Primary Care Improvement Plans

Summary of Implementation Progress at March 2024

1. Introduction

This management information publication provides a national summary of the progress towards implementation of the Memorandum of Understanding (“MoU”: see section 3 for more information). It covers the period up to the end of March 2024 and is based on data provided by Integration Authorities (IAs) in May 2024. It updates the information published in June 2023. The data at IA/NHS Board level is available in the spreadsheet accompanying this publication.

2. Data quality

The data included in this report is provided by IAs. Workforce numbers come from local systems. These systems are dynamic and primarily used for operational purposes. As the data can change over time, the figures presented here are the best available estimates. The Scottish Government is working with IAs to improve data quality. Therefore, previously published information may change to reflect these refinements.

The publication contains data on two broad areas: workforce numbers and access to NHS Board provided services.

Information on staff funded by the Primary Care Improvement Fund and also other sources was collected, which is the same approach as was taken with last year’s collection. This has improved understanding of the wider workforce providing services. For this collection, the only change from 2023, is that we have separated the “Occupational Therapy” role within “Additional Professional Roles”. This should allow greater clarity over the number of these staff, but should not affect overall workforce total as these should have previously been included elsewhere.

As with the last collection, we have asked only if practices have access to health board provided services. As a result, these figures include access from minimal access to full access and any interpretation should take account of this. Scottish Government continues to work with IAs to improve our understanding of levels of access to services, by enhancing data collection on service capacity and delivery models.

3. Background

The 2018 GMS Contract Offer (“the Contract Offer”) and its associated Memorandum of Understanding (“MoU”) between the Scottish Government (SG), the Scottish General Practitioners Committee of the British Medical Association (SGPC), Integration Authorities (IAs) and NHS Boards was a landmark in the reform of primary care in Scotland. The Contract Offer refocused the General Practitioner (GP) role as expert medical generalists. This enabled General Practitioners to do the job they train to do and deliver better care for patients. The Contract Offer committed to a vision placing general practice at the heart of the healthcare system. This vision sees multidisciplinary teams (MDT) inform, empower and deliver services to communities in need. To support these aims, it set out the intent to redistribute non-expert medical generalist workload to the wider primary care MDT. This aims to ensure that patients can benefit from a wider range of expert advice, receiving high quality care. It recognised the statutory role of IAs in commissioning primary care services and service redesign to support the role of the GP as an expert medical generalist. It also recognised the role of NHS Boards in service delivery and as NHS staff employers, and parties to General Medical Services (GMS) contract.

The MoU set out the six priority service areas where IAs, in partnership with Health Boards and GPs, would focus for service redesign and expansion of the MDT: 

• Vaccination Transformation Programme (VTP); 

• Pharmacotherapy; 

• Community Treatment and Care Services (CTAC); 

• Urgent Care; 

• Additional Professional Roles; 

• Community Link Workers (CLW). 

In 2021 the MoU was refreshed (the MoU2) to cover the period 2021-2023. It reaffirmed the commitment to expanding and enhancing multidisciplinary teams to help support the role of GPs as expert medical generalists and to improve patient outcomes. The MoU parties recognised a great deal had been achieved while acknowledging there was still a way to go to fully deliver the GMS Contract Offer commitments. In particular, the MoU noted a focus on three services - Vaccination Transformation Programme, Pharmacotherapy and CTAC. Regulations have since been amended to place a legal responsibility on Health Boards to provide Pharmacotherapy and CTAC services to general practices and their patients, alongside Health Boards’ responsibility for the provision of vaccinations services.

In September 2023, in a communication to all MoU parties, the Scottish Government restated the commitment to MoU implementation and enhancing and expanding the MDT. It recognised that good progress had been made, while acknowledging that implementation gaps remained. It detailed the intention to take a twin-track approach over the following 18 months. This would comprise of the introduction of an additional phased investment programme, supported by additional funding, working with a small number of areas, at different stages of implementation, and from different settings. This aimed to demonstrate what a model of full implementation can look like in practice. It noted that the learning from the programme would be used to inform long-term Scottish Government investment in the MDT. It also set out the intent to continue to work with all areas to support improvement of the MDT within the existing funding envelope.

