Shaping the Future Together: Remote and Rural General Practice Working Group report

PART TWO

Primary Care Improvement Plans: Innovation and Implementation

Primary Care Improvement Plans

The Memorandum of Understanding (MoU) establishes a national governance framework in which Health and Social Care Partnerships must, based on their statutory role (set out in the Public Bodies (Joint Working) (Scotland) Act 2014), and working collaboratively with Health Boards as contractors of GP Practices, commission primary care services and service redesign to support the role of the GP as an expert medical generalist. This MoU was agreed by the Scottish Government, BMA, Health Boards and HSCPs in November 2017 and finalised and published in April 2018 alongside the 2018 GP Contract Offer.

Chief Officers’ views on implementation Part 1 – Implementation Enablers

In May 2019 the Rural Group agreed to canvass Chief Officers for their views in relation to the implementation of the new Contract. This work was led by Pam Dudek, CO for Moray HSCP. In the feedback received, Chief Officers raised risks with Contract implementation that link to:

• Funding
• Workforce including recruitment challenges
• Premises in terms of space to accommodate the new and expanding teams alongside wider infrastructure requirements that would support the changing working environment.
• The TUPE aspect was raised as a concern, as this has not been found to be

straight forward, and so some national support around this may be helpful to consider.

These areas of risk are being considered and monitored through the recent refresh of the PCIPs and local mechanisms of monitoring via the GP Cluster Groups, GP Subcommittees and Local Medical Committees alongside formal sign off by the IJBs. These risks are not unique to the GMS Contract and form the bedrock of the case for change in Scotland as set out in the Christie Commission 2011, noting the workforce and funding pressures versus demand from the demographic profile of Scotland over the following 20-30 years period.

There was an overwhelming belief that the process of implementation was underway and that this was very much coherent with the wider redesign being pursued through integration. Generally. the local experience was positive in terms of ambition albeit considering the inherent risks already noted. The process of development of PCIPs appears to have been viewed as positive and a good lever for dialogue and change locally.

The MoU sets out the Scottish Government’s commitment to increase funding in direct support of general practice annually each year up to £250 million by 2021-22, distributed to HSCPs via the Scottish Resource Allocation formula (often referred to as the NRAC formula as it was developed by the NHS Scotland Resource Allocation Committee) for the specific purpose of delivering PCIPs.

The National GMS Oversight Group is the main oversight Group established by the MoU. It is chaired by the Director for Community Health and Social Care and meets quarterly with representatives from the SGPC, HSCPs and NHS Boards, as the MOU signatories, to oversee implementation of Primary Care Improvement Plans.

The MoU commits HSCPs and Health Boards to produce PCIPs that demonstrate how the funding will enable the redistribution of work from GPs to others and to optimise the role and functionality of the wider MDT. HSCPs are expected to refresh and reconfirm continuing local agreement for PCIPs in April each year, with revised plans – setting out progress achieved in the previous period and providing updates on expected progress for the year ahead - shared with the Scottish Government. HSCPs must agree their PCIPs in collaboration with local GPs through Health Boards and their GP subcommittees of the Area Medical Committee. Primary Care Improvement Plans should state clearly whether they have been signed off by the MoU partners.

The Group’s remit is to support implementation of the new Contract in remote, rural and island communities. We have been working closely with the Scottish Government Primary Care Team to understand how PCIPs for rural areas are developing compared to the national picture. Our first group of recommendations are intended to support rural PCIPs to increase the pace of change, safely and sustainably, and in better recognition of the rural GP role.

Across Scotland, we have seen and heard many examples of areas taking an innovative approach to implementing these services. We sought to record these experiences and one of our early successes was to work with iHub Scotland to create a platform for promoting these as Case Studies of creative, effective ways to deliver the MoU services. GPs are working with their local teams, Boards and HSCPs to scale up creative solutions that may have been in place for some time or become the early adopters of new ideas. We have seen first-hand the ethos of rural exceptionalism in action. Our recommendation to develop a National Centre for Remote and Rural Health and Social Care (Recommendation 5) is based in part, on realising the benefits of gathering and sharing these ideas.

