1. The Scottish GP Contract; an update on the opportunities provided by the new GP contract and more integrated care Frank McGregor Primary Care Division Scottish Government
7th December 2015
Thank you for chance to contribute to the day - purpose is to follow up offer on earlier horizon scanning event where we promised to provide an update on the GP contract and to support the Deep End group’s consideration of its role/impact on the wider system - initially by raising awareness of contract and integration developments

2. 2004 – a big bang?
Introduction of a ‘layered’ contract; Essential, Additional and Enhanced Services
Quality and Outcomes Framework (QOF)
Very brief recap of how we got to where we are now – most will have been around pre-2004 but possibly not all; the pre-2004 ‘superman’ contract; ‘we were asked to and just did everything’

3. 10 years later Increasing workload; particularly multi-morbidity
Increased bureaucracy; reporting, monitoring
Patient-focus; less so
Impact on Health Inequalities; exception reporting
What that has brought us to now?

4. But… More systematised care; for specified conditions
Performance related pay
Standards and processes; with external scrutiny/verification
Still need to remember not all bad – there were some benefits to that approach

5. Drivers for change? Patients; access, multi-morbidity
Professionals/BMA; bureaucracy, workload, demand, recruitment/retention
Scottish Government; integration, 2020 Vision, access, recruitment/retention
Boards; remote and rural, urban challenges – not all the same
All; intended direction of travel; ‘more care at home’
However a series of issues that need to be addressed; leading to common themes and meeting a set of needs; 2 key amongst them - making the career choice attractive again and supporting flexibility for local solutions

6. Change to what?
Future role of the GP; expert-generalist; complex care, undifferentiated illness, quality and leadership
Future role of all professionals; ‘top of licence’
GPs; a voice in the wider system
Towards a ‘Primary care led NHS’
So what might the future look like for a GP/others? These are things that GPs have been asking for for some time now ‘why I chose and trained to be a GP’ (might not have called it working at ‘top of licence’ but that is what it effectively is – doing only what needs to be done by a GP and others, by doing what only they can do, supporting that

7. Expert-generalist Complex care; reactive and proactive
Reactive; source of support to those other professionals working to the ‘top of their licences’
Pro-active; being supported to identify and to work with others to address the needs of a cohort of ‘high gain’ individuals
Focusing on those patients who really need GP input (and more time) – have complex care needs/high demand/high cost, usually elderly with multi-morbidity but not always e.g. young chronic sick, or younger patients in more deprived areas

8. Undifferentiated illness
Managing uncertainty
Determining who needs further investigation, treatment, referral
Bedrock of the expert-generalist
What only a GP can do?
Again a task best suited to high level diagnosticians and therefore not readily delegated to others – wheat and chaff? – those who know that they can be seen by others/we can support toi understand that they can be seen by others should go there instead – agin should free up time for those who need to see a doctor

9. Quality and leadership
Every GP involved in quality
Focussed on outcomes (cf. QOF)
Some GPs involved in leadership; cluster lead
Changes to services; within and out with the practice
Virtuous cycle; PDSA – Plan, Do, Study, Act
All GPs to be supported to be involved in continuous quality improvement – that impacts not just on their GP practice but on the practices in their cluster and across the wider system (social and secondary care) – working on the detail with BMA but will support the aims of integration re cluster/locality working – may involve those in an LMC role
Cabinet Secretary announced 1 October that we would begin steps towards dismantling QOF

10. Implications for whole system
GPs; training and time, numbers?
Other primary care professionals; training and time, numbers?
Secondary care professionals; training and time?
Time = cost
Evaluation/research
In order for this to work a whole range of other professionals working across primary care will need to ‘step up to the plate’ and work to the top of their licence too – big ask but some are clearly up for it e.g. Prescription for Excellence.

11. What have we done so far?
Engaged with professional representatives; BMA/CNO
Engaged with front line clinicians and senior managers; Boards and Integration bodies
Engaged with professional bodies; RCGP
Engaged with key stakeholders
How we came to this conclusion

12. How will we know that it is working?
Care delivered by the person with most appropriate skills
The journey out of hospital is planned and straightforward
People admitted to/attending hospital only when they need to be
High level outcomes

13. Looked at it another way?
GP the career of choice
Improved patient access and confidence
Reduced avoidable admissions to hospital
What will it mean to GPs , patients, the wider system – it needs to benefit them all to be a ‘goer’

14. Pump priming; 60 m investment
Testing, demonstrating and developing new models – in at least ten areas
New pharmacists/pharmacist roles
Mental Health developments
IT developments
Leadership for integration
Equipment for optometrists
GP recruitment, retention and education
Scottish School of Primary Care; research
How we are supporting some of this – not so much about the details as about the myriad of underpinning aspects

15. Testing the new model Elements and totality at scale
Historical programme; scaled up, more focused
Experiential learning; to inform developments
Reactive and pro-active learning and developments
How we plan to ‘test this to destruction’ – will it really work, what might it cost, in terms of resource, personnel and time?

16. Questions
Before questions juts re-emphasise the route by which areas/practices/communities might start to influence future (more appropriate) resource allocation