Primary and Community Health Steering Group minutes: November 2024

Attendees and apologies

• Co-Chair of Primary and Community Health Steering Group and Director of Primary Care Directorate, Scottish Government    
• Chief Allied Health Professions Officer, Scottish Government 
• Professional Nurse Adviser for Primary Care and Chief Nursing Officer representative, Scottish Government     
• Delivery Director, Preventative and Proactive Care Programme, Scottish Government        
• Head of Health and Social Care Analysis, Scottish Government         
• Director of Dentistry, NHS Borders  - deputy attended
• Director of Allied Health Professionals, NHS Fife
• 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        
• Executive Medical Director, NHS 24
• Chief Executive, Scottish Ambulance Service
• 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) 
• Chief Officer South Lanarkshire Health and Social Care Partnership (HSCP) and HSCP Chief Officers Representative       
• Nurse Director, Angus Health and Social Care Partnership     
• National Strategic Lead for Primary Care, Health and Social Care Scotland
• Interim Director, Primary/Community Care, Strategy, Performance & Service Transformation, National Services Scotland (NSS) - deputy attended
• Head of Digital Services in Practitioner Services Division, National Services Scotland (NSS) 
• Chief Executive, National Education for Scotland (NES) Attended
• Director of Place and Wellbeing, Public Health Scotland (PHS) - deputy attended
• Out of Hours (OOH) Oversight Group Representatives
• Chair, Royal College of General Practitioners Scotland (RCGP Scotland)  - deputy attended
• Associate Director, Royal College of Nurses (RCN) - deputy Attended
• Chair, Optometry Scotland
• CEO, Community Pharmacy Scotland
• Director for Scotland, Royal Pharmaceutical Society  - deputy attended
• General Practice Managers Network representative
• Chief Executive and Nurse Director, Queen's Nursing Institute Scotland
• Senior Officer of Development, The ALLIANCE
• Chief Executive, Voluntary Health Scotland 

Apologies

• Co-Chair of Primary and Community Health Steering Group and Deputy Chief Medical Officer, Scottish Government
• Director of National Centre for Remote and Rural Health and Care
• Director of Midwifery, NHS Western Isles
• NHS Board Digital Leads Group representative
• Head of Audiology Services, NHS Tayside and Board Member of the British Academy of Audiology
• Interim Director of Nursing and Systems Improvement, Healthcare Improvement Scotland (HIS)
• Director of Digital, National Education for Scotland (NES) 
• Chair, Scottish General Practitioners Committee of the British Medical Association (SGPC BMA)
• National Director, British Dental Association Scotland
• Professor of Medical Education, University of Glasgow and Co-Director of the Scottish School of Primary Care
• Professor of Health Economics, University of Glasgow

Items and actions

Housekeeping, Welcoming remarks and updates from the Co-Chair

The Co-Chair welcomed members to the fourth meeting and highlighted that this meeting moves members to the next stage of discussions around the “Route Map” for Primary Care, and identifying the practical changes needed to help realise the overall strategic direction that has been discussed so far.

The Co-Chair addressed wider issues of relevance to this meeting and noted apologies from the other Co-Chair and members and welcomed deputies. This included an update on the Scottish Government’s work and intention to ensure Primary Care reform is a central part of broader health and social care reform. It was highlighted that Ministers had recently set out to Parliament in the previous week the Scottish Government’s ongoing commitment to progressing a National Care Service (NCS), including via revised timings for the next stage of the NCS legislation, as quickly and efficiently as possible.

It was emphasised that the work of the steering group to develop the route map for primary care will be central to shaping and setting the agenda for how primary care intersects with wider public service reform.

The group provides a platform for members to connect and carefully work its way through the practical issues impacting on primary care and the opportunities for in primary care and community health.

The Co-Chair highlighted that the 2025/26 Scottish Government Budget will be presented to Parliament on Wednesday 4 December 2024. Primary Care is recognised as crucial to the health and social care (HSC) system and to HSC reform, and the budget will provide further context on government thinking in these respects. It was further highlighted that the deliberations of the steering group members are shaping officials’ advice to Scottish Ministers.

The draft minutes from the last meeting were approved and the Co-Chair confirmed that actions from the previous meeting had been completed.

