Primary and Community Health Steering Group minutes: September 2024

Attendees and apologies

• Co-Chair and Director of Primary Care, Scottish Government
• Co-Chair and Deputy Chief Medical Officer, Scottish Government
• Chief Allied Health Professions Officer, Scottish Government - deputy attended
• Professional Nurse Adviser for Primary Care and Chief Nursing Officer Representative, Scottish Government
• Delivery Director, Preventative and Proactive Care Programme, Scottish Government
• Director of Allied Health Professionals (AHPs), NHS Fife
• Chief Executive, Scottish Ambulance Service (SAS)
• NHS Board Optometric Advisor, NHS Greater Glasgow and Clyde
• Director of Psychology NHS Fife Psychology Service and Vice Chair of Heads of Psychology Scotland (HOPS) - deputy attended
• Nurse Director, Angus Health and Social Care Partnership
• Head of Digital Services in Practitioner Services Division, NSS
• National Director, British Dental Association Scotland
• CEO Community Pharmacy Scotland
• Chair, Royal College of General Practitioners Scotland (RCGP Scotland) - deputy attended
• Director for Scotland, Royal Pharmaceutical Society - Deputy attended
• Chair, Optometry Scotland
• Director of Dentistry, NHS Borders
• Director of Dentistry, NHS Shetland
• Director of Nursing and Systems Improvement & Deputy Chief Executive, Healthcare Improvement Scotland (HIS) - deputy attended
• Out of Hours (OOH) Oversight Group Representative
• Chair, Scottish General Practitioners Committee of the British Medical Association (SGPC BMA)
• Director of Place and Wellbeing, Public Health Scotland (PHS) - deputy attended
• Chief Officer of Development, The ALLIANCE
• Associate Medical Director Primary and Community Services, NHS Borders
• Director, Primary/Community Care (interim), Strategy, Performance & Service Transformation, NSS
• Director of Pharmacy, NHS Borders - deputy attended
• General Practice Managers Network representative
• Scottish Executive Nurse Directors (SEND) Representative and Executive Nurse Director NHS Ayrshire and Arran
• Chief Executive, Voluntary Health Scotland
• Chief Executive Officer, Queen's Nursing Institute Scotland (QNIS) - Deputy attended
• Associate Director, Royal College of Nurses (RCN) - deputy attended
• Primary Care Strategy Unit, Scottish Government
• Primary and Community Health Steering Group Secretariat, Scottish Government

Apologies

• Deputy Medical Director for Primary Care, NHS Greater Glasgow and Clyde and Primary Care Leads Group
• Professor of Health Economics, University of Glasgow

• Director of Midwifery, NHS Western Isles

• Professor of Medical Education, University of Glasgow and Co-Director of the Scottish School of Primary Care

• NHS Board Digital Leads Group representative

• Chief Executive, National Education for Scotland (NES)

• Director of Digital, National Education for Scotland (NES)

Items and actions

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 publication of Programme for Government (PfG) and the inclusion of Primary Care related commitments, were highlighted
• the Co-Chair indicated that the recent Pre-Budget Fiscal Update is an honest appraisal of where the public finances are, focusing on fiscal sustainability. In this context reforming health and social care is more urgent than ever. The PfG commitments on Primary Care demonstrates recognition of the critical role of Primary Care within wider health and social care delivery. Given this context, the importance of this group’s work to further Primary Care reform was emphasised. It will inform important and difficult choices regarding investment and delivery of better value in health and social care
• the aim of this meeting was outlined as a discussion on the refreshed vision and draft principles for integrated care. It was acknowledged that the discussions may feel abstract for some colleagues, but members were assured that future meetings will focus on discussing practical changes that can be made
• group members were also reassured that this group is also a place to influence the direction of National Care Service (NCS) and the approach to National Clinical Framework (NCF) by agreeing a common approach within primary and community health. To support this, it was noted that a number of colleagues from reform programmes across Scottish Government (SG) were supporting the meeting, so members views could feed into this wider context
• some apologies were noted, with deputies in attendance. No issues were raised regarding the minutes of the first meeting, which were therefore accepted as an accurate record. Actions from the second meeting had all been completed
• the second Co-Chair thanked everyone for taking part in the process and recognised the challenges
• the commitment to Primary Care (PC) Reform was recognised and it was stressed that group members feedback is very  to inform the iterative development of the policy discussion papers
• a request was issued for volunteers to continue the work on refining the vision and refreshing the outcomes and anyone interested was asked to get in touch with the secretariat
• the second Co-Chair indicated that the integration concept is not new and there is integration at at different levels and all of them shape the way in which services work together
• in the context of three key pieces of ongoing reform most relevant for Primary Care: the National Care Service (NCS), National Clinical Framework (NCF), and  Population Health Framework, we want to ensure that Primary Care support and align with these reform programmes; but also the core values and principles of PC help inform and shape  Health and Social Care reform, including the role of Community Health preventative care
• it was noted that this material had already been shared internally for feedback, but it is paramount we receive input from all corners of PC during this meeting to further shape it