In February 2024, the Scottish Government confirmed that, following conclusion of the bidding process, the sites chosen as demonstrator areas are Ayrshire and Arran, Edinburgh City, Scottish Borders and Shetland. The site teams will work closely with Healthcare Improvement Scotland (HIS) to use improvement methodologies to more fully implement Pharmacotherapy and CTAC services locally. They will also aim to understand the impact for people, the workforce and the healthcare system. HIS have established a national Primary Care Improvement Collaborative which will support local teams outwith the demonstrator sites to implement quality improvement approaches in pharmacotherapy and CTAC services and in access to primary care services. 

Funding to support the implementation of the MoU has been allocated to IAs through the Primary Care Improvement Fund (PCIF). Locally agreed Primary Care Improvement Plans (PCIPs) covering all 31 IAs in Scotland have been developed and implemented since July 2018. The PCIPs set out in more detail how implementation of the six priority service areas will be achieved. IAs are required to provide annual updates on their PCIPs. These updates are supplied via an agreed standard tracker template, with a focus on workforce and access data.

The delivery of primary care transformation is occurring within a complex local landscape. IAs must work closely with local communities and stakeholders to ensure that PCIPs address specific local challenges and population need. They must also agree where the local priorities lie for the services being reformed. As a result of this, there is geographical variation in service design and delivery models.

4. Workforce numbers

Table 1 shows the number of whole time equivalent (WTE) staff working to support implementation of the six MOU agreed priority services.

The data shows 4,925.1 WTE staff working in the MOU services in March 2024. Of these, 3540.4 were funded by the Primary Care Improvement Fund and 1,384.8 were funded through other sources.

There was an overall increase of 196.4 WTE staff between March 2023 and March 2024. This represents an increase of 310.4 funded through the Primary Care Improvement Fund and a fall of 113.9 funded through other sources.

Increases in workforce may represent progress towards delivery of the MoU. However, there is no agreed target for specific service or total workforce levels required across Scotland.

It should also be recognised that there may be variation in appropriate staffing numbers depending on the clinical model developed, the skills mix of the workforce and local population needs.

Table 1: Number of Staff: Scotland - Whole time equivalent at 31 March

5. NHS Board provided services

NHS Boards are placing the additional primary care staff described in section 4 in general practices and the community. Here they can work alongside GPs and practice teams to deliver an increased range of services, in accordance with the MoU. In doing so, they can support the expert medical generalist model and improve patient care. While some of these services and sub-services represent new areas of activity, in most cases, these had historically been provided by individual general practices. Chart 1 illustrates the percentage of general practices whose patients can now access these services directly from their NHS Board. The data relating to this chart can be found in the spreadsheet which accompanies this publication.

It is not expected that all general practices in Scotland will take up these NHS Board provided services. Since service delivery models are designed specifically according to local population needs, there are variations in approach across the country. For example, there may be some general practices where there is no defined need for a particular professional role. These services may therefore never reach 100 per cent coverage. There may also be local circumstances where local Primary Care Improvement Programme Boards determine it is necessary for one or more local general practices to continue delivering one or more services intended to transfer to board-employed MDT under the MoU.

Between 83 and 98 percent of practices have access to different level 1 pharmacotherapy subservices as at March 2024. Between 64 to 94 percent of practices have access to level 2 pharmacotherapy subservices, and between 52 and 82 percent of practices have access to level 3 pharmacotherapy subservices.

For CTAC services as at March 2024, 86 percent of practices have access to Phlebotomy, 61 percent of practices have access to Chronic Disease Monitoring. Ninety percent of practices had access to Other CTAC services.

The roll out of the Vaccination Transformation Programme is well advanced. Ninety-nine percent of practices have access to school age, pregnancy, pre-school, out of schedule, adult immunisations and adult flu vaccinations. Travel vaccinations are accessed by 98 percent of practices.

Of NHS Board-provided urgent care services, 26 percent of practices have access to services delivered in-practice and 36 percent of practices have access to external services.

Eighty percent of practices have access to a Community Link Worker. However, CLW services are not intended to be universal but should, primarily, be targeted where there is greatest need, in line with deprivation and health inequalities.

Additional professional services include physiotherapy, mental health workers, and occupational therapists. Sixty-one percent of practices have access to a musculoskeletal physiotherapist, 84 percent of practices have access to a mental health worker, and 10% of practices have access to an occupational therapist.