Promoting general practice - RCGP

Promoting general practice

A manifesto for the 2016 Scottish Parliamentary election

Inside

page

1. Grow the workforce

iii

2. Promote values based quality and leadership

iv

3. Promote the interface

v

Addressing the looming tipping point

Replacing the Quality and Outcomes Framework (QOF)

General practice is the hub of the NHS because of the multiple interfaces it works across

4. Promote Out of Hours

vi

A core professional value of general practice

5. Promote Mental Health vii RCGP Scotland believes that mental and physical health need to be given equal standing

5. Promote GPs in Integration vii Delivering care at home or in a homely setting will rely absolutely upon the work of GPs

6. Promote a clear political strategy

Key Quotes from GPs are shown in green

viii

Quotes from the general public are shown in blue

Version Date: September 2015 © RCGP Scotland, 2015. All rights reserved.

Promoting general practice Promoting solutions Over the next four years, Scottish Government has an opportunity to implement solutions and safeguard general practice for our patients in Scotland. It must do so if it is to deliver on the promises of the 2020 Vision. It is vital to secure GP led reform of primary care, backed by sustained, incremental increases in investment in general practice, and to work with the profession to direct such spending. RCGP Scotland’s A blueprint for Scottish general practice (the Blueprint) clearly laid out, among many still necessary measures, how general practice is a cost-effective part of the healthcare system in which to invest and to improve patient outcomes more economically than other parts of the system. This document covers the spectrum of Scottish general practice. Remote and rural practices and Deep End practices have been included through the broader picture, rather then explored individually. It should be clear to all that they have particular needs and the eradication of the

inverse care law sits chief among these. Promoting general practice is central to the future of the NHS in Scotland. The upcoming election is an opportunity to address urgently required commitments to political action. That urgency continues to intensify. Faced by the need for immediate action to safeguard general practice for the future, RCGP has and will continue to fulfil its role as guardian of standards for GPs in the UK, working to promote excellence in primary healthcare. We call on Scotland’s political representatives to fulfil theirs. This manifesto shares pertinent quotations from the experiences of patients, families and carers (in blue) and general practitioners (in green), as relayed in writing to RCGP Scotland (please note: all experiences and opinions shared with RCGP Scotland have been anonymised). It also evidences the facts behind those experiences where necessary, and calls for appropriate actions to be taken by the next Scottish Government.

Published by:

RCGP Scotland 25 Queen Street, Edinburgh EH2 1JX Tel: 020 3188 7730 Email: [email protected] Website: www.rcgp.org.uk The Royal College of General Practitioners is a registered charity in Scotland (No. SC040430) and in England and Wales (No. 223106).

www.putpatientsfirst.rcgp.org.uk

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Royal College of General Practitioners (Scotland)

Manifesto 2016

1. Grow the workforce For two years, RCGP has been warning that rising workloads, a shortage of GPs and declining resources are putting intolerable pressure on local practices and

posing a threat to patient care. Now, with vacancies in many practices, imminent large scale retirement, qualified GPs leaving to practice abroad, recruitment to general

practice a major concern, and with universities not delivering sufficient numbers of doctors to GP specialty training, the profession is close to its tipping point.

‘The biggest issue is a workload crisis colliding with a workforce shortage giving a sense the wheels are falling off general practice fast.’

‘His day begins at 7.30am and he leaves work at 7–7.30 at night. He also covers out-of-hour services at the weekends.’

Calls for actio n

‘Three practices in our small area are without partners and we are feeling the strain of trying to avoid ill health as we could end up leaving the practice 2 Ensur e medical unmanned’ stu

‘The man seems to be there all day every day’

Manifesto 2016

7 Support those considering retireme nt to remain in the profession. Approach those nearing retireme nt to understand how to delay it and look to ‘return’ those already lost to early retireme nt.

‘Patient safety is now being jeopardised by GPs working in a chronically under resourced and under funded service.’

‘We are approaching a tipping point… and without the appropriate funding being available, the service will be unmanned very soon.’

National Records of Scotland projections indicate that between 2010 and 2035 those of pensionable age will increase by 26%, with the associated increase in the number of long term conditions per patient and exponential increase in demand on primary care services.

Funding for general practice has consistently fallen, from 9.8% of NHS spending in 2005/06 to what is a new record low of 7.6% in 2013/14. Budget freezes in 2015/16 meant an inflationary loss of 1.2% for General Medical Services (GMS).

