As indicated in Chapter 1, if primary care is to tackle these priorities effectively, it needs to have the capacity and organisational support. The development of LHCCs is a vital component in this, but equally important are:
Workforce issues
Service redesign
Premises
Information management and technology
and the PCMG recommendations on each of the above are discussed in this chapter of the report.
The organisational support which primary care (particularly LHCCs) requires in order to deliver the recommendations in this report need to take account of the changing and developing needs in the community and these require to be seen in the broader context of partnership working.
The "Joint Future" (2000) agenda, is perhaps the most challenging aspect of partnership working. While there are already examples of joint management and resourcing of health and social care for mental health, older people's and learning disabilities services, the introduction of such arrangements means new ways of working for many staff and the need for support during the change.
Community planning is now the vehicle through which local planning is co-ordinated by local authorities, and LHCCs have a key role to play in ensuring that the health input reflects the local needs which they have identified.
LHCC Development
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Frustrations and Irritations Need to have more devolved power: decision-making, planning, service delivery and resource allocation; involving the local community in planning services has raised expectations about what the LHCC can deliver; LHCCs need to agree priorities with local authority if they are to be portrayed as multi-agency; local responsibility will allow local solutions. |
The PCMG is very conscious that LHCCs are being invited to take on an enhanced role both within the local health care system, and in the developing partnership arrangements. The PCMG recognises that organisational development support will be required to help deliver this challenging agenda.
At the outset, structures and responsibilities for LHCCs were intentionally not prescribed, encouraging local ownership and commitment. During the last two years many LHCCs have evolved into multi-professional, and in some cases, multi-agency organisations. Some have active community involvement. However, the PCMG recognises that the lack of standards presents difficulties around responsibility and accountability. In order to fulfil their role in the future NHSScotland (whatever its final shape) LHCCs must be able to demonstrate consistent and coherent standards and added value (as detailed in "Connecting Communities with the NHS"). In taking forward the good practice in evidence in some parts of the country, there is a need to support NHS professionals to develop their role within LHCCs. LHCCs need to demonstrate inclusiveness (by bringing together all who work in primary care settings as full members) and support all constituents in planning and priority setting, and delivering services within a culture of teamworking.
Accountability for LHCC Development
While the diversity in the development of LHCCs across Scotland has had its benefits, the PCMG believes that the relevant section of the performance assessment framework (PAF) on LHCC development provides an opportunity to measure more systematically the development of LHCCs as key players in the local NHS and joint systems.
The challenges for NHS Boards (while recognising that not all LHCCs can or need to do everything themselves) will be:
Key Roles within LHCCs
The role of the LHCC Lead and Manager will be crucial to the ongoing development of LHCCs. For many LHCC leads the position is undertaken on a part-time basis with competing pressures on their time. There is a diversity of role, reward and support available. The extent to which they believe the LHCC is genuinely in a position to make change and be involved in strategic decisions within the local health system will influence their desire to remain in the position. Similarly, there are wide variations in the role, responsibility and reward for LHCC Managers.
Looking to the future, the PCMG suggests that NHS Boards should seek to identify clinicians in primary care with the potential to become LHCC leads and provide training and development opportunities.
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Developing Best Practice into Common Practice: Perth & Kinross - Care Together: Care Together has a budget of approximately £50m, with responsibility for the provision of a range of health and social care services. The organisational mechanism is set around locality-based teams. Care Together has invested time in the development of an organisational framework, including a human resources implementation plan, the development of financial and information systems. |
The PCMG recommends that:
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Frustrations and Irritations Morale affected by too many changes, too quickly; staff at the "sharp end" need to be able to make decisions; need Scotland-wide agreement on current best practice on extended roles; need dedicated time for clinical staff to meet to discuss clinical patient issues; all staff need time for training. |
Professional Roles and Responsibilities
While the increasing emphasis within primary care is on greater team working, each of the professions faces specific challenges in its contribution to the effectiveness and efficiency of service delivery, e.g.:
It is important that both the undergraduate and postgraduate education systems recognise and respond to the changing professional and service needs. In particular there is an opportunity for the new Special Health Board for NHS Education in Scotland to focus on both the individual and collective needs of the professions in primary care.
