10 - Primary Care General Medical Services Update
North Ayrshire Council · 16 March 2023
Back to Integration Joint Board — 16 March 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 16 March 2023 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 across Ayrshire and Arran. The report sets out how General Practice is continuing to operate in the current challenging environment, as well as continuing to evolve and develop through the implementation of the Primary Care Improvement Plan. Recommendation : It is recommended that the Integration Joint Board: i. Note the current position of Primary Care General Medical Services. ii. Note the progress of implementation of the new GMS Contract through the Primary Care Improvement Plan. iii. Support the current projected balance of the Primary Care Improvement Fund for 2022/23. iv. Approve the transfer of funds from the Primary Care Improvement Fund and General Medical Services to the NHS Ayrshire & Arran Public Health Department for the delivery of vaccinations as set out in Section 3.5 Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required 2. North Ayrshire Council 3. NHS Ayrshire & Arran x 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms BMA British Medical Association COE Centre of Excellence CTAC Community Treatment and Care CQL Cluster Quality Lead EMG Expert Medical Generalist GMS General Medical Services GP General Practice / Practitioner HCSW Healthcare Support Worker HSCP Health and Social Care Partnership IJB Integration Joint Board MDT Multi-disciplinary team
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MHP Mental Health Practitioner MoU Memorandum of Understanding MSK Musculoskeletal NHS AA NHS Ayrshire and Arran PCIF Primary Care Improvement Fund PCIP Primary Care Improvement Plan RAG Red, Amber, Green Status SLWG Short Life Working Group VTP Vaccine Transformation Programme WTE Whole Time Equivalent 1. EXECUTIVE SUMMARY 1.1 Since the previous update to the IJB in 2021 there have been a number of developments across General Medical Services (GMS). General practices continue to face exceptional challenges with increased demand month on month. General practices have remained open throughout the pandemic, although from the start of the pandemic practices had to quickly adapt how they were operating, only allowing entry based on clinical need; this approach was required to reduce the risk to both the public and to practice staff, and reduce the transmission of COVID. Practices were advised in line with national guidance to follow the infection, prevention and control guidance. This ensured that practices complied with the guidance issued and measures that general practice took to protect patients and staff. 1.2 The new GMS contract, being implemented through the Primary Care Improvement Plan (PCIP), provides the basis for an integrated health and care model with a number of additional professionals and service multi-disciplinary teams (MDTs) including nursing staff, pharmacists, mental health practitioners, musculoskeletal (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 and 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 It is recognised that the COVID-19 pandemic and associated remobilisation work has impacted on the original timescales for delivering elements of PCIP 2020-22 and consequently, the implementation of the new GP contract by 2021/22. Throughout 2022 a number of actions agreed to meet the contractual elements within the PCIP continued to progress. A summary of these are noted below: • Successfully transferred the majority of vaccinations from General Practice to NHS Ayrshire & Arran Health Board with this task expected to fully transfer to the responsibility of the NHS Board Public Health Team by 1 April 2023.