Deloitte analysis showed that general practice suffered a real terms loss of £1.1 billion by 2012/13 compared to funding levels staying at 9.8%. 71% of Scots support a shift of funding to GMS to reach 11% of NHS spend.

‘Average working day is now 12-14 hours long’

NHS Scotland’s Information Services Division (ISD) figures show Scotland received only 35 extra Whole Time Equivalent GPs between 2009 and 2013. Over half of GPs feel their current workload is unmanageable or unsustainable. Patient safety is at risk.


One in five GPs in Scotland are aged over 55 and could feasibly retire over the life of the coming parliament. Indeed, the BMA recently found that one in three Scottish GPs was hoping to retire in the next five years.

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Supporting Statements

Scottish GP practice teams carry out around 24.2 million consultations each year – an 11% rise over ten years.

6 Incentivise universi ties for each medical student they deliver to general practice training.

4 Longer consultati on times should be dents and trainees included in future are regularly expose d to wo rkforce projections, general practice each es pe cially when year throughout their co ns ide ring mental learning, broadening he alt h, mu ltimorbidity, their awareness of th e and high deprivation. great career available to them. 8 Enhance retention 5 Commit to ongoing by , actively supporting su sta ine d increases in 3 Expand the wider Continuing Profession investment in general al primary care workforc De velopment. e pr ac tic e un til it receives to support people’s the necessary 11% needs. Numbers of 9 Promote deve lopments NHS Scotland spendin of Practice and g. which ease wo rkload Publish regular statis Community Nurses tics intensity. sh ow ing ho w this is particularly, should being achieved.

‘For patient safety we need more GPs. For that to happen we need better work life balance. More time and monetary investment in general practice.’

90% of all patient contact with NHS Scotland goes through general practice.

be increased, as should greater collaborative working with communities. Al l practice teams shou ld include a Clinical Pharmacist.

patient and GP experiences

1 Commit to a clear objective of recruitin g an extra 740 GPs by 2020 and put an incentivised strategy in place to do so with measurable targets along the way.

2. Promote values based quality and leadership The Quality and Outcomes Framework (QOF), implemented in 2004, adds to administrative burdens on a GP workforce already at capacity. RCGP Scotland believes that the

replacement of QOF is necessary and that a framework should be developed which will meet quality ambitions and ensure patient safety while minimising administrative duties. We can capitalise

on our devolved system, and use these ideas to inform the way in which clusters of general practices could work together to enable a process that is peer led and values driven.

‘The GPs have changed over the years for various reasons but the ethos of the practice has not changed.’

‘[QOF] takes the heart out of the job we are trained to do which is about listening to patients and their needs and helping them to find wellness … it shifts the way we view ourselves, as professionals who are highly trained and skilled at treating people, to number crunchers.’



Calls for action

‘let us look after our patients and not “the books”.’

1 QOF should be replaced with a system of professional, peer led, values driven governance to better meet the local needs of patients and the health care service, and allow skills and expertise to be shared across practice clusters.

greatest importance in their locality. Practices must then have the time and resources to undertake audit and quality improvement work to show that what they are delivering is congruent with those values.

‘As it stands GPs do a large proportion of their administrative work in their own time. This results in 13 hour working days and working at weekends and during annual leave’

4 Trials should be undertaken urgently 2 Clusters of GPs should whereby practices be formed, defined as pilot this model of groups of GP practices governance through within a geographic the clusters approach. locality (community), Funding equivalent to ‘There is a very covering between c. 20QOF payment should basic lesson taught in 50,000 patients. be guaranteed to management circles; do not participating practices attempt to incentivise already 3 Practices should then while trials are incentivised individuals. The be asked to agree to the ay. ‘I am saddened to see my result is you corrupt their core shared values that are of underw younger partners exhausted and values; generally caring for dispirited due to … the overwhelming others (not money) was the burden of administrative and quasireason they became clinical work … We need to aim to reduce ‘Until this fundamental doctors/GPs in the this burden which is NOT the type change is made you will continue to first place.’ of work that GPs entered the lose doctors abroad once trained and profession to practice.’ discourage people from a career in general practice.’

The guidance for QOF gives some indication of the administrative burden. The Scottish Quality and Outcomes Framework guidance for GMS contract 2013/14 ran to 224 pages. After reduction, in 2014/15, it runs to 186 pages.

