Primary Care GMS
North Ayrshire Council · 9 May 2024
Back to Integration Joint Board — 9 May 2024 and its agenda
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Integration Joint Board 9 May 2024 Subject : Primary Care General Medical Services Update Purpose : This report provides an update to the Integration Joint Board on the provision of General Medical Services (GMS) across Ayrshire and Arran. The report also details the current position with implementation of the 2018 GMS contract and wider development work across general practice. Recommendation : It is recommended that the Integration Joint Board: i. Note the current position of Primary Care GMS ii. Note the progress of implementation of the 2018 GMS contract as well as the wider areas of development work across General Practice. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required x 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms BMA British Medical Association CAU Combined Assessment Unit CTAC Community Treatment and Care EMG Expert Medical Generalist GMS General Medical Services GP General Practice / Practitioner HIS Healthcare Improvement Scotland HSCP Health and Social Care Partnership IJB Integration Joint Board MDT Multi-disciplinary team MHP Mental Health Practitioner MoU Memorandum of Understanding MSK Musculoskeletal NHS AA NHS Ayrshire & Arran PLT Protected Learning Time PCIF Primary Care Improvement Fund PCIP Primary Care Improvement Plan TOC Test of Change WTE Whole Time Equivalent
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1. EXECUTIVE SUMMARY 1.1 General practices continue to face challenges with increased demand. Ongoing review of data and feedback has demonstrated that patients are presenting to General Practice with more advanced health concerns than they would have pre-pandemic. This in part can be attributed to this cohort of patients having more complex conditions and being managed longer by their GP whilst awaiting appointments in other parts of the system. Many of these patients require an extended (sometimes double) appointment time and clinicians may need to do a greater degree of follow up with the patient which again increases workload and appointment capacity. 1.2 Progress continues to be made implementing the 2018 GMS contract which provides the basis for an integrated health and care model with a number of additional professionals and services multi-disciplinary teams (MDTs) including nursing staff, pharmacists, mental health practitioners, MSK physiotherapists, and community link workers as well as signposting a number of patients, where appropriate, to other primary healthcare professionals within the community. This is aligned to the NHS Ayrshire & Arran Caring for Ayrshire vision to create a whole system health and care model focussing on individuals, families and communities with general practice and primary care providing accessible, continuing and co-ordinated care. 1.3 The Ayrshire and Arran Primary Care Team was successful bidding on behalf of the three Health and Social Care Partnerships (HSCPs) to be a Primary Care Improvement Phased Investment Programme Demonstrator site to work with NHS Health Improvement Scotland (HIS). This is to demonstrate what a model of full GMS Contract 2018 implementation of the MDT (focussing on Community Treatment and Care (CTAC) and Pharmacotherapy teams) can look like in General Practice. This is a 12-18 month programme which will be nationally funded and delivered by a local programme team with local governance arrangements. Data will be collected which will be used to model full national implementation of priority areas of the GMS 2018 Contract. Ayrshire and Arran will be one of four demonstrator sites across Scotland. 1.4 Development work will also continue alongside this to further embed MDT teams into practice through the GMS Contract which would continue in tandem with the focussed work on Pharmacotherapy and CTAC. 1.5 This report has also been presented to: i. East Ayrshire IJB – 20 March 2024 ii. NHS Ayrshire & Arran Board – 25 March 2024 iii. South Ayrshire IJB – 3 April 2024