Recruitment and Retention
Primary care services face similar challenges to the rest of the NHS in recruiting and retaining staff, although there are greater problems in some remote and rural and deprived areas. RARARI is actively exploring possible solutions for the former, and incentives are also planned or being considered for specific professional groups. It is important that independent contractors (and the staff employed by them) are regarded as part of the wider "NHS family" and that recruitment and retention action plans (such as that being developed under "Facing the Future") encompass all staff, not just those directly employed by the NHS.
Making Best Use of Skills
It is important to utilise the skills of existing staff to their full potential. This is already happening in specific professions and teams in primary care e.g.:
But there is more to be done in using technical and support staff to free
up the time
of more highly skilled professionals.
Developing the Team
While in most parts of Scotland, much has been done to support and develop the primary care team (GPs, practice nurses, community nurses, etc.), the challenge now is to build on that to encompass the wider team and ensure that all the professionals in primary care are seen as valued members. The development of the Public Health Practitioner posts in LHCCs has created an opportunity to co-ordinate activities focusing on promoting health and wellbeing, developing partnerships with other agencies and local communities. The Joint Future agenda, including, for example, the introduction of single-shared assessment of older people from April 2002, further demonstrates the need to extend the team beyond health and into social care and other community-based services. This will not happen without dedicated training and development support, and this needs to include, as equal participants, independent contractors and their staff, as well as direct NHS employees. With increasing emphasis on working in partnership with other agencies, local healthcare systems need to ensure that the resources available are utilised in the most effective way. The "best person" need not be a healthcare professional. For teams to work effectively, they also need the right premises to work from, the information (and information technology) which supports effective communication, and the management and clerical support which allows clinical staff to concentrate on their core activities.
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Developing Best Practice into Common Practice: The introduction of model schemes for pharmaceutical care has provided an opportunity for community pharmacists to complement existing services in primary care and recognise the specific skills of community pharmacists in improving care in the community. Model schemes developed to date include patients requiring palliative care, patients with severe and enduring mental illness and support to frail, elderly patients living at home. |
The PCMG recommends that:
Quality
An overall framework is needed to support development, accountability and continuous improvement. This should support the growing clinical governance agenda (with an increasingly multi-professional focus) and be underpinned by research (using for example, the resources of the Scottish School of Primary Care). The review of national organisations with an interest in clinical quality (CSBS, HTBS, CRAG, etc.) gives the opportunity to build on, in a co-ordinated and inclusive way, initiatives already in place in primary care e.g. the RCGP practice accreditation scheme. Again, getting the right balance between the requirements of individual professionals, of the different teams, and of corporate accountability will be a challenge.
Redesigning Services
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Frustrations and Irritations Patients discharged home without GP being notified; beds blocked due to lack of primary care and social care services; too many short-term pots of money for projects and funding "gets lost in the system"; too many requests for the same, or similar, information from different parts of the system; not clear how decisions are made; clinicians and managers in primary care and secondary care need to meet to discuss proposed change in services and identify knock-on effects; staff in primary care do not understand secondary care and vice versa; insufficient trained staff to make changes happen. |
In the comments received from stakeholders a significant number of "frustrations and irritations" voiced were in relation to the interface between primary care and secondary care (acute services, psychiatric services and specialist older people's services). The present way of working is not resolving these problems as organisational boundaries do not encourage staff to see the problem from the point of view of patients moving through the whole system. LHCCs need to work in collaboration with specialist services to develop the most appropriate models of care, with shared protocols and integrated communication systems. It is only through a genuine collaborative process that redesign of services will be successful.
Redesigning services is fundamentally about rethinking how services are provided, focusing on areas for improvement in service quality and access to care by patients. The process is based on effective teamwork across all sectors and the greatest leverage lies in changing patterns of interaction - removing those steps which provide no added value to the patient. Redesigning services may impact on how staff work and where they work - seeking to make the best use of their skills and knowledge.
Vehicles which may help to facilitate redesign include the "Collaboratives" approach which involves identifying and implementing innovative and successful practices that create fundamental improvements in service utilisation, patient satisfaction and clinical outcomes. Personal Medical Services (PMS) is also giving some LHCCs the opportunity to look at how services can be delivered in a different way.