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One Tayside practice, with a list size of c. 6,000, has annually audited the amount of ‘paperwork’ managed through their electronic (Docman) filing system. They found a yearly increase, from an average of 1,389 items/month in 2006, to 3,424 items/month in 2013 - a 250% rise over just eight years.

A 2015 Scottish Liberal Democrat survey found that 91.9% of respondents thought that QOF should be abolished or reduced (with 54% for abolition and 38% for reduction).

A 2007 large-scale study by Campbell et al could not identify a difference in improvement trend between incentivised and non-incentivised clinical indicators.


A 2010 study by Howie explored the complexity of diagnosis in general practice and concluded that current incentives veer healthcare away from what both patients and clinicians want.

Manifesto 2016

3. Promote the interface Interface is the point of interaction between different systems. In healthcare, interfaces exist where a patient journey crosses from one area of care into another – such as between primary and secondary care or between

health and social care. General practice is the hub of the NHS because of the multiple interfaces it works across to provide co-ordinated patient care. Due to the individual complexity of these different systems, interfaces are

‘[We need] a true primarysecondary care fund to allow discussion on the interface between the two with practical outputs on how patients might benefit from closer working.’

Calls for action

recognised as areas of potentially high risk with factors including different cultures, different professional boundaries, different governance systems, different performance targets and different IT systems. ‘There is a common issue here in my experience of problems occurring in the interface between secondary and primary care as well as GPs and Nurses regarding blood tests etc.’

to support the patient.’

‘So an IT system that allows us to work more efficiently, and reduces admin, instead of increasing it, would be my priority … The Press recently said GPs were unwilling to embrace modern tech! Well we wanted it yesterday, and investment is needed to make it happen tomorrow.’

‘Open access to diagnostics such as CT and MRI would reduce referrals to secondary care and allow speedier diagnosis of significant pathology such as cancer.’

Manifesto 2016

Existing IT systems are currently not considered fit for purpose; they are unreliable, inflexible, incompatible and limited in their functionality. This significantly impacts on safety and efficiency of clinical data sharing.

The United States’ National Center for Biotechnology Information reported in 2009 that, in the UK, 55% of Significant Event Analysis reports described the direct or indirect involvement of other health and social care agencies in the significant event with secondary care making up 30% of those.

A RCGP Scotland survey of members found that an average of 71% of respondents across 12 of Scotland’s Health Boards felt they lacked a recognised system through which to feedback issues relevant to secondary care, with a profound sense of disconnect between primary and secondary care.

‘if we don’t challenge things, we will continue to be buried under inappropriate and dysfunctional NHS systems and our patients will suffer more and more’

The lack of appropriate structures significantly impacts on two-way feedback processes relating to concerns or suggestions for change, and thus hinders improvements in processes or systems.


A significant variation has been found in the ability of GPs to receive easily accessible clinical decision support when required to help inform clinical management and to avoid referral or admission. RCGP Scotland’s Being Rural report describes how ‘Rural practices ... are often limited in services provided by having inadequate or unreliable connectivity’. page v


The Health Foundation reported in 2011 that a review mapping out the medication system in UK primary care demonstrated that error rates are high. Several stages of the process had error rates of 50% or more, interface prescribing among them.

The same report concluded that, ‘Key areas with heightened risk include … the interface between primary and secondary care’.


1 Health boards require ‘The GP is the processes such as patients in the Out of dedicated primary hub of the wheel for Significant Event Hou rs period. and secondary care everyone’s problems, Analysis. medical or not.’ clinical ‘interface 5 Provide appropriate leads’, recognised 3 Increase resourcing of broadband and mobile and resourced within existing IT structures cove rage across job plans to allow to enable safe and Scot land to ensure autonomy and to efficient communication adequate inter face with become involved in across the interfaces, and ‘this is a with in ‘I passionately rem ote and system change. especially that between high risk area rural practice. believe that GPs and primary and secondary their teams are at the that receives scant care and with Out of ‘heart of the matter’ for 2 Specific endorsement attention...we need 6 Extend, further is required of the better patient care, health Hours care. SEAs [Significant develop, and key role of GPs as and wellbeing. They Event Analyses] main tain existing are/should be the key equal partners to that focus on the 4 Improve integrated successful means interface to secondary secondary care in any interface with patient records and of, clinical decision and tertiary care and key policy statements shared learning care plan s to ensu re support. For example, should be key to affecting the wider on both sides’ they are available to all liaising and esta blish dedicated NHS , and in NHS clinicians looking after progressing issues emails and phone lines.