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• The development of the Community Treatment and Care Service (CTAC) is progressing well with a total of 93.10 wte in post with all GP Practices able to access CTAC services. There is a confidence this service will transfer from GP Practices in 2023/24. • There has been a significant amount of work done within the Pharmacotherapy teams who have been engaging with GP Practices to carry out Quality Improvement work to improve systems and processes to allow them to work towards task transfer. • Small Improvement Grants have been provided to GP Practices across Ayrshire to increase clinical space within buildings to support the implementation of the MDTs. • Work is underway with Digital Services colleagues to offer practices the option of on boarding onto the health boards Digital Telephony system which will improve patient access. 1.4 This report has / will also been presented to: i. Ayrshire GP Sub-Committee – 31 January 2023 ii. East Ayrshire IJB – 1 February 2023 iii. South Ayrshire IJB – 15 February 2023 iv. NHS Ayrshire & Arran Board – 27 March 2023 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 Health and Social Care Partnership (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 new GMS contract was introduced in 2018 to facilitate a refocusing of the GP role as Expert Medical Generalist (EMG). This role builds on the core strengths and values of general practice. The national aim is to enable GPs to use their skills and expertise to do the job they trained to do. 2.3 The Contract (1 April 2018) 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 and
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• redefines the role of the GP as an EMG 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. 2.4 The initial priorities include vaccination services, pharmacotherapy services, community treatment and care services, urgent care services and additional professional services including acute musculoskeletal physiotherapy, community mental health and community link workers. GPs will retain a professional leadership role in these services in their capacity as EMG. 2.5 Following the approval of the new GMS contract in January 2018, the first PCIP (2018- 2021) set out the plan to implement the new contract across NHS Ayrshire & Arran by 2021. This was approved at the three IJBs and the NHS Board in June 2018, and was then submitted to the Scottish Government on 28 June 2018. 2.6 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. 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. All Primary Care contractors operate as separate independent businesses in their own right, and are not directly employed by the NHS Ayrshire & Arran. Business types can be from a single handed practice, partnerships of varying size to large multiple Public Limited Companies. Each is governed by its own statute and regulations. Ayrshire and Arran GP Practices hold a specific overarching contract with NHS Ayrshire & Arran to provide general medical services. General practitioners inclusion on the Performer’s List, and therefore eligibility to provide GMS services, is the responsibility of NHS Ayrshire & Arran. There are 53 GP practices across Ayrshire and Arran, with 51 run as a GP Partnership and two which operate as an individual GP single handed practice. A GP Partnership involves two or more GPs, with nurses, practice managers and other staff working together as business partners. GP partners are jointly responsible for meeting the requirements set out in the contract for their practice and share the income it provides. The core elements of a general practice contract includes:
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• 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. 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. GP practices are paid via a nationally-agreed Global Sum, weighted for patient age, type and deprivation and locally agreed enhanced services contracts are paid in addition. Other payments may be received from additional locally agreed contracts i.e. community hospitals. In addition certain practice expenses may be reimbursable as a practice allowance. Administered payments refers to payments set out in the Statement of Financial Entitlements. Payments in this category include, for example, locum allowances and appraisal costs. The diagram below provides more information on how a GP Practice operates and the outgoings involved with running a GP Practice business. 3.2 GP Practice Activity Whilst every GP Practices delivers general medical services through their contract with NHS Ayrshire and 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.
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This then makes it challenging to establish a unifying metric or activity measure common across all that allows meaningful comparisons. There is national agreed data set being progressed with SPIRE for general practice which will assist with robust data collection. Locally we have some local sets available that reflect some of the activity of the practices pre pandemic in 2019 to recent months in 2022. During the pandemic, in line with national guidance issued in 2020, GP Practices moved to a fully telephone first model to allow compliance with infection control and respiratory screening to take place. This resulted in a large amount of assessments carried out over the telephone or other technology such as Near Me for video calls. Since March 2022 GP Practices have moved back to a mixed model, working with a blend of face to face and remote consultations based on clinical need. The data below demonstrates that in December 2022 activity levels are higher than 2019 with 75% of consultations were carried out face to face compared to 82% pre-pandemic. Month Patient reviews Face-to-face reviews December 2022 250,000 75% (187,500 reviews) December 2019 193,000 82% (158,260 reviews) With such high patient demand outweighing clinical capacity available, it is often necessary to triage (or sort into order) the patient contacts to ensure that the sicker patients are prioritised. This has also resulted in some delays to telephone call connection and we have asked our citizens to be patient in the face of this high demand. Staff within practices are working tirelessly to get to every call, although it is recognised that due to ongoing challenges with the current phones lines unable to cope with the demand, patients can have problems getting through with no queuing system available. The recent investment in an improved GP telephony system will be offered to all practices and a roll out programme is already underway to work towards resolving the phone line issue. This is described in more detail later in the paper. 3.3 COE (Centre of Excellence) Relaunch The COE has been in place for a number of years supported by three GP Practice Managers with extensive experience of working within practices across Ayrshire and Arran. The aim of the COE was to provide training, support and mentorship to GP Practice Managers and admin teams. This mainly involved providing a wide range of training courses both internally and externally to ensure all GP Practice admin staff were fully trained on the systems and processes within a GP practice, including complaints handling and HR management. The COE has provided support to new Practice Managers joining Primary Care and has supported practices in their development of Business Continuity Plans, as well as the day to day running of general practice.
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In 2018 the COE reduced to one Practice Manager providing support, training and mentorship to all 53 GP Practices across Ayrshire and Arran. Following feedback regarding the model and the ongoing sustainability a review of the function was commissioned by the Senior Manager for Primary Care Services. A Short Life Working Group (SLWG) was created from volunteers across the Practice Manager network to review the current service delivery model and develop a new training programme to be offered out to all admin and practice manager staff across all Ayrshire and Arran GP Practices. The proposed service specification for COE has been developed between the Primary Care Team and the SLWG to address the need for continued staff training and development within the admin section of GP Practice. The delivery model seeks to develop a robust support programme for new GP Practice Managers to maximise their skills with a view to improve practice efficiency. An Options Appraisal for the service going forward was carried out with three options considered. The option agreed by the GP Sub Committee and Senior Management Team was that the COE team should be provided centrally by four Practice Managers to ensure that a wide range of training and support is made available to all non-clinical staff within General Medical Practices across Ayrshire and Arran. There is a set aside budget of £25k within the Primary Care budget to support this valuable resource. The revised service specification aims to provide an underpinning framework for excellence in General Practice Management across Ayrshire and Arran, and provide expert management input where practices may require additional support. The landscape of general practice has changed significantly since the pandemic and due to demand outweighing clinical capacity, GP Practices have had to adapt the way in which they deliver care to patients. The new COE model re-launch event will take place on Thursday 16 March 2023. 3.4 Update on Primary Care Improvement Plan (PCIP) The aim of the new GMS contract was to transform primary care, sustain general practice, reduce GP workload and improve patient care. The Memorandum of Understanding (MoU) set out seven key principles of the contract: Safe; Person-Centred; Equitable; Outcome focused; Effective; Sustainable; Affordability and value for money. The most recently agreed PCIP included local workforce planning, infrastructure development and patient engagement to allow task transfer to take place. The PCIP covered the five areas from the MoU: • Pharmacotherapy • Community Treatment and Care Service (CTAC) • Vaccinations
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• Urgent Care • Additional MDT roles Following the Scottish Government announcement in 2022 to ensure greater focus on the agreed three main contractual elements of the contract: • Pharmacotherapy • CTAC • Vaccinations There was enhanced detailed financial and workforce planning carried out to confirm full task transfer requirements for each of these areas towards the end of 2022 when Boards and IJBs were advised in that the final date for task transfer was 2023/24. An update on each of the contractual elements is noted below. 3.4.1 Pharmacotherapy – an agreement that every GP practice will have access to a pharmacotherapy service. This service will be provided by a combined skill mix of pharmacists, technicians and support workers. The contract noted that Pharmacy teams will take on responsibility for: • Core elements of the service, including: acute and repeat prescribing, medicines reconciliation, monitoring high risk medicines. • Additional elements of the service, including: medication and polypharmacy reviews and specialist clinics (e.g. chronic pain) The Ayrshire and Arran PCIP set out a three year trajectory from April 2018 to April 2021, to establish a sustainable pharmacotherapy service which includes pharmacy support to every practice. This included a skill mix of pharmacists, pharmacy technicians and pharmacy support workers who will become embedded members of core practice clinical teams. During the three year trajectory to establish a sustainable pharmacotherapy service, the service was front loaded in terms of recruitment and training of the eventual required workforce. This was to ensure that capacity was in place by year three, the final implementation stage, which was delayed mainly due to the pandemic. The pharmacotherapy team are continuing to: • Review the skill mix within the Pharmacotherapy service to increase the utilisation of Pharmacy Technicians and Pharmacy Support Staff to support task transfer • Developing a hub model to support remote and rural practices utilising remote access to GP practices • Optimising prescribing systems to manage demand • Development of collaborative working with community pharmacies • Implementing serial prescribing across all practices
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The Pharmacotherapy Team have continued to refine the service delivery model over the last five years as well as share and utilise best practice nationally to ensure safe, effective, and quality service provision. This is has resulted in a change of skill mix with a change in the ratio of pharmacists, pharmacy technicians and the introduction of pharmacy support workers, aiming for a 50:50 split of pharmacists to technical team. The Pharmacotherapy Service is currently funded for 103.1 WTE roles, however it should be noted there are currently only 88.2 WTE in post due to vacancies and maternity leave. For North HSCP this is a skill mix support of 33.7 WTE within 19 GP practices. Recruitment to fill vacancies is becoming more difficult as the service progresses due to the availability of workforce. The development of the Pharmacotherapy Service has created a career pathway for pharmacists and technicians from trainee level up to senior management posts with a key focus on education and training to ensure retention of staff. To ensure development and retention of pharmacists there is a focus and commitment within the service to drive forward the clinical development of the pharmacists identifying clinical areas of interest to develop pharmacist led clinics and support the local clinical priorities. To support understanding the position against the required task transfer the senior pharmacists for each cluster carried out an audit in December 2022 to rate GP Practice progress Red, Amber, Green (RAG) using criteria agreed through the Pharmacotherapy Implementation Group. Where practices have been RAG rated green current delivery is considered very good at this stage and the teams are working well to be in a position to transfer. Practices within the amber category may require additional resource, need to push forward with serial prescribing and reduce acute numbers. Practices within the red category are still a concern in terms of engagement, workload, or difficulties with recruitment to these areas. The outcomes of audit is noted below: • Green - 58% of practices are on track to support delivery of level one task transfer , however there is still a concern that this won’t be done by 1 April 2023 • Amber - 32% of practices still require some improvement on systems and processes work to achieve level one task transfer • Red – 8% of practices still require a significant amount of input required at this stage High numbers of acute prescriptions requests within some practices remains a barrier to success and work continues to support improvement of processes and reduce the number of acute requests and a move to repeat prescriptions. This includes the launch of a funded GP project in 2021 which 26 practices signed up to during 21/22. Unfortunately only 50% of those practices who signed up completed the project due to other competing demands and priorities within the practice. In 2022/23 11 practices
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have signed up to the project and working through this. In addition to this project there has also been the launch of local acute prescribing quality improvement targeted work within two practices in each locality. Following a series of very successful recruitment rounds over the last five years, the challenges with recruiting to vacancies is also impacting on the ability to provide a full service. In January 2023 the Royal Pharmaceutical Society Scotland and the BMA’s Scottish GP Committee released a joint statement calling for improvements to support delivery of the pharmacotherapy service as per the previous contract commitment. The statement recognises that much progress has been made but states that further improvements are needed to fully maximise the benefits of the service. In particular, it highlights the need for: • Better use of skill mix, including more clearly defining roles and responsibilities • Improved IT enablers to reduce administrative burden • Further developing a tandem model of working comprising hubs with in-practice activity Further national guidance on the directions set out within the GMS contract for Pharmacotherapy is expected early 2023. 3.4.2 Vaccination Transformation Programme - within Ayrshire and Arran all vaccination workload has transferred from general practice to the NHS Ayrshire & Arran mass vaccination teams. There is a local enhanced service in place as part of the transitionary arrangements within practices for no routine vaccinations. This is expected to fully transfer by April 2023. 3.4.3 Community Treatment and Care (CTAC) Services – CTAC services include many non- GP services that patients may need, including (but not limited to): • management of minor injuries and dressings • phlebotomy • ear syringing • suture removal • chronic disease monitoring and related data collection. The CTAC model has been further developed during 2022/23. As set out within the latest PCIP, a workforce of 90 WTE staff would be required to fully deliver CTAC across Ayrshire and Arran. At January 2023, the current workforce is 86.3 WTE with a small number vacant posts that are currently being recruited to. The CTAC workforce consists of Registered Nurses and Healthcare Support Workers (HCSW). The current workforce includes 20 HCSW and 3 Registered Nurses who TUPE’d from General Practice following consultation with GP practices and the NHS Board in September 2021.
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A resilience model was approved in 2022 to support the additional recruitment of 12 WTE Nurses and 6 WTE HCSWs. The aim of the resilience model was to be provide cover for CTAC when staff were on long-term sick or maternity leave to ensure the workload does not fall back to General Practice. As part of the resilience model, there was also approval for 6 WTE Practice Educators on a fixed term basis for two years. The Practice Educator role secures a robust and sustainable education and supervision model in addition to creating resilience across the wider CTAC Service. The staff commenced in September 2022; 2 x staff per HSCP area. A total of 52 practices have full access to CTAC services with one practice only accessing the adult vaccination component at this stage due to the practice not being fully bought in to the CTAC service specification. The practice will continue to be offered sessions at the Ayr Hub for wider CTAC activities. The CTAC workforce are fully supported in their career and development in line with Nursing, Midwifery and Allied Health Professions and HCSW education and development framework and are fully embracing opportunities. The first cohort of registered nurses have graduated with University West of Scotland Graduate Diploma Integrated Community Nursing Programme with two further cohorts in progress. The HCSWs have commenced an SVQ3 and one HCSW is undertaking the Open University pre-registration nursing programme working towards registration. A CTAC service specification has also been developed and approved which clearly sets out the service delivery model, supervision and leadership arrangements of CTAC staff based within General Practice. As part of the CTAC service development, the CTAC nursing interventions were reviewed and there was agreement to extend the range of interventions that could be undertaken by the Registered Nurses and HCSWs. A Test of Change was undertaken in South Ayrshire HSCP to test hub working for the three practices in South Ayrshire who were unable to take their full allocation within practice due to space constraints. Two rooms were identified within North Ayr Health Centre in Ayr and a short-life working group was set up to plan, set up and test a hub model where the participating practices could allocate patients to receive CTAC nursing interventions at the Hub rather than the GP practice. This was carried out over a three month period and evaluated positively with good feedback from patients, staff working at the Hub and participating GP practices. There was agreement that the approach will now be implemented and spread across all three HSCPs. A week of care audit was undertaken within General Practice in November 2022. The aim of the audit was to identify how much CTAC nursing activity was being undertaken
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by CTAC staff and what was still being undertaken by practice-employed staff. The aim was to take a snap-shot of activity over a one week period to estimate how much task transfer had taken place. The results of the audit indicated that 72% of all consultations were undertaken by CTAC staff and 28% were undertaken by practice staff. The main reasons recorded for practice staff undertaking the CTAC nursing interventions was because there was only CTAC staff allocation on certain days (appointment required out with), no available CTAC appointments and CTAC staff being on annual leave or sick leave. This highlighted the requirement for the CTAC resilience posts which will take away the need for practice staff to cover sick leave and annual leave to the same degree but further work is required to ensure full task transfer. Further discussions will take place with practices to start to review task transfer at practice level and consider if adequate staffing is in place to fully meet demand. 3.4.4 Urgent Care – this is an area still being explored locally and nationally to understand how this element of the contract aligns to the urgent care programmes launched nationally. Potential options have been considered locally to support practices linked to the Ayrshire Urgent Care Service, as well increased Advanced Nurse Practitioner Support in GP Practices. This can only be progressed further when there is clarity around the funding envelope. 3.4.5 Additional professional roles – the Mental Health Practitioner (MHP) and MSK roles continue to develop and embed within GP Practices and HSCP services. Future workforce plans to roll out these roles across all practices has been paused following the recent funding announcement and request to focus on the three main contractual elements of the new GMS contract. Below is an update on the current allocation of MSK and MHP’s across practices within each of the partnership areas as outlined below: HSCP MSK MHP North 5.4WTE provide cover for 15 of 19 practices 12.6WTE provide cover for 19 of 19 practices South 3.4WTE provide cover for 12 of 18 practices 7.1WTE provide cover for 18 of 18 practices East 4.0WTE provide cover for 14 of 17 practices 9.6WTE provide cover for 15 of 17 practices
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Due to the funding constraints there is a high risk of not being able to provide these services across all practices in Ayrshire and Arran creating variance across and an inequality of access. This is creating health inequalities and access to services for patients based on a postcode lottery. Unfortunately the financial envelope within the new GMS contract does not allow additional funding to be allocated to services. All GP Practices have access to community link workers/community connectors across Ayrshire to support. The delivery model is different within each HSCP for this support as the services align to the wider HSCP services based on population need and priorities. 3.5 Primary Care Improvement Fund (PCIF) Update The implementation of the 2018 GMS 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. It was anticipated Ayrshire and Arran would be allocated £14,728,980 in 2022/23 as a final allocation of the PCIF. Each of the IJBs also held a carry forward from 2021/22 in reserves to fund the projected workforce plan for 2022/23. In October 2022 the Scottish Government announced a reduction in allocated funds in year to NHS Boards/IJBs with a request to use any IJB reserves in the first instance to fund roles in post or planned recruitment. This equated to approximately £5 million of reserves in total for 2022/23 which had been earmarked against a workforce recruitment plan for recurring roles as well as non-recurring fixed term posts to front load services to support task transfer. In response to this finance announcement all recruitment plans were put hold until confirmation of funding is received. Ayrshire and Arran confirmed with Scottish Government in December 2022 a forecast of £12,022,445 anticipated spend in 2022/23. As at 25 January 2023, the predicted spend is £12,164,389. For each IJB this is: • East £3,619,942 • North £4,682,940 • South £3,861,508 There is currently £10,929,526 available (within North IJB £3,956,396) therefore there will be a request to draw down £1,234,863 in total for Ayrshire and Arran, of which £726,544 for North Ayrshire. Confirmation of funding for 2023/24 is expected from the Scottish Government by early 2023. Thereafter, work will be required at pace to confirm what can be delivered within the financial envelope for delivery of the contract.