Follow up discussion included the following points:

• concerns were raised whether the primary care reform can have a real impact in the context of financial challenges, parliamentary timeline and previous attempts to transform primary care. It was stressed that PfG is viewed as a real opportunity to create a realistic PC vision with this group. Progress has been made in terms of building the capacity of Primary Care but there is still more to do, and this group can be the collective space to take on the challenge. Some narrative emerging in England offers an honest appraisal of the situation.  This group similarly can be the space for acknowledging what's needed for change, where we can articulate what is required, or where things can't continue in the way that they are
• the aim for this group is to work in an open and constructive way on how we achieve sustainable long-term transformation in primary care. However, to achieve that we need to understand what is required in terms of prioritisation and investment decisions. By meeting in this wider forum, coordinated input can be provided to a complex policy landscape

Refreshed Primary Care Vision and Primary Care Principles for Integrated Care - Primary Care Strategy Unit

The presentation provided an update on how steering group member feedback was used to create the first draft of the refreshed primary care vision. It was highlighted that its development is iterative and there is a need to further refine the wording. The feedback from this meeting during the breakout room discussion and development of enablers will continue to inform how we refresh the vision.

The presentation provided an overview of the other health and social care reforms that primary care reform is closely interrelating with. To help guide this, some proposed integration principles for primary care were set out, alongside examples of their use to facilitate integration of wider reforms with primary care.

Discussion of this part of the meeting covered the following points:

• how to best enable engagement with users of primary care services during this work.  Officials noted that the work will continue to be informed by insights from service users from previous engagements, and suggestions from the group for forums to work with in this regard would be welcomed
• there was uncertainty around how the reform/Route Map for Primary Care aligns with the General Medical Services (GMS) contract.  It was highlighted that the Route Map and enablers of the reform are taking a wide view. Specific elements can and will be discussed separately with key stakeholders e.g. at General Medical Services Oversight Group and at the bilateral Scottish Government – Independent Contractor level. The Route Map for Primary Care is a collective aiming point for many elements of Primary Care reform including dental reform, optometry, general practice etc, but is not the only vehicle required – wider engagement and governance structures will continue to be key
• participants stressed the importance of being ambitious and recognised that the opportunity to help shape this work iteratively is essential

It was pointed that the scope of the NCS is not yet defined. It was suggested to use National Performance Framework as a collective aiming point. In respect to this point, it was highlighted that the NCS relates to elements of primary care. New ways of working are emerging, and integration and dialogue will be required, particularly to take account of delivery models within primary care and community health. The parameters and guiding principles around primary care were included in the NCS Bill.

It was confirmed that dialogue in this group will help to define what NCS means for primary care, not only in principle, but also in practice.

Practice in primary care and community health are shaping the NCS and what it is trying to achieve.

It was raised that the role of general practice specifically could be more strongly emphasised in this work.  It was stressed that while the attempt is to create something what speaks to a wide group of professionals across primary care, general practice, general practitioners and Multi-Disciplinary Teams (MDTs) are absolutely recognised as central to primary care and the health and social care system more broadly.

It was indicated that clarity is needed regards the generalist vs. specialist approach. In responding to this, members were welcomed to elaborate on this topic in breakout rooms.

There was an emphasis on recognising the pressures of workforce and financial position and to work and inspire people that primary care and what it delivers in communities is at the heart of the government's thinking.

It was emphasised that the Secretariat and the wider SG team remain available for dialogue outside of the meetings, either bilaterally or collectively.

Breakout groups

Members were then split into three breakout groups to consider the questions below, capturing key points on a mural board:

Question 1: What are the practical activities, either current or planned, which would support integrated care, both within the sector and with wider Health and Social Care services?

Question 2: Are there other key opportunities or risks to improving integrated care?

Question 3: What do these examples, opportunities and risks mean for the draft principles for integrated care? Do these need adjusting?

Question 4: Reflecting on the vision, are you content with the ‘key elements’ of the vision, and does the vision provide sufficient clarity on primary care’s role within the system? Are any other adjustments required?

A summary of main discussion points from each Breakout Room is included at Annex 1.

Overall Summary of Main Points 

Key points from the mural board were presented by the Primary Care Strategy Unit Head under thematic headings relevant to the discussion questions:

Practical examples to improve effective integration

• digitally led sharing of information, including digital prescribing
• direct improvement and promotion of interface pathways (mental health, community glaucoma services & low vision, and dental pathways as good examples of this)
• building on good relationships & culture (community optometry, nursing and pharmacy as examples of this)

• drawing on lessons from Getting It Right For Everyone (GIRFE) pathfinders
• MDT meetings, most important for complex cases
• role of general practice, generalist approach, continuity of care and relational care in enabling seamless care and the first point of contact
• role of specific institutions in enabling effective coordination – e.g. Health Improvement Scotland and Centre for Sustainable Development
• community link worker (CLW) role – driving interface between community and primary care
• pathways for referrals

Risks

• system inefficiencies, for example administrative burden, digital connectivity issues between systems
• siloed working and need to ensure we move out of these (within aspects of primary care and more broadly), governance, trust across system and building strong relationships
• infrastructure and financial resources constraints
• outcomes, standards & performance: focus tends to be on efficiency and processes rather than outcomes.  There is a lack of consistent view on quality
• workforce pressure and sustainability, including time, changes to working patterns and preferences
• imbalance in the system towards secondary/acute care
• lack of universal registration across independent contractors
• national versus local – differences across different areas

Opportunities

• primary care as an asset in the communities, including physical infrastructure already there
• reform offering opportunity to transform, including integration and prevention focus etc. Context of reforms in Scotland and across UK
• digital and data, including understanding population health needs
• workforce roles: valuing and leveraging different expertise in a more coordinated way, for example pharmacists as prescribers, role of receptionists, NHS work on volunteers
• patient voice, help with difficult choices and “challenging the status quo”
• self-management

Any Other Business

None raised.

Action Points and next meeting

Members asked for the invite to the next Steering Group meeting to be issued as soon as possible.

Annex 1 - Summary of breakout group discussions

Question 1 - What are the practical activities, either current or planned, which would support integrated care, both within the sector and with wider Health and Social Care services?

Group 1 

• out of hours services are working with the Scottish Ambulance Service to facilitate people getting to the right place
• continue funding of the Centre for Sustainable Delivery (CfSD)
• strengthen the relationship between primary care and the third sector to support prevention and maintaining/improving health

Group 2

• importance of digital integration was emphasised. Sharing information supports patient safety but also increases efficiency of operational aspects of day-to-day work e.g. time saving, e-prescribe, reduced administrative burden, efficient communication etc. it would support everyone feeling included as for instance dentistry may not feel as part of wider health and social care system
• change – if takes place it should be rolled across the whole system - not only in some parts
• communication issues especially visible if service is operating in cross cutting way e.g. community pharmacy perspective: out of hours – in hours, secondary – primary
• digital tools and consistency of processes; understanding each other roles across PC would support everyone
• NHS Greater Glasgow and Clyde optometry – glaucoma service used as a good example of when the change happens and digital access to patient information support patient’s journey; appetite for change needs be within teams to deliver
• others agreed it is a good example and to engage and connect better with clinicians one medical condition should be picked up e.g. diabetes and integrated care model rolled out across all 4 independent contractors and by implementation across the system everyone will see the benefits of truly integrated care
• the role of MDTs was emphasised
• differentiation across fourteen boards – does not support improvement of interfaces; a national support is needed even if that means mandating some aspects

Group 3

• optometry - three activities: shift for glaucoma care to community optometrists, intra referral to prescribing optometrists, and low vision services
• community link workers - ongoing review of the programme and commitment from Cab Sec for growth and expansion of that provision within general practice
• mental health pathways - work ongoing between Scottish Ambulance Service, the police, and NHS 24 on the service, with work to see how people are supported within general practice and within communities
• NHS developing a new system to support volunteers. Opportunities to see how that works for communities and general practice.
• NHS borders is developing a strategic plan for dentistry, the Oral Health Improvement Plan, to support integrated healthcare
• pharmacy- transformation framework around general practice with three horizons. There is important collaboration between pharmacy, nursing, and medicine for the transformation
• suggestion to see whether there are opportunities through patient pathways to support the integration of care
• suggestion that we need to look at the things that can make the system work better to enable us to perform better, in particular digital aspects
• suggestion that the Primary Care Phased Investment Programme involves representatives from all over Scotland
• suggestion that we need to think past the silos and find a ‘glue’ to hold everything together. There is also a need to see how the ideas translate practically

Question 2: Are there other key opportunities or risks to improving integrated care?

Group 1

• patients do not have a requirement to be registered with a dentist, therefore dentistry cannot be a first point of contact in primary care quite as easily as General Practice
• from 2026, all new pharmacists joining register will be Independent Prescribers (IPs). Real opportunity to harness expanded and additional capacity. Comes with the risk of programmes not being sufficiently remunerated to expand
• risk with visions in the past Has been that they have not been whole system focused

• primary care often has to manage or respond to effects of pressures elsewhere in the system
• opportunity to have a better understanding and insight into population health needs at locality level, with Public Health Scotland working with local partners to determine what is needed and can be used to shape services and workforce
• opportunity to invest in good expert medical generalist access with sufficient time to manage patient conditions, and this offers the best outcomes and value
• a risk is that few of these opportunities can be realised while general practice is still in firefighting mode. There should be real consideration of shifting funding balance back into primary care
• ‘Integration’ is quite abstract, whereas speaking about ‘pathways’ is more concrete and easier to understand for staff and patients. We can still use the word integration but what we are really discussing is ‘seamless pathways’

Group 2

• digital is a risk, but also an opportunity –  needs to be recognised as precursor for integration
• doing less and rather focus on better outcomes
• financial resources e.g. renumeration model may impact how service support MDTs
• factoring in different leavers across 4 independent contractors and boards
• how staff can reconcile that investing time may not bring benefit to your team but somewhere else in the system; how to get buy in for this approach
• sharing right level of information to avoid overwhelming front-line staff
• which roles do we invest in and how is the evidence built for these decisions 
• who is the right professional to support patient and how to incorporate patient experience into these decisions
• helping patients understand how the NHS/whole system can help

Group 3

• risk that there are too many projects going on at the same time, with few things being achieved. This leads to a question about how we can priorities the high value pieces
• risk around IT infrastructure- it is complex and not portable. Systems are in dire need of renewal. Also issues around practice management systems that do not interact between private businesses
• reform cannot rely on traditional siloed-based governance. There is also a risk around unclear governance, especially lack of oversight as a board
• risk around workforce due to increase in part-time working. Example: more optometrists are working part-time than full-time in Scotland and many 35-year-olds and under optometrists are working a four-day week
• risk around contractor framework: for instance, reducing workload can put viability into question for some providers
• opportunity around quality framework to refresh it and make it consistent to see how well we are doing across partnership services
• Once for Scotland - have an honest debate around it and see how it could be operationalised in the future
• areas of good practices: need to ensure they are resourced sufficiently and potentially scaled up
• opportunity to build more on co-production. Communities need to be included to make a real difference in what matters to them

Question 3: What do these examples, opportunities and risks mean for the draft principles for integrated care? Do these need adjusting?