4. Promote Out of Hours, The Green Light Service Out of Hours services (OOH) are a crucial part of primary care, used by those in need of care once their usual practice has closed. Yet OOH services have seen a 3.3% drop in funding in real terms since 2004. RCGP Scotland


‘[We need] more secure arrangements for OOH’

welcomed, and has participated fully in, the Scottish Government’s National Review of Primary Care Out of Hours Services in Scotland. It is a core professional value of general practice that GP driven care

in the community is available at any time. The College sees it as essential that GPs remain a central part of the OOH service to ensure holistic, co-ordinated patient care and that In Hours and OOH should be linked up.

Calls for a

ction 1 Recognise the vit al 3 Reduce barriers for contribution of gene GPs communication ral at all stages of their pr ac tic e to OOH ‘Being the sy stems, such as linke careers to contribute d services since 2004 to only GP covering IT systems, to facilitate , OO H ca re provision. for an extensive region and into the future, care within OOH an d in chronically short staffed to encourage those int erface seamlessly 4 T he OO H GP service rotas is not a desirable job. presently undertakin with other stakeholde g must capitalise on rs. I regularly get job offers the work, and aid th e from Australia or the USA co re va lues and present and future 6 The welfare of with offers of at least skills of GP clusters, recruitment. staff employed double my salary and be multi-disciplinary, mu st be ensured in if OOH workload supportive and secu 2 GP Out of Hours re, ter ms of security, is not addressed needs and utilise the skills a clear identity – of ac co I may leave.’ mm odation, nurses, paramedics, potentially The Gree an d su ste nance. n pharmacists and oth Light Service –throu ers gh to ensure safe, effec which to define its rem tive 7 The service must it care is provided for and communicate its be int eg rat ed within patients. offering to the public the wider health and as central to OOH ca social care service an re 5 Teamwork mu d st provision. ad equately funded to be supported allow the fulfilment by appropriate of ‘She visited us, often twice a its objectives.

‘OOH is in meltdown.’

week during the last months before he died. She also put on his notes that he was not to be taken to hospital if we needed a doctor at the weekend.’


‘My GP is now retired; the service, although changing, continues to be delivered locally 24 hours a day – out-of-hours too – by our local GPs and primary team.’

‘I regularly work in _____ OOH as well as full time as a partner in GP and OOH needs urgent investment/overhaul before complete meltdown occurs.’

NHS Scotland’s Information Services Division (ISD) reported in 2015 that 997,000 OOH patient contacts, involving 894,000 patients and over 200,000 home visits, took place within twelve months. A RCGP Scotland survey of First5 GPs found that roughly only 1% of those who were involved in OOH care only worked in OOH care. The rest worked throughout general practice. page vi


Manifesto 2016

5. Promote Mental Health The Scottish Government’s Mental Health Strategy for Scotland: 2012-2015 is now due to be replaced. RCGP

Scotland believes that mental and physical health need to be given equal standing. We welcome

Calls for action

1 Mental health should be given parity with physical health, erasing the barrier between the two terms.

2 Adequate consultation time must be available to safely care for those suffering mental distress.

‘Dr _____ continued to see me at least every few weeks even during good periods even if it was just to “check in”. I really appreciated her doing this as it allowed her to remain up to date and me to develop a trusting and good, strong therapeutic relationship, vital for identifying and stopping any relapse early.’


‘I was feeling suicidal and had went to the Forth Road Bridge with the intent to jump off it. Dr _____ spoke with me and spoke me down enough for me to turn around and go home to keep myself safe till I seen him the next day I think it was. This is just one of many incidents Dr _____ has enabled me to continue the fight for life. Dr _____ has gotten to know myself pretty well over the last seven years and I can see he believes I can manage my mental ill health rather than it manage me.’

intimation of increased funding to prevent mental health distress and to care for those in distress.

6. Promote GPs in Integration and the 2020 Vision The Integration of Health and Social Care has been one of the main objectives of Scottish Government since the establishment of the 2020 Vision. Delivering care at home or

in a homely setting, will rely absolutely upon the work of GPs. To date, despite clear and evidenced willingness on its part, general practice’s involvement in the establishment of Integration has been

limited. RCGP Scotland recognises the efforts of Scottish Government to encourage Integration Joint Boards (IJBs) to engage. Timescales are now such that more than encouragement is required.