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Following the full transfer of vaccinations as set out section 3.4.2, there is a requirement to move budget from PCIF and also core GMS funding to Public Health to the value of £842,536. For North Ayrshire this is £243,659 from PCIF and £34,000 from GMS funding. The IJB are asked to approve the total transfer of £277,659 for the delivery of vaccinations via the NHS Board mass vaccinations model from 1 April 2023. 3.6 Premises Primary Care Premises continues to be a high risk across the three HSCPs. An overarching Premises Group is in place to discuss and agree priorities and risk. The Group has representation from across the HSCP’s, along with NHS Ayrshire & Arran Estates, and Finance colleagues. Significant investment in required across many GP Practices to support increased populations and additional staff members as set out in the new GMS Contract. To support the short to medium term premises challenges, and to support implementation of the new GMS contract, Scottish Government issued small improvement grant funding accessible for all GP Practices in 2022/23 to increase clinical capacity and support the implementation of MDTs within general practice. Where larger scale work has been requested; site visits have taken place by the Primary Care Team and NHS Estates colleagues to understand any immediate risks in more detail. Collaboration with Digital Services has also been vital when new consulting rooms / space for MDT members has been required. 3.7 Digital There are a number of digital developments underway to support all 53 GP Practices across Ayrshire and Arran which will improve patient care, access and improved delivery of general medical services to the population of Ayrshire and Arran. Below is a snapshot of the development work that is underway. Digital Telephony rollout - A business case has been approved and a programme of work underway to move General Practice on a per practice basis from a fragmented set of independent telephony solutions to a single resilient digital telephony platform supported by NHS Ayrshire and Arran. The proposed new platform offers increased functionality that will benefit general practice clinicians and patients alike. There has been wide engagement with all GP Practices across Ayrshire on the options for a robust GP telephony systems, medium to long term, rather than opting for a variety of short term solutions. Benefits to the patients are outlined below. • More calls answered • Improved waiting times
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• Accessibility improvements • Added functionality The new system will be rolled out across the next 12 months and will deliver enhanced resilience and functionality resulting in a robust and reliable telephony offering being presented to patients. Advanced call management and queuing options will allow patient calls to be routed to the most appropriate member of Practice staff. GP IT Re-provisioning - work is underway with NHS Ayrshire & Arran and GP Practices to progress the national roll out and implementation of a new GP IT system. A Strategic Oversight Group has been established to commence the planning requirements and timescales for implementation for this work to progress in 2023. E-consult - eConsult is a Digital Asynchronous Consultation Solution used by GP Practices in Ayrshire and Arran. It is designed to help enhance patient access, improve efficiencies and empower practices to support their patients effectively. There are now 16 of 53 GP Practices in Ayrshire and Arran actively using eConsult. A number of practices have withdrawn or declined to use eConsult and some others who had previously engaged not able to actively use the platform due to reduced clinical workforce capacity in General Practice. For eConsult to work effectively there needs to be sufficient practice workforce to support the workload generated from the platform. Due to ongoing issues with reduced staffing levels and capacity, this means that practices often decide to switch off the platform on a temporary or longer term basis. There are new features coming on board soon such as “smart inbox”. Smart Inbox is a customisable and collaborative way for the practice to view, manage and respond to the patient’s needs. It will help to visualise, separate, prioritise and manage digital queues from one place. This will ensure there is full visibility enabling the clinician to identify which eConsult needs attention first with full visibility of the queue, optimised for clinical safety. There will also be the option for two-way messaging to receive responses from patients, SMS and video calling. It is hoped the increased functionality with eConsult will increase the uptake across practices. The Primary Care Team will continue to promote this to practices, including the benefits to patient access. 3.8 Quality / Patient Care Quality in general practice is encouraged via the cluster model. GP clusters are typically groups of between five to eight GP practices in a close geographical location. As described in the Scottish Government's publication, 'Improving Together', the purpose of clusters is to encourage GPs to take part in quality improvement activity with their peers, and contribute to the oversight and development of their local healthcare system.