Analysis of the PCIPs indicates there has been a clear acceleration of both the pace and the scale of the development of primary care multidisciplinary teams of health and care professionals across all areas of Scotland since 2018, and a step change in the nature of clinical leadership in the GP profession in co-designing reform. This is testament to strong partnership working across service commissioners and providers.

Pharmacotherapy appears to be the most progressed across all plans, and where positive impact is being felt by GPs. Positive progress is also underway around planning and implementing mental health support and recruiting community links workers. Particular challenges have been evident with the Vaccination Transformation Programme, Community Care and Treatment Services and Urgent Care Services.

Across all plans there are several commonly cited barriers impeding implementation, and where solutions have been developed to overcome them there has been quicker and more effective progress:

• Workforce - The supply of skilled qualified staff remains the biggest single obstacle to implementation. Some areas are working to address this through models that optimise skills mix and test a range of digital solutions. While an increase in the workforce is clearly needed, there is also considerable potential to be unlocked by maximising the skills of the existing workforce. We address this in the second and ninth recommendations.
• Digital and physical infrastructure - There is an urgent need for reliable, interoperable and remote access IT and appropriate hardware to support rapidly expanding services and teams who may need to work remotely. IT systems across primary and social care need to support multidisciplinary working. The Scottish Government is establishing a primary care digital programme board to improve governance.It is necessary to develop the NHS estate, including GP practices, to support the shift in the balance of care into the community and facilitate the expansion of Multi-Disciplinary Teams The existing model of GP premises ownership posed a risk to the sustainability of general practice. As part of the new Contract, a GP Premises Sustainability Fund was established to address this through loans to practices which own their premises and a process for practices to transfer their leases to Boards. In addition, further consideration is needed about what support is being offered to upgrade premises where they are owned by Health Boards. Digital and physical infrastructure issues are addressed in the sixth and seventh recommendations.

• Change management capacity - change does not happen by itself. It is an incremental process and requires a supportive infrastructure which needs to include commitment, money, time, strong leadership and a clear pathway to change, together with evidence of impact. Planning for change needs the time and involvement of staff who are already delivering services and are stretched due to workload pressures. This requires major shifts in values, relationships and care systems.

Health and Social Care Partnerships and the GMS National Oversight Group have asked the Scottish Government to consider whether further change management support could be provided to assist with implementation, and the Rural Group is contributing its views to that developing work. We address this in the eighth recommendation.

Progress in Remote, Rural and Island Communities

Broadly these same barriers and enablers are evident across remote and rural areas of Scotland, although many areas note challenges relating to their geographical situation – including problems relating to recruitment and dis-economies of scale when setting up MDTs. Colleagues in NHS Highland and North Highland Health and Social Care Partnership noted particular risks around equity for all practices, and that geographical challenges mean that a single model is not achievable in all MoU areas.

Pharmacotherapy, Additional Professional Roles, Community Link Workers

The MoU sets out the services to be transferred to Health Boards. There are professional roles naturally associated with those services, such as musculoskeletal provision by physiotherapists in first-point-of-contact roles. Across our engagement, we found support for recognising the importance of considering a wide range of roles with the aim of providing expertise that enhances the already extended skill set of the Rural Primary Care Team. The concept of “Generalists Delivering Specialist Services” might be a useful way of considering the roles and further potential of Rural Primary Care Teams.

External advice and support should be readily available to the teams, with clear pathways to access support. The external MDT team may include:

• Hospital Consultants
• Specialist Nurses
• Access to experienced nurses and AHPs in geographically distant teams
• Pharmacists
• Physiotherapists
• Community Mental Health Teams
• Community Link Workers
• Occupational Therapy
• Health Visitors

The level of involvement of the external MDT could vary, depending on the size and location of the Rural Primary Care Team.

The challenge is to plan these services around existing and expected workforce capacity and doing so in a sensible way that recognises where factors such as long travel times across rural areas will risk impacting on the availability and quality of the service for patients. For example, a small island team, or a team working across a large dispersed area, might get little in terms of visiting specialist MDT services, but may utilise their specialist input to clinical care and specialist advice through remote access working, telephone conversations or video consultations.

Rural case study: GP Near Me

We have seen effective examples of this approach for Pharmacotherapy services in rural areas. Video consulting is being used by the primary care team in NHS Highland to improve access to care.