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2. BACKGROUND 2.1 The Public Bodies (Joint Working) Scotland Act 2014 provides a legislative framework for the delivery of Primary Care Services in Scotland. East Ayrshire HSCP, through Lead HSCP arrangements, are responsible for the delivery of Primary Care Services across Ayrshire and Arran. In addition NHS Ayrshire & Arran directly commission East Ayrshire HSCP to conduct Primary Care Contracting on behalf of the Board, this being a function that cannot be delegated to IJBs at this time. 2.2 The 2018 GMS contract was introduced to facilitate a refocusing of the GP role as Expert Medical Generalist (EMG). The contract is a joint agreement between the Scottish Government and the British Medical Association (BMA) which sets out to: • Provide a new direction for general practice in Scotland which aims to improve access for patients, address health inequalities and improve population health including mental health • Provide financial stability for GPs, and reduce GP workload through the expansion of the primary care multidisciplinary team • Redefines the role of the GP as an expert medical generalist focusing on complex care, reduce the risks associated with becoming a GP partner and encourage new entrants to the profession as well as help retain existing GPs 2.3 The first Primary Care Improvement Plan (PCIP) (2018-2021) set out the plan to implement the new contract across NHS Ayrshire & Arran by 2021. The PCIP 2 (2020- 22) was approved at each of the IJBs, NHS Board and Local Medical Committee in December 2019. It set out a collaborative approach for delivery across the three Ayrshire IJBs, the NHS Board and the local GP sub-committee / Local Medical Committee. This inclusive collaboration has been essential in developing an the ambition for all parties to develop our Primary Care services to be both sustainable and meet the future needs of our communities within each of the partnership areas. 2.4 In 2022 Scottish Government advised that there would be greater focus on the delivery of Pharmacotherapy, CTAC and Vaccinations following agreement with the BMA that these would be the contractual elements of the 2018 contract. This then became the priority across Ayrshire and Arran. 3. PROPOSALS 3.1 Overview of General Practice Primary Care is usually a patient’s first point of contact with NHS Ayrshire & Arran and it is estimated that around 90% of NHS contacts take place within general practice. There are 53 GP practices across Ayrshire and Arran who all operate as separate independent businesses in their own right, and are not directly employed by the NHS Ayrshire & Arran.
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Within Ayrshire and Arran there are currently no Health Board managed practices, however the Primary Care Team continue to work closely with those practices that require support. The core elements of a general practice contract includes: • An agreed geographical or population area the practice will cover • Require the practice to maintain a list of patients for the area and sets out who this list covers and under what circumstances a patient might be removed from it • The establishment of essential medical services a general practice must provide to its patients • Outlines key policies including indemnity, complaints, liability, insurance, clinical governance and termination of the contract. 3.2 GP Practice Activity Whilst every GP Practice delivers general medical services through their contract with NHS Ayrshire & Arran, they have flexibility to deliver that in a manner that best suits their patient population as well as business model. One size does not fit all and all practices operate very differently in terms of clinics that operate on a daily basis, their clinical workforce model, and also how appointments are triaged and allocated. Recent available data shows that 55% of practices offer a triage first model for all requests for a clinician with the remaining 45% offering straight to clinical appointment. The majority of practices offer pre-bookable appointments. The small number of practices not offering pre-bookable appointments fed back that they feel that either their “same day” demand is too high to adopt the system, or they feel their appointments are already well managed without it. Those not operating triage first felt that it was unpopular with patients, duplicated work or was unnecessary given the current availability of pre-bookable and same day appointments at their practices. Data from the primary care information system shows that there has been a 20% increase in consultations from 2019 to 2023 with patients contacting their GP with more complex conditions. Patient Consultations currently sit at 2.5 million per year compared to just under 2 million pre-pandemic. During the pandemic a number of practices introduced an online platform for their patients to access practice services and clinical advice. Practices reported that this was easier for their working population to access services out with core opening hours and allowed staff to respond to patients directly without requiring an appointment and a time suitable to the practice/patient. This has also supported more efficient use of admin time.