The Co-Chair thanked members for their contributions on the draft refreshed Primary Care vision and the ‘principles for integrated care’ at the last steering group meeting, highlighting that the secretariat received and are incorporating a lot of extremely useful feedback, and that this reflects the strength and productivity of this group in shaping primary care and wider reform.

The Strategic Direction Sub-group had been formed to further consider the strategic direction for Primary Care, finalising the draft refreshed vision agreed by the steering group to ensure the vision is clear, accessible, fit for purpose for all areas of primary care, and aligned to wider reform.  The sub-group was scheduled to meet on 12 December 2024.

Presentation giving overview of papers and guidance on facilitated discussion – Primary Care Strategy Unit 

This highlighted to members that the outputs from the meeting will be used to identify practical priority actions that can be taken forward collectively in the final route map product. During this meeting, members were asked to consider how to strengthen drivers (previously referred to as ‘enablers’) to achieve the strategic direction for primary care. Following feedback from the Care and Wellbeing Portfolio, the enablers/enabling functions within the route map will be renamed as ‘drivers’ to support system cohesion and clarity.

During this meeting members were asked to discuss the first two drivers: ‘governance, contracts and planning’ and ‘innovation, best practice, learning and improvement’. Following members’ request, in addition to these two drivers, members will have the opportunity to discuss primary care and community health interactions in dedicated breakout rooms.

An overview of the draft timeline for finalising the strategic direction and primary care reform Route Map was provided, highlighting that the Strategic Direction Sub-Group will meet on 12 December 2024 to start finalising the strategic direction and primary care outcomes.

It was recognised that, in discussing practical actions for change, there is a lot of excellent work already ongoing around many or all of the driver areas and there is also a need to engage more broadly beyond this group in order to generate fresh ideas. The Scottish Government’s Primary Care Strategy Unit indicated that they are very keen to work with members to identify opportunities to engage further with the primary care workforce and those receiving primary care services.

An overview of the emerging strategic direction for primary care was provided, linked to the Cabinet Secretary’s vision for health and social care.

The primary care and community health interactions discussion group were asked to discuss the opportunities for strengthening the relationships between these two overlapping sectors and consider interactions that are already in place that support integrated services.

The innovation, best practice, learning and improvement discussion group was asked to explore how to support continuous improvement and shared learning for primary care, consider how it currently operates and how we can improve it.

The paper supporting this breakout group drew from the Healthcare Improvement Scotland (HIS) Quality Management System (QMS), and an overview of the proposed overall approach was provided, stating that implementation of the core elements of the QMS should be:

• supported by national and local mechanisms, and leadership
• systematically and proportionately applied across and within services
• established, owned and driven by those delivering services
• person-led
• aligned with strategic priorities for Primary Care, as part of a whole systems policy framework:  visible and connected to the wider system

The governance, planning and contracts group were asked to discuss how to strengthen existing structures and accountability mechanisms for primary care and community health, with the overall approach being:

• primary Care’s strategic direction – by which we mean the refreshed vision and outcomes - need to be embedded at the heart of service planning; with appropriate governance structures enabling clear lines of accountability which support reform, and are strongly aligned to quality, improvement and outcomes in line with local population needs
• primary care governance needs to link appropriately across the whole system - recognising its cross-system role, and the need for primary care to sit at the heart of the HSC system. This will require and provide infrastructure for whole system integrated planning and delivery governance as set out above – and thus primary care should be a core part of planning, delivery and governance in wider reform, including National Clinical Framework (NCF) and NCS plans
• contracts and other arrangements should support a strong, sustainable independent contractor landscape also aligned to Primary Care priorities

Breakout groups

Members split into three breakout groups with a dedicated facilitator. The facilitator guided the conversation in line with the questions below, with the secretariat capturing key points on a mural board and Microsoft PowerPoint slide for feedback:

1. what is in place currently that supports the approach proposed in the community health/improvement/governance paper? 
2. what makes it difficult to support the approach set out in the community health/ improvement/ governance paper, now or in the past?
3. what are the practical actions we can take to better support this approach? Consider opportunities we can leverage and other actions to take. 
4. reflecting on this conversation, do you agree with the overall approach proposed in the community health/ improvement/ governance paper? Does it need to be altered or added to?  

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

Feedback from breakout rooms and discussion – Primary Care Directorate Officials

Officials from the Scottish Government’s Primary Care Directorate provided a short summary of the discussions from each breakout group.

Main Points presented during the meeting included:

Governance, Planning & Contracts

• known arrangements provide stability – an understanding of what the contractual parameters are in which we are working and where roles and responsibilities sit
• willingness in system to work better together and do things differently – challenge to get the system to catch up with people’s temperaments
• care navigation – not enough discussion between different Groups and providing platforms to do so around care navigation
• digital: would be nice to have system that gives real-time information on system capacity, in line with what secondary care use.
• current system not built for reform – need a much more responsive system to enable transformation
• assurance and accountability – don’t have external assurance for all four contractors groups like other UK nations
• declutter landscape to provide clarity and accountability
• interface working
• creating space for collaboration and joint working

Primary Care and Community Health Interactions

• there is good practice currently around Integration Authorities (IAs)
• MDT Model – can it be expanded upon beyond what is currently in place?
• community mental health – critical part of Primary Care
• community health is wider than simply NHS
• silo working due to locality - how can this be improved and enhance
• how can best practice be shared and celebrated?
• introduction of single digital record
• consideration of governance/ commissioning arrangements and if they need to be refreshed.
• how can we bring the patient into integration principles?

Innovation, best practice, learning and improvement

• people are the biggest asset:
  • need time, backfilled posts, protected time
  • time to build partnerships, continuity of professional relationships
• value of independence and agility of independent contractors (ICs), allows for more innovation and responsiveness
• pockets of innovation and good practice – need to make more visible and connected, and reduce variation in improvement and innovation
• need to increase focus on outcomes, rather than service delivery
• data: example of unscheduled care data – following patient journey, improving ethnicity data, better support for using local population data.
• improved PC partnership for improvement – e.g. multidisciplinary clusters, 'PC Contract', 'amplifying voices, not diminishing voices'
• need to support people to take risks and 'fail fast' - system does not reward failure
• digital – need for shared patient record, using digital to tap into professional experience
• need to amplify value of PC to the whole system, however 'bedrock' term can be problematic

 A summary of each group’s discussion can be found in Annex 1.

Plenary Discussion

• a single patient record has been identified by many parts of the HSC system. A request was made that we reframe thoughts about the technical difficulties of delivering it and rather think about what can be delivered or achieved over the next two years
• it is important that people's (patients) experiences, views and perspectives are integrated into the drivers, and that these views inform improvement activity, all of which could help to ensure we are focused on achieving the outcomes

Annex 1 - Breakout rooms discussion summary

Question 1 – What is in place (within service, local or nationally) currently that supports the overall approach set out in the paper (consider service/local/national)?

Room 1 - Governance, Planning and Contracts

• existing arrangements provide a degree of stability – provide an understanding of the contractual parameters that we work within and where roles and responsibilities sit
• Scottish Government oversee most elements of central primary care investment
• local systems can devise and develop Primary Care Improvement Plans (PCIPs) and discuss locally with partners what is needed
• an insightful system is in place where there are opportunities for increased efficiency and improvement including improving understanding of local need and circumstances
• governance of patients’ pathways: Some mapping out of practice boundaries given as example and what areas are covered so there is a central overview of what different contracts cover geographically
• good working arrangements in many places locally: for example, direct referrals from optometry for e.g. where third party is not required, and responsibility is clearer so you can measure the activity better
• willingness in system to work better together and do things differently
• roles and extended roles in primary care and community health have been enabled through contractual arrangements: opportunity for doing more here

Room 2 – Primary Care and Community Health Interactions

• primary care mental health, in particular nursing, is an effective point of contact. In some places, it works very well, holding that space between PC and mental health
• development of Integration Authorities are a good example and enabler of integrated working and can be developed. Important to continue bringing in local communities’ voices into these processes
• opportunities to maximise on multidisciplinary team working and community link worker programme