Under the Highland Near Me model, a GP practice has its own virtual waiting area. Patients enter the virtual waiting room via a “start video call” button on the practice’s website. They are then held in the virtual waiting room until a clinician connects their call. Multiple clinicians can consult simultaneously, mirroring a physical waiting room in the practice.

The virtual consulting model was first tested by the NHS Highland rural pharmacy team. In a Health Foundation funded project, they demonstrated that not only was it possible to provide medication reviews for patients remotely but that patients actively preferred it, because they could attend the consultation from home/work rather than travel to the practice.

That learning led to further testing with GPs and practice nurses, plus members of the wider primary care team including community mental health workers, physiotherapy and a health visitor. There are currently 10 practices in NHS Highland involved, and it is expected to be extended further.

Access to care is improved in two ways: patients can attend appointments remotely by video, and clinicians can work remotely from a GP practice. For patients, this is useful for people who are at work, find it difficult to travel due to physical or mental health, have caring responsibilities or transport barriers. For clinicians, remote consulting can improve availability of visiting clinicians, improve sustainability of practices, and improve work-life balance for clinicians by cutting travel or enabling home-working.

However, the challenge with Near Me is remote access to clinical information. The video consulting is the easy part, ensuring the clinician has full read-write access to all appropriate information can be more difficult.

Dr Neil Houston, one of the GPs involved in testing Near Me in primary care, said: “Being able to see a patient in their own environment gave me a much deeper understanding of their situation than during a telephone call or in the GP Practice. This was particularly striking when video consulting with a new parent who was struggling to cope: I saw her distress more clearly and built a closer rapport with her because I could see her in her own home.”

Remote consulting is not a panacea. There will always be a need to see some patients in person. But it is a positive solution for improving access to care. The Group recognises the benefits of supporting these innovative approaches. The Group approved an investment of £200,000 from the 2019/20 Primary Care Rural Fund to support the deployment of Attend Anywhere to remote and rural practices. Innovative digital solutions that enable opportunities for remote care, training and collaborative working should be embraced at all levels of implementation. We also address this in Recommendation 6.

This is one of many possible ways to use creative MDT roles to effectively support remote and rural general practice.

“In Dumfries and Galloway, we have been able to embed Primary Care Mental Health Nurse (PCMHN) sessions within each GP practice within a relatively short space of time. This was not without teething problems, however, feedback now that the nurses are in post is extremely positive.”

– Justina Ritchie, Lead Nurse CMHN, NHS Dumfries and Galloway

Rural case study: Pharmacotherapy in NHS Dumfries and Galloway

Another creative approach to using MDT roles is being used in NHS Dumfries & Galloway. The HSCP area covers a large geographic area, with three main towns and a large community dispersed across 23 settlements with populations of 4500 or less. The area is supported by a central hospital and a Community and some Cottage Hospitals. Workforce challenges and long travel times for centrally based MDTs created a sustainability risk for the new service, and there was an additional concern that recruiting to new Pharmacotherapy roles would risk destabilising existing services in secondary and community care.

To address these challenges, the Board developed an innovative recruitment plan based on creating bespoke posts that included student technician roles and options for split-working between acute and community pharmacies. The HSCP built resilience into this model working collaboratively with local partners from its inception. They agreed a memorandum of understanding with key stakeholders, worked with the existing locality GPs, GP clusters, practice managers and pharmacists to develop an overarching action plan. A consistent approach was created across localities by agreeing a shared induction pack for new recruits. They also considered the wider recruitment picture by targeting areas in the North of England and Ireland that were not actively recruiting in the same roles, developed strong relationships with Schools, Colleges, Universities, and Pharmacy Schools to connect to the upcoming pharmacy workforce, and sought advice and best practice from other Health Boards.

This work has led to 80% of the initial 25WTE newly identified vacancies successfully recruited to without destabilising community hospital pharmacy services. The Student Technician model won a Scottish Pharmacy Award for Innovation and a highly commended award at the 2018 national SP3AA conference.

“From an AHP perspective, progress across remote and rural areas is mixed. All Boards, with the exception of NHS Dumfries and Galloway, have introduced or are in the process of introducing the first contact physiotherapy practitioner model within the practice. This has proven challenging in many remote and rural areas due to difficulties in recruitment and/or access to suitable accommodation.”