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Reasons provided by practices for not using the online platform include: • Concerns their patient population not being able to access due to no digital access • Not popular with patients, uptake low, and some patients found it difficult to use or access • Not enough staff to manage another entry route into the practice • Current systems suffice for patient management To fully understand the current status of each GP Practice in detail it was agreed in December 2023 to carry out a survey of all practices to inform a wider deep dive review of General Practice in Ayrshire and Arran. The questions in the survey were based on regular feedback or themes reported through various forums, including patient feedback which would allow the primary care team to present an overall position of primary care at the current time: • Practice staffing levels (including workforce numbers and hours worked by each profession – this included those hours worked over and above committed time) • Consultation capacity per professional • Patient access – including extended opening times • Feedback on areas that cause increased activity and pressure As anticipated, the findings have highlighted areas of variance in service delivery models, with key areas such as consultation numbers and gaps in workforce that need explored further at an individual practice level. The data also confirms that patient demand is exceeding capacity. The findings will be shared with the practices and taken through local forums to inform next steps in response to the areas that have been reported on. This will also include how we engage with the public. As GP Practices are only open for a certain number of hours per day, there is a maximum number of consultations that can be carried out. Practices are often at capacity by mid-day or earlier. It is also important to note that the increased demand from patients waiting for outpatient treatment is in the main being absorbed into General Practice and is not being referred onto hospital services. GP referrals to University Hospital Crosshouse CAU (Combined Assessment Unit) from General Practice remain similar to pre- pandemic levels whilst GP referral rates into University Hospital Ayr CAU have reduced. The consistent downward trend in Emergency Department attendances also suggests that patients are engaging with their GP in the event of deteriorating health rather than making unplanned hospital attendances in greater numbers.
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To support practices with the high volume of unscheduled care demand at the end of the day an Urgent Care test of change (ToC) was initiated in December 2023. Generally all clinical resource within the practice is aimed at unscheduled care with no capacity for planned care. It is hoped this model will allow for practices to structure planned care time late afternoon. This involves the Ayrshire Urgent Care Services (AUCS) working alongside General Practice to support local practices with home visits between the hours of 3.30pm and 5.30pm. This was developed recognising the impact on General Practice when patients present to the practice late in the afternoon with an urgent care need requiring a home visit, and the requirement to ensure this is sufficient workforce in place to respond to this daily. To ensure safe delivery of the ToC, it is being rolled out on a phased basis at cluster level to ensure activity is monitored and evaluated. To date this now covers all of South Ayrshire, three practices within the Irvine Valley Cluster and most recently the Kilmarnock Cluster. This covers a total population of 108,376 patients. Numbers of referrals from the practices involved are growing week on week. Feedback has been positive from the practices taking part and early reports highlight this has allowed clinicians within practice to focus on planned appointments or patient engagement of results or care plans without having to block time in the event the clinician is required to attend a last minute home visit. The ToC will continue to be monitored and evaluated with a plan to extend wider across Ayrshire early throughout 2024 with a view to developing the model further to include in-person appointments. This model aligns to the urgent care principles within the 2018 contract as well as the vision of creating a 24/7 seamless urgent care pathway with general practice and AUCS working together. 3.3 Update on 2018 GMS Contract - Primary Care Improvement Plan In September 2023 Scottish Government provided an update on the implementation of the Memorandum of Understanding (MoU) nationally. This update confirmed that there was still commitment to the 2018 GMS contract and the principles within it, but it was recognised there was significant variation across the country. Board areas were advised there was a need to understand what a sustainable model of full delivery of the 2018 GMS contract looks like, and what additional outcomes it will achieve. The additional ‘phased investment programme’ was announced in this update stating that additional investment of £10-£15 million would be made available for a maximum of 2-3 areas in Scotland to bid to be a demonstrator site.