Calls for action

Manifesto 2016


‘[We need} funded time for grass roots GPs to contribute and influence strategic planning by IJBs. If integration is to succeed the voice of GPs working at the ‘coal face’ and struggling to meet increasing demand is essential.’

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‘Time to allow the primary care team to contribute meaningfully with the integration agenda will be essential. If colleagues cannot leave their practices to engage with partners there will be a serious risk that the changes will flop.’

involved in this process s 1 Integration Joint Board and in the subsequent must initiate urgent and work of providing adequate engagement satisfactory integrated with general practice, care. beginning with the c development of specifi 4 Social prescribing planning groups. development, such as that provided by k 2 Integration should see Links practitioners, to utilise the developing must be resourced to structure of GP clusters allow people to access within localities. non-pharmacological services where these 3 Appropriate time and would be beneficial to funding must be made their wellbeing. available for GPs

7. Promote a clear political strategy The perceived lack of a political strategy for primary care has encumbered its development. Current, long-term funding trends could be interpreted as a strategy of a deliberate reduction of general practice for Scotland. The Primary Care Fund, announced by Scottish Government in June 2015, is a welcome beginning towards addressing problems but is very clearly far from enough. A much


‘Politicians and the media constantly talk up public expectations of a consumerist type health service but they don’t fund it at a level to provide that service.’

larger, strategic financial response is called for. With the Scottish Government committing to the trial of new models of primary care in the development of the planned 2017 General Medical Services contract, it must be acknowledged that any new model can only be made fit for purpose with the full engagement of the profession. As a minimum requirement, we need a clear political

strategy for general practice, allowing delivery of safe, person-centred care, underpinned by the ‘Four Cs’ of general practice (see below), in an adequately resourced and empowered environment. RCGP Scotland believes that high quality GP consultations are the key focal point for enabling patient centred care and patient safety in the future.

‘He asks about the ‘If more different aspects of my care money was to ensure he has an overview available for general of what is going on and is practice it would allow ready to listen.’ more money to recruit and train GPs. With more GPs the practice could provide a better service … increase the number of patient appointments and extend appointment times to 15 minutes to give time to more 3 As far as possible, 1 A clear political be st complex cases. It would allow mu ts ien pat strategy should be more nursing and ancillary the in rs tne par published by the Scottish staff to be appointed so ir the of ent pm elo dev Government describing that more services would be healthcare, enabled the safeguarding and available for patients to actively protect and development of general not requiring the attention . enhance their wellbeing of a GP. It would allow practice. Government should facilities to educate e to support tinu con in patients on how to ent pm elo 2 Any dev development of the the manage their long in e ctic pra l genera of Care model use Ho term health be st mu d Scotlan ent of erm pow em conditions and how its and underpinned by the to be a good ts. ien pat ‘Four Cs’ of general patient’.

‘As a child our family GP was the central point in all our family care. The level of care has carried on for most of my life. Always our first point of care.’

Calls for action

‘The practice I am registered with has already reached crisis point and they have had to urgently prioritise all their services which has resulted in such things as the withdrawal of the medical service to a local cottage hospital. All I would ask for, therefore, is to stop this happening elsewhere and for proper resources to be made available and a reduction in paperwork, practice. to ensure that I and fellow patients equally receive the appropriate care when needed no ‘GPs [are] the matter where we vital bedrock of the live in Scotland NHS and healthcare and no matter what time of and wellbeing’ the day.’

‘It was fantastic to have the continuity of care’

‘I don’t think I would be here, if it wasn’t for them ... It doesn’t matter what the problem is.’

‘He is generally the first point of contact if I’m in crisis or going towards crisis because I trust him and in general he is my main support and at times has been my only support.’

The ‘Four Cs’ of general practice Contact: General practice is the default place, the first point of contact, for the vast majority of patients seeking access to healthcare for the first time. Comprehensiveness: It’s not just about seeing the person and their presenting complaint. GPs see people in their holistic lived experience. GPs are uniquely placed to deal with aspects page viii

of medical, social, and psychological factors. GPs ask people about something they didn’t come in for and take the time to listen, identifying major issues. Continuity: GPs are there from cradle to grave, with care benefitting from longterm relationships with patients. Co-ordination: Critically, GPs are able to

oversee care from multiple providers and act as a ‘system failure service’ for the NHS. When anything goes wrong, GPs are usually the ones to hear about it. The co-ordination of services at primary care level is an important determining element in the responsiveness of health services provision and the health system as a whole. Acknowledged from Barbara Starfield


Manifesto 2016