– Joan Pollard, Associate Director of Allied Health Professions

Rural Case Study: First Contact Physiotherapy (FCP) in Rural practices in North West Scotland

FCPs are operational across 20 practices in North and West Highland, covering Skye, Lochalsh, Wester Ross and Caithness with Lochaber & Sutherland expected to follow in due course.

Implementation of the FCP service into rural general practice has presented several challenges, including the unique geography and character of the region. Serving widely dispersed small communities, clinicians travel considerable distances on single track roads. In addition, applying the agreed 1:13000 model in NHS Highland meant smaller allocation of resource to smaller practices.

Previous access to MSK Physiotherapy included a mixed model, mainly determined by the availability of services. Referred by GPs, some patients travelled long distances to physiotherapy services based in local hospitals. Some attended a visiting physiotherapist in the GP practice. Patient waits were consistently high across all areas.

Collaborative working with GPs, physiotherapists and practice managers developed the FCP approach at each local level. All were keen to have a FCP on site, as part of the team, and it quickly became evident that in rural practice there is a well-established and resourceful community spirit. Everyone works together to reach pragmatic solutions to issues relating to geography and remoteness from larger centres of population. Creating flexible delivery enabled mutually agreeable solutions, with a commitment to revisit and review, e.g. practices with small allocations agreed a fortnightly visit might work best, practices with 2 sites settled on alternate weekly visits to each site. These options reduce clinician travel thereby maximising appointments and see patient travel reduce whilst delivering on the primary aim to reduce the MSK workload for the GPs.

FCP implementation is project managed by Lead AHP, E-health, GPs, practice managers and physiotherapy leads, thus providing robust governance and support, promoting from the outset a culture of collaboration. The commitment and sense of joint-purpose has been clearly evident moving from planning to implementation and has been a major factor in finding solutions to challenges as the service is developed.

While the overall pace of implementation for Pharmacotherapy, Additional Professional Roles and Community Link Workers services in rural areas is mixed, these examples show there is enthusiasm to try new, creative approaches that are sustainable, equitable and demonstrate the benefits of flexible roles that encompass both service delivery and educational functions.

Urgent and Unscheduled Care, and Home Visits

A good example of how national challenges are exacerbated by rural realities is seen in the provision of Urgent and Unscheduled Care and home visits. Recruitment and retention difficulties in a rural practice with a widely dispersed population means much time is lost to travel when providing home visits to patients.

Rural Case Study – Home Visit Service in Wigtownshire

In Wigtownshire, an audit carried out in 2018 showed that their most rural practices lost 19 hours per week to travel for visiting patients. To free up GP time, NHS Dumfries and Galloway working with SAS recruited three paramedics to work across two rural practices using a rotational model that ensured no skills atrophy for acute and trauma care for the paramedics. The paramedics delivered home visits allocated by the GP, who offered advice by telephone if needed. After 6 weeks there was a 45% reduction in GP time spent visiting patients. While this freed up GP time in the practice, they continued to see urgent presentations to the practice when they arose.

This practical service reflects the reality we have seen and heard across our engagement about the role rural GPs serve in their communities as a provider of urgent and emergency services due to sometimes long travel times involved for other first responders such as SAS. This role is often 24/7 and in smaller remote communities it can also include the management of severe trauma and life-threatening illness. Configuration of these services requires input from GPs, SAS staff, experienced generalist nurses and other appropriate members of the Rural Primary Care Teams and will differ depending in part on remoteness and availability of Community Hospitals, Rural General Hospitals, SAS and OOH services.

The Rural Group recognises the benefits of freeing up GP time and reducing home visits through using paramedics and other resources, however we also recognise that the emergency role is intrinsic to the work of a very rural GP. Currently, there is no standard national or regional specification or payment model for rural GPs and practices for providing a pre-hospital emergency response, except for those in North Highland, Western Isles and Dumfries & Galloway. GPs in other rural areas do it as a voluntary part of their rural GP role and receive no additional funding for it. We think this needs to be better understood, recognised and reflected at regional and national levels.