Room 3 – Innovation, best practice, learning and improvement

• each health board has a pharmacy services plan looking at demographics, current services and what might need to be included in service planning. An opportunity to work on those to fully integrate them with planning around services
• using existing data can be powerful to drive and inform transformation. Health and Care Experience Survey (HACE): Scottish Government fund and deliver HACE and is available at general practice level and are currently planning for next two-year cycle. An opportunity for secondary analysis of that data at the local level. Interested to know how we can optimise HACE and make it more useful to people
• strong values-based frameworks (for example) Realistic Medicine combined with the reflexivity of independent contractors. We’re starting to see much more joined up thinking and person-led and person-centred approaches locally and nationally with respect to 24/7 primary care provision. Best opportunity and best value should be collective focus. Pharmaceutical Care Services Plan: looks at what services can be developed locally, allowing and supporting services that meet the local population, but it introduces variation across the system. Pockets of great service can emerge which are difficult to spread nationally

Question 2:  What is missing or what makes it difficult to support the overall approach set out?  What would you/your area/your service do differently if you could?

Room 1 – Governance, Planning and Contracts

• care navigation – not enough discussion between different professionals and services and there is a need for a platform to enable cross-boundary care navigation
• understanding of the ‘bigger picture’/wider system: we need to enable primary care providers to know their place within the wider system (beyond the boundaries of their service/responsibilities) and within the wider vision/ambition for health and care
• permissiveness of dental contracts: Independent Contractors decide for themselves their balance of NHS care versus private care, which Territorial Boards have to respond to
• governance framework does not support whole system transformation
• lack of external assurance and accountability for all four Independent Contractors as is present in other UK nations and this undermines public confidence
• PCIPs have limitations: They had specific focus and specific limitations, and care is needed when thinking about how we can utilise PCIPs differently going forward
• language of governance: governance can mean different things in different places and different things to different people

Room 2 - Primary Care and Community Health Interactions

• challenge of integrating across private businesses (i.e. Independent Contractors): Need to include Independent Contractors early on when discussing changes. Different models are challenging
• data available to Integrated Joint Boards (IJBs): challenges for IJBs accessing the range of performance data needed to plan and integrate effectively. Additionally, there are variations throughout Scotland in delivery models and in the associated performance management and quality management data
• insufficient awareness and understanding across the wider community sector or HSC system of different roles within primary care  and community health: examples given of community links workers and pharmacists in general practice, and the role of occupational health in addiction, mental health, and social prescribing

Room 3 – Innovation, best practice, learning and improvement

• sharing of good practice and innovation: Appraisers capture a lot of innovation at practice level, but it’s not shared. Innovative practice needs to be captured and shared, while acknowledging resource and capacity is required to embed it
• creating capacity for improvement: need to identify what we stop doing, what we start, and what we continue, to free up capacity for work such as quality improvement and multiprofessional/interdisciplinary learning across primary care
• risk appetite for innovation: the system rewards doing the same things and does not incentivise or encourage taking risks in pursuit of innovation and change
• agility of systems, services and people: the system is not configured to facilitate or enable effective change. For example: a range of common conditions are now being managed through prescribing within community pharmacies, but pharmacists do not have access to patient records and are basing decisions and managing risk on the information patients provide
• primary care contracts: Urban and rural communities face different challenges and the uniformity of primary care contracts operating across these different contexts restricts the innovation that is necessary to respond to the particular needs of different communities

Question 3 – What are the practical actions we can take to better support this overall approach? Consider opportunities we can leverage and other actions to take.     

Room 1 - Governance, Planning and Contracts

• broadening of PCIPs need to be encompass all of primary care and the role and work of the full sector
• streamlining and clarifying governance landscape: Need to declutter and streamline governance and approvals processes and provide clarity on responsibilities and accountability, which can could improve interface working. Need to recognise the existing structure provides stability and enables change to an extent and simultaneously limits how much change can be created

• digital systems: It is challenging to work across organisational boundaries, so we need to facilitate collaboration by introducing shared patient records and other systems into primary care such as Datix and OPAL

• focus on understanding and developing pathways into and out of primary care and the connections with the wider system
• creating capacity for personal development: Consistent personal learning time (PLT) and support arrangements for more extended team to come together to learn and develop
• need physical and virtual spaces for cross-primary care learning and development. There are contractual barriers to services closing together and a stand-in service to support patients during this time – need to understand the national picture of local hours of service schemes
• developing understanding of where one sits within the wider system: Independent Contractors need to feel like part of the system, understand the wider system and not just their own remit

