were shared. No issues were raised regarding the minutes of the first meeting, which were therefore accepted as an accurate record. Actions from the previous meeting have all been completed.

Update and orientation on next steps on the Route Map and vision and outcomes - Primary Care Strategy Unit, Scottish Government

The presentation recapped the wider package of HSC reform within which primary care reform sits, as well as the Scottish Government’s vision for HSC, its joint principles and the interconnected pieces of work including both NHS and National Care Service (NCS) – linking primary care reform into these is key. This group has emphasised the importance of a person-centred approach to all of this work. 

A further recap of the key principles of the route map and the existing primary care role and vision (and the contemporary context driving a refresh of these) was given to set the scene for the focus of this meeting.

The six identified enablers have flowed from discussions held so far – the reshaping of these to create the conditions for change will be done collectively with this group over the next few meetings. Feedback was sought from members on whether the deliverables and timeline presented feel realistic.

Recent policy analysis and further exploration with the focus group earlier this month identified some characteristics of primary care which are considered as critical for the vision and principles for the wider HSC system to be realised. These characteristics formed the basis of discussion in the breakout groups, and members were also encouraged to share any further feedback or reflection beyond the meeting

Discussion around the presentation covered a number of areas:

• engagement with users of primary care services during this work: this will build on existing work done and be conducted through wider programmes such as Getting it Right for Everyone (GIRFE) and the learning it has brought about what matters to patients, to ensure a person-centred approach. Further detail on which groups and sectors should be involved, and how, will be worked up and set out in more detail by the Scottish Government Primary Care Strategy Engagement team
• recognising and defining ‘diversity’ as outlined in the proposed principles for the route map: in this context, diversity refers to the range of independent contractors and operating models within primary care - there are however cross-cutting themes within this breadth and complexity which can be brought together into a person-centred approach (in alignment with GIRFE intentions) and which reflect specific needs and characteristics of communities, third sector and professions
• the King’s Fund House of Care model was raised as having a similar foundation for this work: there was a suggestion that work on the enablers should consider what has been learnt from the implementation of the 2016 vision. The practical aspects of delivering the Route Map and vision were emphasised as critical for developing a coherent support and investment package that will deliver it
• language and scope of primary care: this may be brought out in the vision and acknowledgement of how it interrelates with community care. This group will help to define the scope through its work and holistic engagement
• different lenses of primary care – as a group of providers, as a setting and as a set of principles: all should be considered when developing the vision
• it was suggested that, while such an ambitious timeline is important and helpful, careful prioritisation will be required to ensure it can be met

Further comments/feedback from before/after the meeting:

• more emphasis on the need to be ambitious with this work was suggested, and recognition that the opportunity to help shape this work iteratively is important. There needs to be a strong focus on digital as an underpinning enabler

Breakout Rooms 

Members then split into smaller breakout rooms to consider which characteristics of primary care need to be in place to achieve the draft vision for health and social care, specifically the four elements underpinning the vision: access, prevention, quality, and living and working conditions,

For each of the four elements, members were invited to  discuss the following questions, and post responses on a mural board:

• what are your views on the characteristics of primary care which emerged from the focus group as important to support the overall vision?  
• which are most or least critical to support the four elements of the overall vision?
• are there any characteristics which are specific to a service or profession, for example general practice, or GPs, rather than primary care as a whole?
• what are your views on which of these are most important to work effectively with broader community health in supporting the wider vision? 

A summary of main discussion points from each of the three breakout rooms is included at Annex 1.

Overall Summary and Feedback of Main Points 

The key points in this section were taken from the mural board following small group discussions, and then presented to the whole group. They are not derived from analysis of meeting notes.

Additional characteristics, beyond those already identified in the focus group:

Access to high quality health information resources (Prevention)

• recognising value of Primary Care (taking a wide understanding of value, not just efficiency/economy) - (Quality)
• both Generalist (person not condition) and Specialist services - (Quality) 
• proportionate universalism & care appropriate to need - (Living and working conditions)
• wellbeing of the workforce - (Living and working conditions)

Critical priorities:

• human rights and responsibilities - (Access)

• access to high quality health information resources - (Prevention)

• value of procedures - (Quality)

• specialist services in primary care as well as generalist - (Quality) 

• proportionate universalism & care appropriate to need - (Living and working conditions)

• wellbeing of the workforce - (Living and working conditions)

Working effectively with Community Health and Social Care

• trust across professions and tools and systems to support that - (Living & working conditions)
• trust in the system, between patients and practitioners - (Living & working conditions)

General points:

• human rights and responsibilities - (Access)
• importance of a mixed approach (transactional and relational) and shared, accessible records, value for money/best value and managing risk in complexity - (Quality)
• effective team working and networks – significance of community health and of building trust across professions, tools and systems to support joined-up care and earlier support (Living and working conditions)
• focus on person, not condition – ability for primary care systems and workforce to be adaptive and flexible to respond to shifts in population needs over time - (Access, Quality)

The Co-Chairs encouraged further reflective feedback by email following this meeting and thanked members for their productive discussions

Any Other Business

Chief Officer South Lanarkshire HSCP delivered a presentation on a Lanarkshire study examining patient perspectives on primary care transformation. Key points:

• GP numbers are low in Lanarkshire, practices are very busy and there is patient dissatisfaction with access
• the study is focusing on access to general practice, maximising efficiency, new services (including digital) and redesign of existing services
• the study is using Public Health Scotland as well as local data to examine what practices are doing and reasons patients are accessing services 
• online consultation and digital prescribing are currently playing limited roles but have significant potential for enabling more time to deliver person centred/relational interventions
• qualitative data is also being gathered from conversations via telephone interviews of circa 4000 patients and following up with focus group sessions over this summer
• this research could accelerate the route map development work being proposed to this group

Comments from the Group: does this capture contact with general practice or with GPs specifically? Suggestion that as models of general practice are changing, patients’ views on their ability to access a consultation is very important – and to consider that volume of appointments does not necessarily bring improved satisfaction. This study is speaking to this: which aspects that do not require the human touch can be taken away to free up more time for those that do.

Action Points and next meeting

• Scottish Government officials: drafting refreshed vision  based on points of discussion as reflected on the Mural Board. Complete
• Scottish Government: initial outline of enabling functions for further discussion in subsequent steering group meetings. Consideration to be given to whether real life illustrative examples of good practice can be used, in the documentation and/or meetings. Complete

Annex 1  - Summary of Breakout Room Discussions

Question 1: What are your views on the characteristics of Primary Care which emerged from the focus group as important to support the overall vision?

Room 1:

• consideration of how human rights underpin all of this. Focus of primary care on the person, not the condition, perhaps fits with this
• exploring the principle of not just generalism as a characteristic but also of appropriately moving some specialist services into primary care too
• also balance between relational and transactional interventions – both very relevant
• need to balance patients’ rights with their responsibilities – e.g. self care – healthcare should not necessarily be unconditional. Availability of accurate and relevant information to support this is crucial – interface between primary care and innovation

Room 2:

• how do we bring in proportionate universalism so areas with greatest need get greatest support (health inequality lens)?
• the importance of non-stigmatisation across the piece and taking care of our workforce
• care with use of “unconditional access” – barriers to access should be removed but healthcare should be appropriate for people’s needs, not their wants

Room 3: 

• prevention should be the core of primary care work – currently the limited appointment time reduces opportunities for this 
• person centred care, with treatments focused on personal outcomes not condition
• physical premises that enable accessibility (when and where access is required)

Question 2: Which of these are most/least critical to support the overall vision?

Room 1:

• accessibility was discussed as a critical factor – a need for agility to be able to respond to changing future population health needs.
• watchful waiting, understanding risk
• suggested use of the term “best value” rather than “value for money” – how we can use data to evidence this

Room 2:

• primary care's role as a “super connector” - therefore must be community based and have the workforce and tools to enable these connections
• valuing continuity for improved patient outcomes

Room 3:

• Focus on the person and not the condition, and the importance of general practice in providing holistic care for multimorbidity
• Targeted action to address health inequalities
• Shared patient record that is also accessible to patients

Question 3: Are there any characteristics which are specific to a service or profession, for example general practice, or GP's, rather than Primary Care as a whole?

Room 1:

• increasing complexity of patients’ presentations in general practice necessitates more specialist knowledge – which requires ongoing  education and training

Room 2: 

• media profile of GPs all being closed; value of care and the complexity of GP teams not well understood by public.
• trust and longitudinal relationships (GP/patient) built up over years.

Room 3: 

• noted that primary care is a 24/7, 365 days a year system within which demand cannot be tempered to a certain time window – clear articulation of what provisions are available 24/7 is important
• volume of GP appointments and the lower cost of these relative to  many other parts of the system; actions & outputs not well understood though

Question 4: What are your views on which of these are most important to work effectively with broader community health in supporting the wider vision?

Room 1:

• facilitating close multi-disciplinary team working across services and boundaries between primary care and community health to develop a “prehab” agenda (more proactive approach, e.g. frailty)

Room 2: 

• relationships and communications are not just with patients, but with everyone working together – trust in the system (health and wider) not just the service

Room 3: 

• workforce and its future, given changing demographics and work patterns and conditions (there was an offer to share recent optometry work on this)
• effective triage so that patients with the most urgent care requirements are prioritised

Other

Room 1:

• should we acknowledge the role of private healthcare too? Noted that the “free” element hasn’t come up, also that it is not always ‘free’ (e.g. dentistry)
• registration – not universal across all primary care 'pillars' (i.e. general practice, community dentistry, optometry, community pharmacy, and community urgent care) therefore shared patient record important for safe, consistent and efficient care.

Room 2:

• importance of shared patient record
• need to better support navigation of complex health & social care systems

Room 3:

• importance of a shared record (perhaps held by the patient themselves in a primary care setting, but with the ability for this to be discussed with a clinician before any life-changing information was read and so that patients understand their data)
• enhancements in digital tech will require appropriate support for patients to use these options
• interface between primary and secondary care – strong but could be further developed
• further work into efficiencies and examples of good practice could be better highlighted
• consideration of a robust implementation plan is crucial to rapidly embed the changes into primary care.