We have agreed to the use of the Rural Fund to begin addressing this. The Pre-Hospital Emergency Care Fund was set up to reimburse remote and rural GP Practices for having GPs and practice employed practitioners (with BASICS training) on call for their expertise in an event of emergency. This will help develop a comprehensive co-ordinated network of trained and equipped BASICS Responders across remote and rural Scotland. This scheme will begin as a pilot on 1 January 2020 and go live across Scotland from 1 April 2020.

The Rural Group has also agreed to establish a sub-group to consider what more can be done to help rural GPs delivering pre-hospital emergency care. The sub-group will, for example, consider what standard drugs and equipment should be available in all BASICs Responder practices and what pastoral and mental health support is available for practitioners who may need support following attendance at a traumatic incident. We will update the Rural Group website as this work progresses.

“While I believe we would all welcome and support the need for shifting the model to a more integrated approach based on an extended workforce model, it is also important to recognise that historically rural areas, especially, but not exclusively, in smaller practices provide a more holistic model that larger urban practices. This has therefore made the approach around Community Care and Treatment Services and Vaccination programmes more challenging and in some situations less supported than is perhaps the case in urban settings.

In the future, while ensuring we maintain the focus on the key principles in the Contract, I believe it is important that we also properly explore the flexibility required to make sure the Contract is fit for purpose in the rural context - this should be a key area of future focus.”

- Ralph Roberts, Chief Executive, NHS Borders and SRMC Chair

Community Treatment and Care Services, and the Vaccination Transformation Programme

The Community Treatment and Care (CTAC) work stream, encompassing services such as phlebotomy and wound care management, and the Vaccination Transformation Programme (VTP) have been a clear focal point for the challenges of implementation across rural communities. Throughout our engagement programme rural GPs shared concerns about the ability of visiting MDTs to deliver an effective and cost-efficient service. There is significant pride in the vaccination rates achieved by practices and a concern that the same rates would not be achieved with a new model. It was felt that the current system was performing as good or better than a Board delivered service could provide. There was also concern about the impact on patients if new service models created the need to travel to treatment room centres.

CTAC and vaccination services are at the forefront of an ongoing dialogue involving rural GPs, Boards and HSCPs, the BMA and the Scottish Government focused on what flexibility is available within the context of service redesign to recognise these issues.

Our engagement work, alongside our work to develop and promote Case Studies or service redesign, has provided a number of examples of creative solutions used to implement safe, sustainable CTAC and vaccination services.

Case Study: CTAC and Vaccination Service in NHS Western Isles

NHS Western Isles (NHSWI) has 9 GP practices across 6 island groups. Staffing resources compounded with the geography of the islands created a challenge to developing a VTP team that maintained patient safety and quality of service. NHSWI decided to take an innovative approach that recognised that the models of travelling VTP teams used in other areas was simply too impractical for their geography and would risk creating a service that could not meet the MoU principles. They developed a model that uses the existing highly skilled local team in an overlapping CTAC and vaccination service. To achieve this they applied a number of creative solutions such as using PCIP funds and Transfer of Undertakings (TUPE) rules to support already skilled staff to move into the Community Nursing Team, and identifying where staff had transferable skills, or additional educational and training needs.

This approach allowed NHSWI to integrate Pertussis and Teen vaccinations into the maternity and school nursing teams respectively. In its first year, vaccination rates increased from 67% in 2017/18 to 74% in 2018/19. This change also allowed for systemisation and standardisation of practice throughout NHSWI.

Flexibility

The successful model used in NHSWI is an example of the effective application of the expectation set out in the GP Contract Memorandum of Understanding that a flexible approach, determined locally, would be necessary for successful implementation:

“The extent and pace of change to deliver the changes to ways of working over the three years (2018-21) will be determined largely by workforce availability, training, competency and capability, the availability of resources through the Primary Care Funding:” (p.8).

This is also described in the Scottish Government’s National Health and Social Care Workforce Plan for Primary Care in Scotland (Part 3), published in 2018:

“The extent and pace of change over the next three years will be determined locally but will be affected by a number of factors including workforce availability, degree of skills enhancement and the needs of individual practices or practice clusters. In a small number of cases it may be locally determined that GPs and their staff continue to provide some of these services, for example in some very small remote and rural practices. Patient safety will also be a determining factor in local implementation in that the changes will only be made when it is safe to do so. These changes will require investment in the skills of the workforce so that these match the service needs.” (p.34)

However, the Group recognises that it is one thing to prescribe flexibility and another to define its limits. We found that there is considerable variance in understanding the intent of the MoU and the emphasis it places on supporting flexible, intelligence driven models of care.