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Developing Best Practice into Common Practice: Within NHS Forth Valley a number of service redesign projects have led to significant benefits for patients, including: Redesign of acute emergency medical admission and discharge practices to ensure a patient focus, improving clinical effectiveness. The project aims include addressing unacceptable practice, such as frequent decanting, long patient waits on trolleys and unplanned discharge and to develop acute/elective admission care pathways. |
The PCMG recommends that:
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Frustrations and Irritations Lack of community-focused health care centres which could meet the needs of all aspects of patient/client care; need more funding to upgrade premises to accommodate the primary care team; need to improve transport systems - particularly in remote and rural areas. |
Developments to Date
The expansion of the level and range of services provided in primary care and community settings, the wish to improve access to services by patients and the requirements for continuous improvements in the quality of services has led to increasing pressures on primary care premises. The Modernisation Programme, in addition to the traditional funding sources, has produced some important development models but it is acknowledged that there is still much to be done. The earlier chapter on "Access" lists some specific action on the overall planning and provision of premises. There are also specific aspects which need to be considered:
Community Pharmacy Services
Dental Services
In both services, however, it is clear that the traditional funding methods, whereby individual contractors/bodies undertook the whole capital investment, need to be reviewed.
Opportunities for Further Development
It is important that there continues to be an overall programme to develop the capacity of premises to support:
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Developing Best Practice into Common Practice: Opened in 2001, the Dalmellington Area Centre developed to serve a largely rural community and is a prime example of joint partnership planning. The Centre provides a wide range of primary health care and social work services, together with police services and a business technology and training centre. The local community are involved in the planning and provision of services through the Centre User Group. Visitors to the Centre and service providers are already seeing the advantages of co-location. Funding for the project was secured through a range of sources including the Primary and Community Care Premises Modernisation Programme. |
The PCMG recommends that:
Information Management and Technology
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Frustrations and Irritations Common databases and registers would improve efficiency in all sectors - avoiding duplications and gaps in service provision; too many delays in receiving results on diagnostic tests; software packages cannot deliver requirements of primary care team; not all members of the primary care team have access to a PC; systems do not link across the various interfaces; not enough training. |
Demands for Information
Capitalising on the potential of clinically-focused information technology will be a key factor in improving access to services, integrated service delivery, the management of chronic diseases and continuous quality improvement. IM & T developments need to encompass links within the primary care team and with other sectors - most noticeably secondary care and social work. At the same time, there are important issues of patient confidentiality and access to information which need to be taken into account.
It is important that those working in the service have a clear understanding of the overall IM & T strategy for NHSScotland and its implications for how they may work now and in the future.
Investment in Primary Care IM & T
Historically the various professions in primary and secondary care have developed information systems independent of each other, presenting many challenges for team working. The creation of LHCCs has added an impetus for integrated information systems. There has been significant investment in IM & T infrastructure over recent years which provides a basis on which integration of systems can begin to take place.
The enhancement of practice-based systems provides an opportunity for GPs, their staff and practice-attached community staff to make use of the technology as an integral part of their work, to support clinical care. Progress is being made to fulfil the Programme for Government commitment to link community pharmacists to NHSnet and parallel development work is underway to create the capability to transfer prescriptions electronically and exchange appropriate clinical information between GPs and community pharmacists. Similar links to NHSnet for dentists are under active consideration.
It is recognised that further resources will be required on a recurring basis to meet clinical information requirements and keep pace with technological developments. It is equally important to ensure that value for money is being obtained from the technology available e.g. better sharing of access to facilities, staff appropriately trained. NHS Boards should ensure that the infrastructure is robust and has the capacity to perform the task of supporting clinical practice.
Partnership Working
With the emphasis on improving the patient's journey, information and IT developments need to encompass links with other sectors - including:
Future Developments
Developments include:
In future developments, it is important that NHS Boards adopt a balanced approach to investment. The desire to invest in innovative projects should not be to the detriment of the infrastructure needed for basic electronic communications which some clinical staff (e.g. many PAMs and dentists) do not yet have.
NHS Boards are accountable for developing a local IM & T strategy, with progress being monitored through the PAF. It is essential that implementation plans build in resources for training and support for users - directly employed staff, independent contractors and their staff.
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Developing Best Practice into Common Practice: Sponsored by the Modernising Government Fund the e-Care project is being developed in Lanarkshire and other parts of the country to support more effective and efficient joint working - based on a person-centred approach, the project is developing new approaches to the management and delivery of health and social services. |
The PCMG recommends: