Nhslothian Strategic Plan and 2020 Vision

Nhslothian Strategic Plan and 2020 Vision

NHSLothian Strategic Plan and 2020 Vision:

Primary Care requirements to make it work

Our ‘2020 Vision’

“Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.

We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission”. Scottish Government

And yet…..1

And:“spending on acute services increased by 24.3% between 2003/4 and 2005/6 and by 41.9% between 2006/7 and 2010/11”1

General Practice share of NHS spend in Scotland2:

8.45% 7.78%(2003-4 to 2011-12)

And elsewhere:

  • England 8.5%, Wales 7.77%, and Northern Ireland 8.1%
  • UK overall: 8.4%

Objectives for primary care

  • Emergency measures for rapid expansion of General Practice in view of the current severe lack of capacity and destabilisation;
  • Establish infrastructure to support 2020Vision, which will require amongst other developments, and as a minimum: 10% more GPs; 10 more practices; increase in the GP share of NHS funding to the 11% recommended by the RCGP, more community nurses and other support staff; single point of contact available 8am to 7pm Monday to Friday for admissions avoidance (including transport arrangements); expansion of enhanced service funding, including those to support increased community based medical care of vulnerable and multi-morbid patients (General Practice ‘Intensive Care Units’); resource weighting to at least cover the additional workload associated with deprivation; improved IT;
  • Resourcing LUCS in line with its workload and supporting development of innovative schemes to support out-of-hours working;
  • Improve integration with H&SC Partnerships;
  • Improve joint working with secondary care, including at locality level;
  • Develop a new workforce to undertake current secondary care work in the community and absorb that associated with new ways of outpatient working;
  • Maximise quality and efficiency by fully supporting GP clinical leadership roles in prescribing, referrals and admissions management clinical investigation workstreams. Some of this workshould help facilitate disinvestment.

Implementation: 20 requirements for 2020Vision

This is a summary with fuller detail in the appendices. Some of this DOES appear in the Strategic Plan, particularly the appendices, but is acknowledged here too.

  1. 2020 Vision requires - above all -more GP hours in Lothian. GPs are already working in the way outlined by the strategic plan – expert generalists at: efficiency (and already far down that curve…) rapid diagnosis, risk assessment, managing uncertainty, team working (with a central ‘directing’ and hub roleand crucially maintaining long-term relationships and stability), using community facilities, integrated care, prescribing, LTCs, palliative care, record keeping, IT, patient knowledge, holistic care, communication skills, teaching, training and public health implementation. For £70.00 per patient per year, GPs provide high quality records, prescriptions, unlimited consultations, house calls, nurse time and telephone calls, at a fraction of the cost of a single outpatient appointment3. Extensive American-based reviews suggest that an increase of one GP per 10,000 population is associated with an average reduction of 49 fewer deaths per 10,000 p.a.1 Mental health is another area where GPs are the key deliverers of care - and this, above all, requires adequate and therapeutic GP time and space. Increasing evidence supports psychological therapies, and yet there remains a chronic under-provision of formal mental health services. That ‘there is no health without mental health’ is supported by the evidence: we know that co-morbidity is a huge determinant of mortality and morbidity (including admissions – see 15) and there are few pharmacological or technological short cuts to aiding recovery.

GPs are core to managing complexity and multi-morbidity in the community and 2020Vision will not work without more of them. LUCS is dependent on having a big enough pool of experienced, motivated, and non-exhausted GPs for its work and this is currently compromised. We already work on the right hand side of the table, but are being driven to the left by lack of resource, cut-backs, workload and fragmentation. 10% of the population consults with us weekly, an astonishing level of access, surely the highest in the world?

To an extent the challenge is process (Hannah and her ‘colleagues’ should help with that), but mainly volume and interface working – both will need to expand considerably. NHS Scotland’s route map to 2020 Vision4makes it clear that there is an “urgent need for an expanded role for primary care and general practice in particular…is at the heart of 2020 Vision…and represents a critical prerequisite to tackling health inequalities and the challenges facing unscheduled care…”.

  1. The Workforce Demographic.The evidence in the UK is: more part time working (especially younger GPs), early retirement; emigration; fewer entering General Practice; and female GPs in particular leaving the profession at a young age. Every GP costs the taxpayer half a million pounds to train.Nationally six out of ten GPs intend to retire early (particularly worrying as 40% of GPs are over 50, 22% over 553), GP training applications are 15% down in the last year and there has been no dedicated funding for new premises for over a decade.NHSL has to account for the new demographic when it considers and implements policies, particularly as the 2013 Primary Care Workforce Survey (ISD) showed that non-partners and younger GPs tended to have lower sessional commitments. In a recent South-East of Scotland survey of GP trainees (see below) only half were considering partnership in the long-term (at 10 years). NHSL has sometimes restricted measures which retain GPs – (wrongly) reducing funded Retainer sessions from 4 to 3; less generous maternity/paternity provision than almost all other Health Boards and so on.Dr Amy Small’s survey of final year GP Registrars(2014) saw a return of 31 questionnaires (62% response rate). Their expressed ambitions were:
  2. In the next year: 8 salaried, 2 partners, 2 retainers, 28 locum;
  3. In the next 2 years: 20 salaried, 6 partners and 1 retainer;
  4. In the next 10 years: 4 as salaried, 15 as partners and 4 unsure;
  5. Out of Hours work: 22 are considering, 4 definitely not and 4 unsure;
  6. No-one planned to still be undertaking locum work in 5 years.

The view of Professor Anthea Lints (NES) is that: “Lothian, Fife & Bordersfills most of its training places through the annual recruitment cycle, though in recent years there have been significant numbers of unfilled vacancies elsewhere in Scotland, particularly in the north and west. This year (2014) there were 33 unfilled GPST programmes in Scotland after recruitment was complete compared to 25 unfilled programmesin 2013.However nationally therewere slightly fewer applicants for GPST programmesoverall but significantly fewer (-558)applying from UK Foundation Programmes.

Increasing recruitment would not provide an immediate solution to increase the trained GP workforce. More effort needs to be made to encourage retention and re-entry. The retainer scheme continues to thrive in Lothian through support from the Health Board however lack of protected funding has hindered a more proactive approach to support post-CCT doctors returning after a career break or thosewho are included on theGMC GP Register butwith no experience of working in the NHS. Induction and returner programmes are available locally but funding is uncertain and unreliable. Scottish Government, Health Boards and the Scotland Deanery are considering how funding could be managed sustainably and how these programmes could then be advertised more actively.

Similar strategies are being discussed in England.Returner programmes in Englandare educationally similar to those proposed in Scotland although entry criteria and assessments are slightly different. Assuming an increased supply of "inducted" trained doctors from strategies on both sides of the border, Scottish practices who need trained GPs could offer attractive opportunities within a competitive UK market (such as flexible working hours, protected time to engage with local PBSGL groups or attend CPD events, opportunities to develop special interests within and outside practice, involvement in local health planning and in local partnerships, better conditions through working with NHS in Scotland, study leave and funding, mentoring arrangements)”

3. GP Sustainability. This is integral to maintaining the workforce. Lothian now has to do everything it can to make Lothian a good place to work on all fronts – to maintain our GP headcount we have to compete to be more attractive than elsewhere, including to retainers, returners and the newly-qualified, and advertise those advantages to the world. The strategy needs to state explicitlythat we need to make working in Lothian appealing to GPs, and support GP functions in order to do this.This is on a background of Scottish GP contractors earning almost £20 000 p.a. less than their English counterparts and considerably less than their Welsh and Northern Irish colleagues. However, Lothiandoes offer benefits: a high quality medical environment both in primary and secondary care; the Scottish - rather than English - infrastructure and approach, includingnone of the CCG, CQC, private primary care provision and other difficulties of the NHS down south, and a helpful and interactive PCCO. NHS Lothian is currently unique in Scotland in continuing to offer comprehensive Occupational Health provision to practices: we have just been informed of the withdrawal of this service, which is not helpful in terms of enhancing recruitment. Yet all these mean very little if the daily workload of a GP is overwhelming and increasingly impossible, with ongoing erosion of any semblance of an adequate work-life balance. We need to reverse the downward spiral of morale and promote a positive vision of General Practice within Lothian and the press,develop better premises, good relationships and improved working with secondary care. We know from healthcare evidence that the locus of control is critical to individual wellbeing, another reason to establish new mechanisms for agreeing, and managing, the current unresourced secondary care workload (which GPs find very dispiriting), as well as that associated with 2020 Vision.

  1. 10 new practice premises with funding for all the practice expansion/development identified by the LEGUP (List Extension Growth Uplift) consultation and in the Premises Paper (Edinburgh). An equivalent is now required for the other areas of Lothian, where greater populations expansions than Edinburgh are anticipated. In 2010-2020 it is predicted that the over- 65s will increase by between a quarter and a third in each of West-, Mid- and East-Lothian. LEGUP brings inequity (non-LEGUP practices under huge pressure are registering new patients without added resource) and risk to practices (if they cannot maintain patient numbers), but is arguably efficient – allowing practices to essentially expand witha minimal additional spend. This has ‘natural limits’ and the Board should be attempting to maximise - rather than restrict - LEGUP payments to make use of this mechanism whilst it remains feasible. Its lifespan is pretty short as there is a ceiling to GP efficiencies and practices are finding it increasingly difficult to recruit staff. Primary care builds, including new practices, need to be better defined in the Plan – in line with secondary care ones- or we fear that they won’t take place.Our view is that many of the secondary care spends outlined in the Strategic Plan are not affordable - page 46 of the Strategic Plan states: “The large funding gap in the years 2016-2019 is due to large capital schemes”.
  1. New secondary care nurses and HCAs in the community to perform bloods, ECGs, BPs, surgical wound careand so ondelegated to GPs by hospitals. Currently GPs undertake 100-150 chemotherapy bloods daily, thousands of PSAs and many other tasks requested by secondary care: 4,000+ pre-op MRSA swabs are required in Lothian for cataract surgery alone(GPs already do some unresourced) and many could be done closer to home, reducing hospital-based care. Such work currently has a DOUBLE costfor GPs– who have to organise the test itself, but often also inform secondary care of the result, or check that it is being managed.(NB: There are very significant clinical governance issues relating to this too - particularly round PSAs). This workforce may also be needed to undertake DMARD work if that is not fully funded in the enhanced service. We need an agreed Charter of joint working, which should alsoimprove quality, reduce risk and enhance working relationships. We now reluctantly accept that we have to contemplate a deadline after which GPs will no longer undertake tests for secondary care, in order to maintain clinical safety. Such an agreement will also be required to progress work round any data sharing, and the Clinical Portal.
  1. A six month rapid needs appraisal. Practices (& the PCCO) can readily submit: ACPs, patients over 65, 75, 85, patients on palliative care register, housebound, care homes, health inequalities and so on. Some of this work is already underway and partly as a QOF Quality Improvement Data set.
  1. New community staff: We need to establish safe levels of community staffing for a defined and expanding workload. This should include new community palliative care nurses on the basis of thousand patients over 65; new practice-attached community nurses per thousand over 75 (>65 for practices with 35% of patients in SMD 1stquintile, reflecting the evidence base) to undertake holistic multidisciplinary care with chronic disease support. This is crucial for improved Support for Self-Management (SSM). The ‘Primary Care Strategy Demand, Capacity and Access’ appendix clearly outlines the pressures of the increasing population and that community nurse provision has FALLEN in relation to this, and this fall is even more severe as patient complexity has increased and there is a documented rise in deaths at home (terminal care is extremely costly in District Nurse time). More community nurses will be needed for the rises in dementia (70% in the next 20 years), multi-morbidity (associated with the 22% increase in >75 by 2020) and cancer (20.5% increase estimated in Lothian by 2020). Also needed is community nurse support for care homes(and perhaps other work too) to act as first point of contact for problems, including those presenting out-of-hours, in order to safeguard GP capacity. We also need more HVs, particularly in view of the impractical and unnecessary ‘named person’ scheme, and more community midwives, especially in areas of deprivation.
  1. Care Home Standard Operating Procedure. Drs Carl Bickler and Nigel Williams have offered to do this.
  1. Out of Hours. LUCS needs significantly more GPs to be sustainable, very much mirroring the in-hours requirements.See appendix 3 (Dr Sian Tucker).
  1. Full funding of enhanced services – our principalcurrent mechanism for significant resource transfer. We have currently limited, or no, funding for DMARDs, vLARC and the new Diabetes ES proposal. We need assurance of further resource subsequently – tackling diabetes in the middle years was identified by the Strategy as an effective intervention, but remains unfunded. We needrealistic resource for the ES for elderly-frail-multimorbidity-housebound and Care home work.The second of the Government’s ‘triple aims’ is to improve the health of the population and the Committee has already objected to the anticipated withdrawal of the Alcohol enhanced service. Of note, too, is that we have some excellent innovators in Lothian, who provide potential models for new work, including round dementia and health inequalities (eg. Dr Patricia Donald’s 17c work; David White’s Headroom Project).
  1. Integrationhas to change how we work but we still lack the evidence base for money saved: the early analysis is that it does change approaches to patient care but does not necessarily reduce costs5. The much-quoted Nairn model didnot save money but did move patients from secondary to primary care and provides an evidence base and mechanism for this6.
  1. Primary-secondary care working. There is extensive room for improvement and expansion. There have been multiple secondary care-led attempts to rationalise referrals in particular. The King’s Fund has clearly outlined that systems change will not be effective using this model, and requires instead the activeparticipation of all those involved. The 2011 Audit Scotland national Review of Community Health Partnerships7 advocated change, noting that GPs indirectly commit significant NHS resources, but are not fully involved in decisions about how resources are used. ‘Teams without Walls’8 the joint RCGP, RCP and RCPaediatrics & Child Health document also outlines the benefits of joint approaches to services planning. Entirely newsystems workstreams with resourced GPs at their centre will be needed to take this work forward. (See appendix 2).
  1. IT. This has generally transformed our work for the better, but is also slow and often poor. GPs have identified packages and systems which would help both clinical and backroom functions in terms of time and efficiency savings but are told funding is not available for these. Investment would free up some capacity – particularly ‘backroom’- and be much more efficient than alternative proposals round systems sharing. The GP Sub-Committee is about to review data sharing arrangements and continues to collaborate positively with the Integrated Resource Framework and SPIRE. Every Care Home needs a terminal with web access to allow GPs, DNs and LUCS to use Vision 360 and the Clinical Portal and this should be part of the Care Home SOP.
  1. Prescribing. The LJF is an extremely cost-effective resource – and GPs have saved huge amounts of money through its use and judicious prescribing. These efficiencies need to be fully implemented in secondary care and every effort made to maintain and develop the LJF itself. Not including premises, prescribing is the 2nd biggest NHS cost after staff (£132million p.a. in Lothian primary care).In order to save money we need a routine Community Pharmacy presence in practices. See Appendix 2.
  1. Laboratory tests. There is a proven track record in Lothian of a joint primary-secondary care group (PLIG) saving NHSL substantial money over the years through reductions and rationalisation of laboratory testing. This group has also improved quality and safety round test ordering and understanding, so crucial to good clinical management. ALL its guidance is produced with an evidence base, agreement between primary care, secondary care clinicians and senior laboratory staff and approved by the GP Sub-Committee. There is considerable capacity for further savings – in terms of rationalising tests (saves GP workload too in terms of processing results) and introducing new tests which potentially save referrals and admissions. The laboratories are keen to do more, but unfortunately it has not been possible to fund a post of a GP session a week to take forward this important work which would save money, support quality, facilitate transfer of work from secondary to primary care. Three years on, we still do not have funding for BNP, a test which NICE claims substantial cost savings as it allows primary care to readily exclude heart failure without a referral for a cardiac echo, and may prevent admissions. This does not auger well for effective change more generally.
  1. Health Inequalities. NHSL does not resource this work to any meaningful scale in primary care – and yet poorer populations generate a very disproportionate morbidity and workload for both practices and secondary care. The Audit Scotland report, ‘Health Inequalities in Scotland’9outlined that there were some improvements but:
  2. the health inequalities due todeprivation (the biggest driver) remain and are significant
  3. healthy life expectancy has not improved (18 years between worst and best): the Strategic Plan itself states that that people living in the most affluent communities in Lothian can expect to live 21 years longer than people living in the most deprived communities)
  4. the life expectancy gap for women is increasing (7.5 years between worst and best; the equivalent for men is 11 years);
  5. average life expectancy in Scotland is lower than the UK averages (and most of Western Europe) for both men and women.

The report states that “Primary care is the main focus of most efforts to reduce health inequalities”, and refers to the Equally Well advice that: “NHS action to reduce health inequalities starts with primary care, where more than 90% of patient contacts take place”. It is not clear to us (or to the Audit Scotland) where the £170million(2011-12) allocated to Boards for this work was spent, nor that there has been implementation of the report’s recommendations for Boards to “review the distribution of primary care services to ensure that needs associated with higher levels of deprivation are adequately resourced”.

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