Over the course of our early work we have contributed advice, based on the expertise of our members and our learning from listening to the rural GP experience, to the Scottish Government and BMA to help set out further clarity on flexible implementation models:

• Primary Care Improvement Plan Guidance (March 2019) – this document, reproduced as Annex E, was agreed jointly by the BMA and Scottish Government, was informed by feedback from the GMS Oversight Group and advice offered by the Rural Group. The document reiterated the messages in the MoU around the importance of local collaboration and local insight into specific circumstances and that “in rare circumstances it may be appropriate for GP practices, such as small remote and rural practices, to agree to continue delivering…services through locally agreed contract options”. It set the expectation that these agreements would be reached through local appraisal of the population needs and options available for service delivery.

It also reminded HSCPs of the importance of preserving continuity of care, reflecting key concerns raised throughout our engagement – and highlighted specifically by RGPAS in their Looking at the Right Map report – that moving to models of Board delivered services increased the risk of disrupting existing models that preserved continuity of care. The Scottish Government requested that PCIPs note in their plans how local implementation partners were maximising continuity of care in establishing new services and expanding the MDT. It set an expectation that “where appropriate, reconfigured general medical services should continue to be delivered in or near GP practices”.

• Joint statement (September 2019) – This document was agreed by Andrew Buist, Chair of the SGPC, and Jeanne Freeman MSP, Cabinet Secretary for Health and Sport. It was developed following their attendance at a meeting of the Group in June 2019, where a number of concerns were raised about the Options Appraisal process:

  “We have listened to the views expressed at the Rural General Practice Working Group on 4 June 2019 and in particular the view that further guidance is required around implementing the flexibilities contained in the Contract. We will therefore develop options appraisal guidance on how these principles can be operationalised. The expertise of the Rural Working Group will assist in developing this guidance.”

  The statement also recognised the emerging role of the Group itself in offering advice to both parties on implementation, reflecting the Group’s positive contribution in helping to elevate the concerns raised throughout our engagement up to that point:

  “It is vital that our response to these recommendations is developed collaboratively with the Working Group, and remote and rural GPs and their teams more widely.”

  The document set out the intention for a refreshed role for the Group, in which it would no longer be considered ‘short-life’. This build on the positive contributions made by the Group to highlight both the challenges of rural general practice and the opportunities for innovative solutions that we were encountering through our engagement work. It set us on a path of agreeing new terms of reference to enable the Group to be better at enhancing rural general practice as international exemplars of service delivery. This role is now reflected in our new terms of reference, published on our Group website.

• Options Appraisal Guidance (December 2019) - This document provides further clarity to the September guidance about the circumstances where GPs would continue to deliver services. It sets out a detailed process including principles that should be applied to all cases considered, the scope and governance of the appraisal, and arrangements for reporting and review.

Chief Officers’ views on implementation Part 2 - Flexibility

In terms of further guidance generally or specifically in relation to flexibilities, there was a mixed response, with many COs stating that they were very clear and had worked with SG, and locally with their GP Subcommittee and Local Medical Committee to consider and agree any points where clarity would be helpful, however for a small number of respondents there was a feeling that further assistance/guidance may be helpful. Concern was raised that any further flexibility should be proportionate, as some areas had progressed well, and any significant change in direction would potentially undermine the work to date.

By far the biggest areas of concern relating to the MoU were the Vaccination Transformation Programme and the Community Treatment and Care Service, and how this might translate in a remote and rural setting.

For the VTP it appears that concerns regarding lack of clarity/flexibility were mainly in this area and there was a need for stronger support and further opportunities for shared learning. All areas are working through their VTP programmes of work with the aim of identifying the level of issue to be addressed or seeking to ensure the flexibilities available are applied to secure sensible solutions.

For the Community Treatment Rooms most remote and rural areas - but not all - were still trying to work out how this would be discharged successfully with some areas using the link with the Health Improvement Scotland Team for Primary Care to work through this, taking a shared learning approach.