Room 2 – Primary Care and Community Health Interactions

• utilising volunteers and health coaches to do things differently and work in more contemporary ways, underpinned and assured by governance and robust systems
• sharing best practice and innovation Need a platform and opportunities for sharing of the good practice and innovation that is taking place across Scotland that people do not hear about
• create the conditions to build in ‘fail-safes’ into patient care pathways and the interrelationships required to provide robust pathways for those accessing services: Give people space (including co-location), time, multidisciplinary conversations about patient’s with complex needs/multimorbidity, a single shared patient record and use of systems such as ALISS, in tandem with care navigation role, right decision services, and the referral help that GPs use – minimising reliance on a single care provider who might be off work on a particular day
• use of governance framework to encourage and enable collaboration and hold people/organization accountable to achieve policy objectives
• provide clarity on responsibilities and what people have permission to do
• need to focus on functions, not individual services: Risk of lots of vertical planning and vertical services. We need more horizontal approaches to delivering care, and design it around the person
• community appointment days are evaluating well and very person-centred: whilst initially around MSK waits - can be transferred into other specialties with planning and thought
• consider moving beyond designing approaches around ‘professions’: Community Treatment and Care (CTAC) and pharmacotherapy on general medical services are good case studies, it was professional defined which created a coherent argument about how ‘it was not my job’

Room 3 – Innovation, best practice, learning and improvement

• demand mapping, understanding scale of the problem: You could then build in redundancies form a planning perspective
• data and digital: A single shared digital record and digital prescribing and dispensing needed. A Once for Scotland approach to digital
• democratization of professional roles - Especially the way Scotland is configured. If you want to tap into workforce, you could add value across the country
• promoting cross-service/inter-professional improvement: Inviting other providers of primary care into clusters to work collaboratively across the different professional groups. If we had parity across the professions, we could make greater progress
• resource and capacity to enable personal/individual and inter-service/inter-professional learning and development: development time is often deprioritised with work pressures. In community pharmacy, the contract requires core opening hours and with more members of the public accessing care from community pharmacies, therefore moments of "downtime" for improvement work is under pressure, and very little opportunity to plan for that

Question 4: Reflecting on this conversation, do we think the overall approach set out is sufficient, does it need to be tweaked or added to? 

Room 1 - Governance, Planning and Contracts

• language: The wording that Primary Care is at the heart of the system is too conceptual and does not support developing integrated whole HSC system – one part of the system not better than another 
• national contracts: How can the significant differences across the country (rural, health inequalities etc.) can be accounted for efficiently in a single national contract? Little progress made in rural areas was acknowledged. EQIA should be used better to understand disparities across the country

Room 2 – Primary Care and Community Health Interactions

• behavioural changes are required for change within the system to be maintained. Engagement to identify the gaps: need to hear more experiences from the system about how it is currently disjointed
• integration principles need to reflect the patient
• there is a complete gap between national policy and what is possible to implement on the ground. Need to lay out what will happen and how does this enable things on the ground? From a third sector point of view, health and social care partnerships are in difficulties. Try to future proof and enabling this to be possible. Hand holding through that process
• focus on addressing health inequalities
• case study of existing IJBs and integration schemes to commission against outcomes: identify the successes of integration and a stronger focus on how to integrate effectively

Room 3 – Innovation, best practice, learning and improvement

• strengthening the role and recognition of all primary care professionals: working together as one primary care sector and amplifying the value and contribution of others
• limitations of current contracts: Consider if/how all services could be brought under a single contract. There are limitations right now about being a dispensing practice. If they were all under one contract as Primary Care, it could change the way people look at services
• highlighting the value of primary care: the value proposition for primary care is critical to the operation and delivery of the whole system
• career choices: difficulties of getting people to choose general practice as a career leads to increased occurrence of inverse care law, as people do not want to be a GP in deprived areas due to workload
• local population data: support teams to access, interpret and utilise this, and improve aspects of data collection e.g. on ethnicity.
• digital literacy: a recognised determinant of health outcomes, need to understand the national picture on this