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The aim of the demonstrator sites would be to look at the different stages of implementation to demonstrate what a model of full implementation can look like in practice. It was proposed this would then build the case for additional investment in a sustainable and evidence-based way. Ayrshire and Arran bid on behalf of the three HSCPs to continue with a pan Ayrshire approach locally. The selection process took place in December 2023 which involved an interview with Scottish Government and NHS HIS. Applications and the interview feedback was then considered by a panel made up various senior stakeholders across Scottish Government and NHS Scotland. Ayrshire and Arran were successful in their bid for an additional £3.5 m (approx. 60wte additional) to further implement the contractual elements of the GMS contract. Following the Scottish Government announcement in 2022 to ensure greater focus on the agreed three main contractual elements of the contract (Pharmacotherapy, CTAC, and vaccinations) Ayrshire Arran, as demonstrator site, will be supported to use improvement methodologies to fully implement Pharmacotherapy and CTAC services as far as possible locally, while maintaining full delivery of the Vaccination Transformation Programme. The aim of this work is also to understand the impact for people, the workforce and the healthcare system, with reduction in GP and practice workload and improvement in patient outcomes a key aim. The work will collect evidence on the impact and the cost-effectiveness of MDT working which will then inform and support future model and long term investment associated with the GMS contact. Whilst the focus will be on these two services, all MoU Services will be considered in the monitoring and evaluation of the demonstrator sites as part of a whole systems approach to quality improvement. In 2018 Ayrshire and Arran developed a detailed delivery framework to implement the contract with timelines aligned to the agreed phased financial investment at that time. There has been significant progress across each of the contract areas with vaccinations transferred and the majority of practices accessing the additional roles described within the contract. For each area of the programme there is delegated involvement, responsibility and accountability from representatives across the three HSCPs, NHS Board, and GP Sub Committee within Ayrshire and Arran. There are co-leadership arrangements with MoU workstream leads and local GP Sub Executive Members to oversee decision making and progress through the current implementation structure. This is further strengthened with involvement from the Clinical Director and GP Stakeholder role from each of the HSCP areas who are well engaged with practice teams and wider community teams on the ground. This group come together every 8 weeks as the GMS Oversight Group. Consideration will be given to the frequency of these meetings in 2024/25 to ensure an appropriate level of oversight and input being a Demonstrator Site.
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General practice and wider community teams have been fully engaged in developing service specifications aligned to the MoU. We are confident with additional support and focus we could demonstrate what full delivery could look like for a Board wide area. A two day site visit took place with NHS HIS on 29 February / 1 March to understand our system and further explore our bid which is outlined below. Funding has been confirmed for the 18 month programme – full year 2024/25 and part year 2025/26. The programme will be continuously evaluated by NHS HIS with discussions on the future recommendations of the contract taking place throughout. 3.3.1 Pharmacotherapy – a three year trajectory was set (2018-2021) to establish a sustainable pharmacotherapy service to every practice. This included a skill mix of pharmacists, pharmacy technicians and pharmacy support workers. The service was front loaded in terms of recruitment and training with an agreed service specification in place. The delivery model has continuously been refined adjusting the ratio of pharmacists, pharmacy technicians, and the introduction of pharmacy support workers. The Pharmacotherapy Service is now made up of 103.3 WTE roles with all GP Practices having access. Although reaching the agreed compliment of staff, there are still a number of challenges with implementation. These relate to a range of areas including: • Systems and processes • Further development work required with current teams to embed the agreed service specification • Improved digital enablers to reduce administrative burden • Developing central hubs to support remotely during absence or high demand Recent data shows the Pharmacotherapy Team are delivering the majority of medicines reconciliation across all GP practices. Locality based hubs are in place to cover planned or unplanned leave to ensure work is not diverted back to the GPs. There is currently no resilience in these hub teams and the recent successful bid includes additionality requirements. A target has been developed locally to enable pharmacy teams to manage acute prescribing workload safely and effectively. Current data demonstrates significant variation across practices in the number of acute prescriptions. The additional Quality Improvement support from NHS HIS will support closer review of these processes at scale. Achieving and sustaining this target will be essential to delivery of this element of the contract. There is also variation with pharmacist confidence in making prescribing decisions balancing risk and safety. The bid includes clinical supervision funding to support pharmacists to become more confident prescribers.
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3.3.2 Community Treatment and Care (CTAC) Services – a total of 52 practices have full access to CTAC services with one practice not supportive of the CTAC service specification. There is ongoing dialogue with this practice. There is also a hub model tried and tested which has supported areas where accommodation has been challenging. It was previously estimated that 90 WTE staff, skill mix of Band 5 registered nurses and Band 3 Healthcare Support Workers would be required to fully deliver on CTAC. There is a total of 103.6 WTE mix of staff in post with an agreed service specification in place. Recent audits to understand what CTAC activity was still being undertaken by general practice staff has identified, that the main reasons for practice staff still undertaking the CTAC interventions is due to CTAC allocation not enough or CTAC staff being on annual leave or sick leave. There is a request within the demonstrator site bid to increase the CTAC resource required to meet the gaps, as well as mitigate the need for general practice to cover any leave to ensure full task transfer. The recent audit indicated that 72% of CTAC activity was undertaken by CTAC staff and 28% undertaken by practice staff. In order to provide full task transfer, to include additional resilience, there is a requirement to increase the workforce as well as further review the skill mix of total workforce. During the CTAC development phase there has also been fixed term investment of two Band 6 Practice Educator roles per HSCP to provide a robust education and supervision model whilst implementing the service specification. Due to the size of the workforce, and scale of working across a large number of practices within each HSCP, it has been agreed the continuation of these roles is fundamental to the ongoing safe delivery of CTAC services. These roles will also be explored as part of the demonstrator site work. 3.3.3 Extended Multi-Disciplinary Team (MDT) Professional Roles – Since its implementation, significant progress has been made to roll out the 2018 GMS Contract. • All Practices have access to Pharmacotherapy staff • All Practices have access to all immunisations through the Vaccine Transformation Programme (except pregnancy and non-routine adult vaccinations) • All Practices have access to a Community Link Worker • All Practices except one in South Ayrshire have access to a CTAC Nurse / Healthcare Support Worker Due to the funding constraints there is a high risk of not being able to providing these services across all practices in Ayrshire and Arran creating an inequality of access.
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This is creating health inequalities and access to services for patients based on a post code lottery. Unfortunately the financial envelope within the new GMS contract does not allow additional funding to be allocated to services at this stage. A breakdown of the MSK and MHP roles is noted in the table below. HSCP MSK MHP North 4.05WTE provide cover for 13 of 19 practices 9.9WTE provide cover for 16 of 19 practices South 4.2WTE provide cover for 16 of 18 practices 8.4WTE provide cover for 18 of 18 practices East 3.5WTE provide cover for 12 of 16 practices 9.6WTE provide cover for 16 of 16 practices The overall additional MDT resource in total is split 30% in the East, 35% in the North and 30% in the South. This is largely in keeping with the partnership patient list size – • East Ayrshire – 134,137 patients (35%) across 16 Practices • North Ayrshire – 145,290 patients (37%) across 19 Practices • South Ayrshire – 110,006 patients (28%) across 18 Practices It should be noted that the analysis of the extended MDT workforce aligned to the new GP contract has been captured at a moment in time and can vary across the year. 3.4 Primary Care Improvement Fund (PCIF) Update The implementation of the 2018 General Medical Services contract for Scotland intended to see an additional investment of £250m per annum in support of General Practice by 2021. This was part of an overall commitment of £500 million per annum investment in Primary and Community health services that was previously committed by Scottish Government. Since 2021/22 and 2022/23 Primary Care Improvement Fund (PCIF) was allocated as tranche 1 and tranche 2 based on projections and spend against each of the IJBs National Resource Allocation Committee (NRAC) share. Although the focus changed in 2022 to pharmacotherapy and CTAC, the HSCPs continued to invest in the additional wider roles set out as above. Each area has been at different stages throughout, and prioritised different services based on their population need. It should be noted that as the PCIF is ‘flat cash’ all pay awards/uplifts are consumed within the budget itself. This has impacted significantly on the available funds available for additional investment.
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The final allocation for 2023/24 was confirmed in February 2023 which is line with what was anticipated. The allocation is noted below per IJB: • East Ayrshire - £4,915,035 (includes non-recurring carry forward of £466k from 2022/23) • North Ayrshire - £4,821,036 (-£157k was deducted start of year due to overspend in 2022/23) • South Ayrshire - £4,202,060 (includes non-recurring carry forward of £65k from 2022/23) East Ayrshire IJB carried forward a higher underspend than was expected from 2022/23 year as noted above due to a large number of senior vacancies across the pharmacotherapy team and no replacement workforce, as well as vacancies across the MHP team. Joint discussions have taken place, and are ongoing with the North Ayrshire HSCP senior team to work through their budget allocation and committed resource. The final end of year position for each IJB is not available from the finance team at the time of report submission, but will be updated verbally at the IJB. 3.5 Premises Many GP practices are facing increasing challenges to accommodate the number of additional staff aligned to them through the PCIP. The lack of availability of assessment rooms means some practices are unable to access their full allocation of MDT resource therefore capacity to appoint patients to these practitioners is reduced. Many of the buildings within the GP practice estate are also needing significant investment or alternative accommodation identified for longer term viability. Infrastructure planning for Primary Care Services commenced in October 2023 along with the three Ayrshire HSCPs aligned to Caring for Ayrshire to look at greater cluster level models of care. This examined patient populations and premises across each of the three HSCP areas and considered the best use of the estate, virtual appointment delivery and scoping potential for some MDT services to be provided from local community hubs and where these could be located. The sessions also included engaging with each GP Practice to understand their premises and service delivery models, along with community facilities to identify our areas of greatest challenge as well as opportunity for future models of care. There was 100% return rate from General Practice. The outputs of this will also be included within the NHS Ayrshire & Arran whole system plan. It is anticipated this will progress over the next three years aligned to the organisation’s short/medium/long term plans.
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3.6 Digital In line with national requirements to phase out analogue telephone lines by 2025, the proposal agreed locally in 2022 in Ayrshire and Arran was for a single digital system, hosted by the health board, with improved functionality and enhanced patient access to be offered to all practices. The proposed system allows for better call handling and monitoring in the style of a “Call Centre” where multiple calls come through a queuing system and call recording functionality is available. It was anticipated that this single solution would also be more cost effective for practices who were signed up to long contracts with a range of different providers, often at high costs. Following initial agreement to proceed in 2022, the project experienced initial delays due to difficulties in recruiting to the technical support team and also delays in the delivery of necessary new equipment which did not arrive until February 2023. To date, two practices have been successfully transferred and a further eleven are in progress. Delays in implementation and technical issues with legacy infrastructure have meant that some practices have chosen to opt out of the proposed Board model with two practices recently entering new long-term contracts with alternative providers. There is a risk that further practices will follow suit which in turn creates uncertainty to the proposed pricing structure and programme costs which were originally based on an agreed number of practices making the switch. The Digital Team have set out to transfer one practice per month onto the new system and it is hoped that this could be increased to two practices per month as the programme gathers momentum, and processes are fully embedded. There are currently two practices on target to transfer over in January 2024. It should be noted that successful transfers are also dependant on the collaboration with the external commercial telephone providers which can lead to delays. GP IT Re-provisioning - NHS Ayrshire & Arran has progressed with a single award to one provider in January 2024 with transition roll out planned currently scheduled to happen across all GP Practices from February to December 2025. The primary care team will be scoping and defining the requirements alongside digital services colleagues to ensure service delivery to patients is not compromised during the transition. This will be a new significant piece of work across both teams under the leadership and direction of the new GP IT Re-provisioning Programme Board. The Programme Board has wide representation across primary care management, clinical leadership, and digital services. The Scottish Government has agreed to fund the increase in costs associated with the new IT system as well as central costs over the implementation period.
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3.7 2024/25 Priorities There is a national focus on short term actions to sustain the current system and reduce risk be taken forward over one year that include: • Stabilisation plan for General Practice – focus to be on retention and supporting the core building blocks of general practice. • Chronic Disease Management – recovery plans to focus on what is needed to enable proactive management and review • MDT Working – consideration, sharing learning and understanding variation with a focus on team working and changing ways of working to fully realise the role of the EMG. These actions align to the priorities locally and objectives set out within local delivery plans. Key areas being taken forward include: • GP Contract Reviews - Annual reviews of General Practice GMS Contracts were stood down in 2018 but have now been reinstated by the Primary Care Management Team. A programme for annual review will review practice operating models, quality indicators (including chronic disease management) and identify any improvement work. In advance of each review, the practice will be asked to complete paperwork which will then facilitate a face to face meeting with the practice representative and primary care manager, supported by the Clinical Director as required to provide assurance of delivery of their contractual obligations. It also allows for any specific concerns to be discussed. This programme of work will enhance oversight of core service delivery by the Board and help to early identify any issues or additional support practices may require to sustain service delivery. • Demonstrator Site – this will be an extensive programme carried out at pace supported by NHS HIS with the local teams and GP Practices. The Ayrshire and Arran high level action plan is due to be submitted on 29 March 2024 which will inform the work plan and expectation across the next 18 months. • GP IT-Provisioning – Further work is now being taken forward to understand the scale of the transition work in year and also 2025/26 in terms of preparatory work for digital services and for practices in advance of the transition as well as the detailed roll out, including additional workforce to take forward the roll out plan. A business case will be developed through the Programme Board and progressed through local governance groups.
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3.8 Quality / Patient Care Quality improvement within General Practice Clusters has continued to develop and strengthen throughout 2023. A range of improvement work has been carried out by the Clusters with some pieces of work done in collaboration with NHS HIS. Online Continual Professional Development events are hosted fortnightly with an open invite to staff in the whole MDT working in General Practice. Clinical Directors meet regularly with Stakeholder GPs to understand any barriers for improvement within clusters and ensure they are supported to undertake quality improvement initiatives identified through local data analysis. An All Ayrshire GP call is scheduled fortnightly and hosted by the Deputy Medical Director of Primary and Urgent Care. This is an open invite for all GPs and Practice Managers to attend and provides a forum for two-way communication to share information on developments and current challenges across the system, particularly across the interface with acute services. Invites are also extended to other key members of the wider healthcare community to provide expert knowledge on issues scheduled for discussion. Attendees have fed back that they find these sessions useful and provides them with an insight on current system pressures and how this is impacting on the patient journey. All GP Practices across Ayrshire and Arran are offered regular afternoon sessions throughout the year for Protected Learning Time (PLT). This allows the practice teams to come together as a practice to focus on reviewing service delivery models, staff development, discuss any opportunities for learning or improvements and opportunities for future ways of working. Calls into the practices participating in PLT on these afternoons are re-directed to AUCS to support patients during this time. 3.9 Anticipated Outcomes The purpose of the work underway is to help people access the right person, in the right place, at the right time in line with the Scottish Government Primary Care Vision and Outcomes. Including: • Maintaining and improving access • Introducing a wider range of health and social care professionals to support the Expert Medical Generalist • Enabling more time with the GP for patients when it’s really needed • Proving more information and support for patients. As we have worked to build our devolved Health and Social Care System in Ayrshire and Arran, the critical role of primary care has been emphasised throughout implementation to date, and is viewed as a core component of an integrated community based care system.
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This provides a solid foundation for developing a whole system health and care model which focuses on individuals, families and communities with general practice and primary care providing accessible, continuing and co-ordinated care. The aim is to empower people to take control of their own health and care as far as possible, enabling self-management, promotion of wellbeing and prevention of ill- health, use of telecare and telehealth and maximising care provided in and around communities. 3.10 Measuring Impact Implementation of the PCIP has created opportunities seen in the context of the aim of the Caring for Ayrshire agenda to design a fully integrated system wide approach to ensure people are able to access the right care at the right time in the right place. Primary care clinicians have more interactions with patients than other parts of the NHS therefore the whole system transformational change relies on sustainable and accessible primary care services. 4. IMPLICATIONS 4.1 Financial Primary Care Improvement Fund – the allocated fund available for the PCIP is not sufficient to ensure full roll out of the wider MDT roles. The projected additionality for CTAC and Pharmacotherapy is captured within the Demonstrator Site bid and funding. This will create and inequity across practices and different populations. There has been a request to NHS HIS to capture the impact of this as part of the evaluation process. Discussions have taken place nationally to baseline the PCIF into core budgets, but there is no agreement on this to date. Until the budget is baselined, the cost pressure associated with agreed pay awards will continue to impact on the number of roles that can be recruited to. Phased Investment Programme Demonstrator Site – the funding associated with this programme of work has only been confirmed for 2024/25 and part year 2025/26. There is no commitment beyond this time period. The detailed work being taken forward as a demo site will inform future investment, but there is no guarantee of ongoing funding. Discussions will take place as the programme progresses to determine staff turnover projections and the risk appetite at an IJB level to determine permanent vs fixed term job roles. GP IT-Provisioning – although the system costs will be funded nationally, there will still require to be a local business case for additional implementation resource given the size and scale of work required. There is minimum shared learning available at this time from other Board areas to help inform projected resource requirements. This will become clearer during 2024/25 and the planned scoping work.
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GP Practice Sustainability – there has been an increase in the number of practices who have indicated to the primary care team that they have sustainability concerns either relating to practice income or relating to their premises. Historic payments have been agreed with practices which will be reviewed 2024/25 and the primary care team will also be working closely with practices to understand sustainability concerns in more detail, providing guidance and support with the Local Medical Committee also. There is no dedicated funding allocation available for practices. The national GP Sustainability Loan scheme has been in place since 2018 which is open to all GP Practices who own their building to apply for an interest free sustainability loan up to the value of 20% of their property. The deadline for applications is 31 March 2024, but there has already been guidance issued to confirm that only those payments that have already gone through the extensive legal process will be progressed over the next 12 months. Since the scheme was introduced in 2018, 14 practices have applied from Ayrshire and Arran. Five practices have withdrawn their application, six practices have received their loans and three practices have their application in process. 4.2 Human Resources GP workforce remains a risk with a number of GPs retiring or choosing to leave the profession. There is ongoing work with current GPs and also trainees to make GP roles as attractive as possible in Ayrshire and Arran. The majority of roles within the additional workforce bid aligned to the demonstrator site bid ranges focusses on creating career pathways from schools or colleges. Availability and recruitment of the wider MDT staff and professional groups is becoming more challenging as other Health Board areas also progress their workforce plans. Many of the roles being created within the new service developments are new job roles and require job evaluation ahead of recruitment. Services plan ahead as much as possible when workforce planning, but there can still be significant delays when recruiting to these services. 4.3 Legal None. 4.4 Equality/Socio-Economic The aim through the reformed primary care service is not just to extend life, but aim to reduce the time spent in poor health. Implementing the 2018 GMS contract is an opportunity to mitigate health inequalities where possible.
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4.5 Risk Continued sustainability of GP practices is at risk while the new GMS contract is being implemented. For those practices who have highlighted risks to service delivery or workforce availability, the Primary Care Managers carry out bi-monthly meetings with the Practice Manager and GP Practice Quality Lead to understand the practice issues and risks. There is a risk that GP Practices will be unable to recruit to GP or Locum roles due to availability of workforce. The Primary Care Team have supported a number of successful rolling media programmes to promote GP Practices in Ayrshire and Arran and will continue to work with practices to forecast potential vacancies. There is a risk of not being able to implement all aspects of the 2018 GMS contract due to financial constraints and the ability to recruit to additional professional roles to either expand the MDT teams, ensuring sufficient resilience for leave or vacancies within each of the services. 4.6 Community Wealth Building The wellbeing of people and communities is core to the aims and successes of Community Planning. The Primary Care Improvement Plan, delivered as an integral part of the Wellbeing Deliver Plan, Integration Authorities Strategic Commissioning Plan of both the NHS and Council, will contribute to support this wellbeing agenda. 4.7 Key Priorities The strategy and programme outlined in this report will assist the IJB to deliver the following Strategic Objectives from its Strategic Plan to: • Provide early and effective support • Improve mental and physical health and wellbeing • Develop and support our workforce 5. CONSULTATION Consultation has taken place through the Primary Care structures involving all stakeholders across each HSCPs and GP Sub Committee. Ongoing communication with all stakeholders and the population will be critical as implementation and reform progresses post COVID-19 arrangements and challenges. Vicki Campbell Head of Primary and Urgent Care Services Vicki.campbell@aapct.scot.nhs.uk
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Implementation Officer and Person to Contact: Claire McCamon Senior Manager Primary Care Services Claire.McCamon@aapct.scot.nhs.uk 07 March 2024