General Practice Funding, Contract Implementation and Options Appraisal

The new GP Contract sets out the goal of transferring services from GP delivery towards board supported provision, while keeping practice resources stable. This is intended to reduce workload, allowing GPs and their teams to focus on more complex care, keeping more care in the community and improving overall patient outcomes.

The MoU recognises that these changes might not be possible in very remote and rural areas where there is no viable alternative provision under the principles of the MoU. In these circumstances the BMA and SG have established an expectation that GPs and their practice staff may continue to deliver some of the MoU services. The Rural Group has contributed to the developing understanding of this flexibility through its input into PCIP advice, the joint statement, and Options Appraisal Guidance.

A common concern expressed was that medium and long term funding arrangements should be agreed and resolved for those practices that would necessarily have to continue to provide services in the best interest of their local communities. While this mainly applies particularly to vaccinations this may also affect community treatment and care services and urgent care services.

Few of the commitments in the MoU were accompanied by changes to GMS or PMS regulations. The Scottish Government has made clear that services will only transfer and be removed from future iterations of the regulations, when it is appropriate under the principles of the MoU to do so.

The MoU sets out the main purpose of the Primary Care Improvement Fund as to pay for recruitment of more board-employed multidisciplinary team members to support practices to transfer MoU services. However, the issue of funding was notable across our engagement, and has been raised in particular by RGPAS. Some GPs from a range of practices in remote locations, as well as in towns located in urban areas, have indicated that where they are continuing to deliver MoU services they would be able to offer a better service if supported to do so from Primary Care Improvement Funds.

The shared position of the Scottish Government and BMA is that all GP practices that can do so under the principles of the MoU should transfer MoU services, by April 2021. They also recognise that there will be a small number of practices for which support under the MoU principles is not likely to be available in the short or medium term. The intention has been to use the 3-year transition period of implementation to identify those practices so that better support can be made available to them in any future iteration of the national funding model. Options appraisals will play a vital role in that process, as will data on practice income and expenses currently being gathered across Scotland’s GP practices.

The BMA and Scottish Government have committed to re-evaluating this position as we move towards the end of the MoU transition period (April 2021) and will work with the Rural Group and Oversight Group to respond to concerns arising in the interim.

To this end, initiatives have been introduced via the Rural Fund that will help to shape proposals for future funding models alongside the Options Appraisal and data gathering work. In particular, new funding has been made available for change management support in rural areas, improved financial support for dispensing practices, investment to target improved use of IT in remote and rural areas, and the Pre-Hospital Emergency Care fund that is helping to introduce a standardised approach to recognising and remunerating GPs for responding to emergency situations in their communities. These are discussed in more detail in Part 3 of this report.

Chief Officers’ views on implementation Part 3 - Suggested Way Forward

In general, no appetite was expressed for moving away from the current MoU requirements but there is perhaps a need to ensure that understanding of flexibilities is clear in all partnerships.

Local Primary Care Leads should ensure good involvement and communication with those practices in remote and rural settings, to ensure appropriate support is in place to allow the best solutions to emerge for those local populations, applying flexibilities as appropriate.

Risk assessments should support the PCIPs and confidence ratings to ensure good surveillance in implementation. A shared position on the risk appetite may be worthy of consideration.

Engaging with Patients and Communities

“It is important that patients, carers and communities are engaged as key stakeholders in the planning and delivery of new services. However, the level of patient engagement varies across HSCPs, with poor engagement leading to concerns around continuity of care.

Each HSCP should ensure that patient engagement is a key part of their Primary Care Improvement Plans. Scottish Government should assess these plans and showcase the ones that have communicated well with patients and the public.”

– Colin Angus, Chair, Patient Representative, RCGP P3 group

The MoU sets out clearly that:

‘HSCPs have a statutory duty via the Public Bodies (Joint Working) (Prescribed Consultees) (Scotland) Regulations 2014 to consult a wide range of local stakeholders and professional groups on their Strategic Plans and take decisions on the size and shape of local health and social care services on a collective basis based on dialogue with the local communities and service users. In relation to the development of the Primary Care Improvement Plan that would include (but not be limited to):

Patients, their families and carers, Local communities, SAS and NHS 24, Primary care professionals (through, for example, GP Subcommittees of the Area Medical Committee and Local Medical Committees), Primary care providers, Primary Care staff who are not healthcare professionals, Third Sector bodies carrying out activities related to the provision of primary care.

In order to ensure that the provision of any new or reconfigured service has a patient-centred approach to care based on an understanding of patient’s needs, life circumstances and experiences it is important that patients, carers and communities are engaged as key stakeholders in the planning and delivery of new services. HSCPs should ensure that patient engagement is a key part of their Primary Care Improvement Plans.’

From January 2018, some rural patients raised concerns about the implementation of the Contract in rural areas, with particular concerns around the long-term sustainability of rural General Practices. The Rural and Remote Patients Group was launched in February 2018 with the setting up of a Twitter and Facebook campaign to raise their concerns about the implementation of the Contract.

Members of this group initially raised their concerns through the third sector group Health and Social Care Alliance Scotland (the Alliance). The Scottish Government commissioned the Alliance to deliver workshops across Scotland in February and March 2018 to engage with patients around the delivery of the Contract. These were held across a mix of urban/rural communities and including Portree, Skye. The Alliance also developed a facilitator’s toolkit for local communities and groups to use to discuss the impact of the Contract to their local areas. A number of areas, particularly in Argyll & Bute, utilised this tool and fed into the Alliance report: Your GP and You that provides a summary of the outcomes of this work.

The Remote and Rural Patients Group submitted the Rural Patients Petition to the Public Petitions Committee in May 2018, outlining their concerns about the new GMS Contract. This, along with other submitted evidence, was considered by the petition committee on a number of occasions, including a session attended by the Cabinet Secretary for Health and Sport in May 2019. Dr David Hogg (former Chair of RGPAS) and Mrs Karen Murphy (Rural and Remote Patient Group) were invited to give evidence to the Health and Sport Committee in October 2019. The Petitions Committee agreed to refer the petition to the Health and Sports Committee as part of their work considering the future of Primary Care.

In recognition of the concerns of rural patients, the Rural Group agreed at its first meeting in June 2018 that it was important that there was rural patient representation on the group. The chair of the RCGP P3 group, Colin Angus was approached and kindly agreed to join the group in August 2018. In this role Colin Angus undertook engagement with Karen Murphy from the Rural and Remote Patients’ Group.

In September 2018 we met with Karen Murphy, lead for the Rural and Remote Patients group, in Oban, to discuss the concerns of the group. This meeting covered a range of topics including the role and remit of the working group, patient representation on the working group, SWF and the impact of the Contract on the long-term sustainability of rural practices. They agreed that ongoing communication with GPs and communities was important and the development of a Rural Group website would be helpful.

The Rural Group website was launched in October 2018. The terms of reference, minutes of the meeting and the regular rural bulletins are published on the Group website. To date the Group has published six Bulletins, which share the work of the group, details of engagement visits and other areas of interest.

In November 2018, the team attended the Scottish Rural Parliament in Stranraer, alongside the Scottish Rural Medicine Collaborative. The team, including Colin Angus, ran an interactive workshop with members on the impact of the Contract on rural communities. There was a lively discussion with the main theme from the public being how could they get involved in helping to design and support local services. There was also concerns raised about the sustainability of services, with a particular focus of challenges in Dumfries and Galloway, where the Rural Parliament met.

At the December 2018 meeting of the Group, Colin Angus presented a paper on patient engagement, and in particular, highlighted the requirements of HSCPs to engage with the public on any changes to primary care services.

In addition, Colin Angus led on promoting a Case Study of good practice in community engagement in the Clydesdale locality, South Lanarkshire HSCP. The Locality recognised that there was a gap in the existing arrangements for public engagement in the area and collaborated with NHS Lanarkshire on a range of engagement activities including presenting at local community and voluntary groups, engaging with pupils and staff at Biggar High School, and ensuring that strategic groups within South Lanarkshire HSCP included community representatives. This example of good practice has been recorded as a case study and added to the iHub Scotland website as a resource for others to learn from and apply to their own engagement work.

Further engagement with the public and communities about the implementation of the Contract is ongoing and being considered by each HSCP as part of their Primary Care Improvement Plans.

Visits with colleagues throughout remote and rural Scotland