Background:
In June 2001, the Minister for Health and Community Care announced a "contract for change" with primary care in Scotland. This included:
(a) a positive response to the report of the LHCC Best Practice Group "Connecting Communities with the NHS". The policy paper LHCC Development: The Next Steps was published in July and set out how the new NHS Boards were expected to support and develop LHCCs in ways which empowered those in the frontline to plan and deliver services. LHCCs were to be given a voice in the strategic planning of change, with a formal advisory role. This greater responsibility was to be balanced with clearer and more robust accountability for resources and service improvement.
(b) additional investment to strengthen the core capacity of LHCC-based primary care. In August 2001, a £30m investment package over three years was announced, with a requirement that the money should be spent in agreement with and through LHCCs. The funding was to be targeted at:
(c) The establishment of a high level Primary Care Modernisation Group to drive the agenda for change.
The Primary Care Modernisation Group (PCMG) was established in August 2001 with a remit to:
The membership of the Group is shown in Appendix A.
Process:
The aim has been to develop a framework and action plan that reflect the requirements of patients and the public, staff and partner organisations.
In addition to seeking written input from a wide range of stakeholders across
Scotland, meetings were held in Inverness, Glasgow and Dunfermline to discuss
current issues, including aspects of the service which could be improved upon,
and future priorities.
It was clear that, for many staff, there are frustrations and irritations in
the current system and current ways of working which prevent staff offering
the best service to patients. It was equally clear that in many areas people
have devised ways of tackling these concerns and making the system work better
for patients. A summary of relevant "frustrations and irritations" is included
at the beginning of each chapter, to reflect what the PCMG heard and what it
has tried (at least in part) to address in the report and recommendations.
From the outset the PCMG was keen not to reinvent the wheel, but rather refer to evidence-based practice and standards, existing policies and strategies (e.g. for dental services, pharmaceutical care) and practical examples already happening in specific parts of Scotland. The PCMG wanted to highlight examples of what was already happening in parts of Scotland and which have been included in the report as "best practice". There are, of course, many other examples but the key issue is making that "best practice" wherever it happens common practice across Scotland.
While reference is made in this report to current organisational arrangements, the PCMG is aware that work is being commissioned which may affect, in due course, the configuration of NHS organisations within NHSScotland. It is assumed that LHCCs will continue to play a key role in the future, and will need the support of whatever structures are in place to help deliver many of the recommendations.
Vision:
People live in communities, primary care has its roots in the community. People want to be supported to help stay well and if ill, cared for in, or near, their home.
Primary care is first contact, continuous, comprehensive and co-ordinated care to individuals and communities. If it can be done in primary care then it should be done in primary care. To help make this a reality, the ongoing development of primary care needs to be supported so that best practice becomes common practice across Scotland.
Primary care is central to the NHS and works in partnership with all other parts of the NHS and other agencies (particularly local authorities). It is uniquely placed to influence and promote system-wide seamless care. It has enormous strengths on which to build in providing convenient, accessible and high quality care to people in their own communities. Primary care can and should:
While much of the detail of this report concerns activity, capacity and support within primary care, it is essential that this is seen as a component of a well-connected overall NHS and social care system. Divisions between different parts of the system need to be tackled to produce a cohesive and integrated approach. NHS Boards have that overall responsibility and thus are uniquely placed to ensure implementation of the recommendations in this report.
Strategy for Primary Care Services
Our National Health provides a clear direction on the national priorities for health and health care. The PCMG recognised that it had to focus on a small number of priorities for primary care if real progress is to be made. For the reasons outlined later in this chapter the PCMG identified the initial priorities as:
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- Chronic Disease Management |
The PCMG recognises that there is also a need to focus on promoting health and wellbeing and preventing ill-health, and would wish to tackle this in the next stage of its work. This would encompass activities undertaken with other agencies and local communities as well as the direct preventive services provided within primary care.
The PCMG also recognised that, in order to tackle the initial priorities, it was essential to look at the organisational support needed. This is done in the second half of the report. In particular, the PCMG is aware that, to enable LHCCs to truly influence changes in the health services and health status of their local communities as outlined in the "contract for change", the devolved responsibilities and accountabilities and the capacity of LHCCs require to be enhanced. Organisational support also includes:
Providing Services in the 21st Century:
Primary care (in common with other parts of the health and social care system) faces a range of challenges including:
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Tomorrow's patient: The generation of older people who are alive in 20 years' time will have lived very different lives to those of their parents. On a positive side, they are less likely to smoke, will have had access to health care throughout their lives thanks to the NHS and will be on average better off. On the negative side, they are more likely to be obese, have led sedentary lifestyles and lived in a society with greater income inequality. (Wanless Review - 2001) |
Geographical and sociological variations across Scotland: Scottish mortality rates remain high relative to the rest of the UK. Health in Scotland 2000 (2001) identified the clear association between deprivation and most cancers; there is a clear gradient of increasing incidence and mortality from coronary heart disease with increasing deprivation and the prevalence of common mental health disorders is significantly influenced by socio-economic factors. In addition to these "health variations", there are major differences in the way in which services are and can be provided in different parts of Scotland - from the large urban settings to the remote and rural areas.
Increasing Incidence of Chronic Disease: In the 21st century there are many aspects of the healthcare system in Scotland which are greatly influenced by acute disease while chronic disease has become the principal medical problem.
30% of households contain at least one person with a long-standing limiting illness, health problem or disability
20% of adults registered with a doctor visited their GP on 3-5 occasions in the last year, 13% visited more than 10 times.
Technology and medical advance: Technology is one of the most important drivers of health spending and of changes in the way in which services are delivered. The advances in human genetics and the genome project will lead to a greater understanding of diseases and lead to significant advances in their treatment and prevention. Developments in technologies such as miniaturisation and electronic communications will shift certain diagnosis and treatment from hospitals to primary care.
The expectations of the public and patients: The evidence behind Our National Health confirmed that people want to be more involved in decisions about their treatment and care. They want more information and to feel valued and enabled throughout their journey of care.
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In the future the public will expect:
(Wanless Review - 2001) |
Impact on NHSScotland
The changing profile of the population will not only have consequences in terms of the community to be served, but also how services are delivered and those available to work in NHSScotland. NHSScotland as a whole will need to consider new and innovative models of service delivery. The emphasis on improving access to services - at the outset and throughout the patient's journey of care - means looking again at the traditional boundaries between the various health professionals, and using the development of services, such as NHS 24, to redesign how the public access and make the best use of primary care. The use of smarter technology, including information technology, will help to support the provision of seamless care within primary care and across the NHS. The correlation between deprivation and health status and the increasing demands on primary care reinforces the need to work in partnership with patients, carers and other agencies.