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Frustrations and Irritations Poor communication systems cause confusion for patients; need better information for staff and patients on "out of hours services"; too many referrals need to go through a GP for primary care, secondary care and social care services and equipment; primary care practitioners need better access to diagnostic services and rehabilitation; inappropriate triage by non-clinical staff in GP surgeries; increasing waiting times for, and cancellations of, hospital out-patient clinics creates additional workload for primary care. |
The Scottish Consumer Council Report "Access to Primary Care Services in Scotland" (2001) demonstrates that this is a key issue for people. It does not matter how good a service is if those who need it are unable to access it. Access can be limited in a variety of ways - this may be related to where services are provided, how they are provided or when they are provided. But in promoting easier access to services, there are tensions which must be recognised. People value the length of time that they have with a GP or other primary care professional, and it is important that ready access and quality time is afforded first to those who need it most. In addition, those working in primary care can be frustrated when having seen people quickly, it is difficult for those patients to access secondary care.
Achieving Better, Fairer Access to Services
The PCMG, in focusing its main attention on primary care, recognises that, despite the efforts of many hard-pressed staff, access to primary care services is poorer in many of the most disadvantaged communities (Poverty & Social Exclusion in Rural Scotland, 2000 and SCC Report). Improved access, together with improved prevention and earlier intervention in health problems, is central to ensuring that primary care makes an optimal contribution to reducing health inequalities (Fair for All: Working Together Towards Culturally-Competent Services, 2002). Significant groups in the population who can be disadvantaged in seeking access to primary care services include homeless people, travelling people, people from ethnic and other minority groups. Chapter 3 seeks to address the difficulties experienced by individuals with mental health problems.
It is vital that individuals, including those with physical disabilities and other impairments, can gain access to the premises. While there has been a valuable programme of investment in upgrading and replacement of primary care premises, there is a recognition that more needs to be done, not least because of the importance of meeting the requirements of the Disability Discrimination Act 1995.
Access to Information and the Right Member of Staff
The public need ready access to information on health and how to access health services. In some parts of the country interpreting and translation services are being introduced to assist individuals with communication difficulties. The introduction of NHS 24 in 2002 will provide another way for the public to obtain information as well as providing opportunities to redesign the public's first point of contact with primary care.
Alongside the provision of information and support - encouraging individuals to take a more active role in managing their health - a challenge for NHSScotland is to reassure the public that "when you are unwell you don't always need to see a doctor". In Our National Health the Government made a commitment to work with the professions to enable the public to access an appropriate member of the primary care team in no more than 48 hours. This reinforces the point that primary care is a team effort - with a range of complementary skills and roles, so that the right team member can provide the initial clinical assessment and onward access, where appropriate, to another professional.
Increased Flexibility
The development of the extended primary care team over recent years has provided an opportunity to utilise the skills of all disciplines more effectively - e.g. nurses providing chronic disease management and triage services, community pharmacists providing advice on health and treating common ailments. The traditional role of the GP as the gatekeeper into much of the rest of primary care and specialist services is changing. There will need to be changes in the system, together with a change of culture - both for professionals and the public - if the opportunities available are to be fully exploited, for example:
The PCMG believes that direct access by patients to the relevant primary care professional and from that professional direct to others in primary care and secondary care (when needed) is appropriate and all clinical staff should have ready access to relevant diagnostic facilities. The constraints which some perceive often turn out not to be real in practice.
For the small percentage (some 10%) of patients who present to primary care who require onward referral to secondary care, improving the referral and discharge systems and communications between primary care and secondary care is essential for better co-ordination of patient care.
Reducing Waiting Times and Improving the Patient's Journey
Evidence suggests (Wanless Review - 2001) that patient expectations
are, and will
be, for longer consultations with a GP or other health professional. Service
redesign, new technologies, greater flexibility in roles and responsibilities
of different staff
groups and tackling bureaucracy can all create scope to increase the proportion
of time health care professionals spend with patients. Better informed patients
who take more responsibility for their health and care will change the nature
of the relationship between patient and professional. There need to be well
resourced approaches to helping LHCCs and primary care teams tackle these challenges,
and the PCMG has noted the initial positive outcomes from the Primary Care Collaborative
methodology developed in England.
Some new resources have already been invested. In September 2001 £30m over three years was allocated to develop primary care, through LHCCs. Across the country, LHCCs have allocated some of this funding to specific aspects of service access, as well as supporting and developing a range of clinical services in primary care. It is important that the opportunity is taken to make the most effective use of all the funding available - for premises improvements, IM & T, Health Improvement Fund, etc.
In the wider agenda of joint resourcing and joint management, LHCCs have a major role to play in helping to design services which make better use of skills and resources across the whole health/social care spectrum.
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Developing Best Practice into Common Practice: A "model pharmacy" has been developed in Possilpark, Glasgow providing a resource centre where other staff can work - complementing the core pharmaceutical services normally available. The local community can access a range of services from one convenient location. |
The PCMG believes that the following actions should be largely focused at LHCC level, although it recognises that (depending on local circumstances) they will need varying levels of support from NHS Boards and PCTs to help them deliver: It recommends that:
overall access to primary care services in each locality should be systematically audited and action plans developed to move towards the target of accessing a relevant member of the primary care team within 48 hours In doing so, the specific needs of particular disadvantaged groups should be addressed;
as part of local property strategies, an audit of primary care premises in each locality should be undertaken, identifying suitability for current and future use, including the standard of accommodation and location. This audit should cover the whole of primary care including dental, optical, pharmaceutical, and professions allied to medicine (PAM) services;
the broader local community needs, as demonstrated through the community planning process, and the outcome of the premises audit should be used to develop a premises strategy which makes the most effective use of existing facilities and the various sources of funding available for primary and community care developments.
To help people have access to the right member of primary care staff to meet their needs, there should be locally planned programmes, underpinned by relevant training, which could include:
telephone triage systems
development and more effective use of the skills of all primary care staff
direct access to the full range of primary care staff
local protocols for inter-disciplinary referrals within primary care
information to local people about how to access and make the best use of services
use of NHS 24.
Service redesign approaches should be supported which:
improve access to primary care (in particular, the Primary Care Collaborative approach should be adapted for, and tested out, in Scotland)
improve referrals to, and discharges from, secondary care (this needs to include direct access from a wider range of primary care staff and be supported by improved information and communication technology).
Inappropriate use of clinical time should be tackled:
locally - by better use of support staff (clerical and technical)