Group 1

• access and equity need to sit at heart of principles, alongside capacity and capacity realisation. Additionally, a principle about joint responsibility for delivery and outcomes, and shared responsibility for identifying how we achieve that within the system
• continuity and relationship-based care is imperative to the best outcome for patient-centered care, including relational, informational, and pathway continuity
• data and information governance is crucial to achieving change. Removing barriers to sharing of appropriate information
• the principles provided are more a list of things we are planning to do/or broad categories of what we are doing. Principles are more about the manner in which we do things to address the big issues. Need to give people the headspace to address issues
• it is important the vision and principles support mutual respect and recognition between professional groups, care environments and citizens

Group 2

• principles are missing SU persecutive and are overwhelmingly service focused
• permission to teams in the system to do what works  best and not overly prescribe them
• in order for Integrated teams to work effectively we need to relax the grip on digital; trust and permission for others outside of GPs to also refer; focus on working well together
• principles need to be bolder, going beyond just nudging the system in the right direction
• digital first – as core principle and Patients needs alongside
• principles are needed not on planning but how the system works
• clarification needed whether discussed principles would apply across the wider health and social care reform
• continuity of care with the named person – proved to reduce harm etc
• the need to include in principles: relational care and practice and continuity of care is a key – otherwise we will create something which does not work; lack of trust among people/lack of understanding so we need support people to be safe; if no faith in the system - this makes people use the service differently
• duty and responsibility – every work stream should be encouraged to support patient; no wrong door to access the right pathway
• dentist – continuity of care is there alongside focus on preventions; Who do we see and when; what we are doing if going back to general practitioners for referral is not always solution for the patient
• culture of prevention in dentistry and optometry enshrined in the contracts and service model so good model to highlight more widely

Group 3

• emphasis that primary care will lead the shift towards preventative and proactive care
• including a level of granularity in the vision statement in the principles, to include things like socio-economic, geographical, and systemic barriers to care
• the vision and principles do not touch enough on the people and their experience. The relational approach should be reflected in the principles
• need better clarity of understanding of what these principles are about. E.g., what does the principle of ‘equitable care’ mean? What does that mean to professionals who are delivering the service? What does that mean to the public who receive the service?

Question 4: Reflecting on the vision, are you content with the ‘key elements’ of the vision, and does the vision provide sufficient

Group 1

• we need to mention continuity
• first paragraph can feel a bit superficial at first. Adequately funded and resourced’ might be stronger
• moving the whole system beyond ideas of 'better self-care' into concepts of PC operating more of a pull model based on normative need for priority conditions and shifting away from a push model of patients turning up whenever they feel a subjective need: instead turning to their own forms of support first. The health system instead having a role to pull in people with certain presentations and high-priority conditions

Group 2

• not just driving prevention, but the role is to promote, prevent and provide
• all people are informed and empowered suggests that we are trying to 'make' people self-manage. Might be better stated as 'shared responsibility' for health and care
• the Vision sounds as being 'done to' services users. It is about trust and it is about people having a sense of safety.
• language issue in the proposed refreshed vision - 3 paragraphs; in dentistry previously, there was a language focused on – securing and maintaining – but deliberately we were asked to shift to ” managing oral care”; SG policy decided it needs to be modernised to reflect some patients don’t want to engage with the treatment so maintaining is not possible. We cannot always maintain – patient may have information you give them but they have right to decide – patient autonomy
• inevitable changes recently were introduced to cope with the volume and capacity issues – how this shifted our focus?

Group 3

• discussion around including the idea that Primary care should be recognised and valued between participants - for some it is a given and it is not necessary to state that; for others, the valued part is important, especially for general practitioners because they feel undervalued
• need to include something around the continuity of care, especially as it is key to patient satisfaction. Need to put yourself in the patient’s space and think about all the touch points across primary care
• need some frameworks around the principles to monitor progress and key actions
• for whom are we writing this? Need to think about providers, but also about the people of Scotland, like people in our communities and people who will hold us accountable for the level of service and care
• the vision and principles are good, as long as we can start to qualify some of the inequalities and the role of digital and innovations.
• discussion around ‘user effort’ - the effort of transition between different channels or pathways. People who are consuming the services will be bothered about the value product proposition, rather than the vision statement. All envisaged reform must be readily navigable by those receiving and delivering services
• need to include more about what expectations people can have. Opportunity to do a communication piece around this, where we explain what the services are about and what we can offer to people 
• there is a need to look back and identify what has not worked. Would we be able to take an old vision and just slightly adjust it to then take it forward in the future? 
• a quality framework would really support us and direct investment and focus on things that we collectively feel are important