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There is a nominated Practice Quality Lead in each GP practice and each cluster has a Cluster Quality Lead (CQL). CQLs support their local GP practices and liaise with locality teams and other professional groups and organisations. The planning of GP Cluster quality improvement initiatives is informed by evidence and on population health needs, service capacity and demand and effective interventions to improve health and reduce inequalities. ISD Scotland holds a range of data supporting Primary Care, GP Clusters and Health and Social Care Partnerships to deliver high quality, effective and efficient services to meet the changing needs of the Scottish population. Ayrshire and Arran HSCP’s have 11 GP clusters who will use data and health intelligence at a local level, cognisant of local priorities, to facilitate assurance and to drive improvement in the quality of care provided by different parts of the health and social care system. NHS Ayrshire & Arran, supported by NHS Education Scotland and Healthcare Improvement Scotland, held an Ayrshire wide CQL event on Wednesday 1 February 2023 to relaunch and refocus the Quality Improvement and learning needs agenda across general practice. 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. 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.
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4. IMPLICATIONS 4.1 Financial In November 2021 Scottish Government announced a support allocation of £15 million across Scottish GP Practices in 2021/22 with a commitment of a further payment of £15 million in 2022-23. This sum was approximately based on £5 per patient in Scotland and allocated to practices by the Scottish Workload Formula and Income and Expenses Guarantee. The first payment was made to all Ayrshire and Arran practices in December 2021 with a further payment expected by September 2022. This payment was intended to support General practices over the winter period. Many GP practices as a result of the increase in patient demand, utilised the money allocated for additional hours for current staffing, and in some cases chose to recruit additional staff. GP Practices were directed to use the recurring funding to support the day to day running of GP practices to allow them to continue to deliver patient care and support sustainability of practices. In October 2022, it was announced that the £15 million had been reduced to £10million due to financial constraints. This caused GP practices additional stress and pressure and many had already planned their workforce and delivery model based on the funding they expected to receive. It not known if this funding will be continued beyond 2022/23. Due to not having confirmation of PCIF beyond this year, this has further delayed the progress and implementation of the PCIP and task transfer for practices. It should be noted that discussions are ongoing nationally with the BMA and Scottish Government on transitionary payments to practices should any contractual functions not transfer by the final deadline set. The detail and criteria for this has still be explored fully, with no information at this stage how it will be funded. 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. This also includes the introduction of GPs with Extended Roles to create a portfolio career where GPs will work part time in general practice and either one or two days in a specialty area within acute services. Development of these new services has created to date approximately 327 WTE new roles across general practice in Ayrshire and Arran, which includes CTAC, Pharmacotherapy, MHP, MSK and Vaccination staff groups. This has ranged from school leavers starting on a structured career path, new graduates to experienced clinicians.
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Availability and recruitment of the wider MDT staff and professional groups is becoming more challenging as other Health Boards 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 delays of up to 12 months 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 new GMS contract is an opportunity to mitigate health inequalities where possible. 4.5 Risk Continued sustainability of GP practices is at risk while the new GMS contract is being implemented. The Primary Care Team are in regular contact with practice managers and teams to understand in detail the status of their service delivery and also sighted on any issues early to be able to resolve these where possible. 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 new GMS contract due to financial constraints and the ability to recruit to additional professional roles to either expand the MDTs, ensuring sufficient resilience for leave or vacancies within each of the services. Due to lack of space within practices it’s becoming increasingly more difficult to allocate additional MDT staff if they are recruited resulting in practices not being able to take their full allocation which will in turn lead to patients not having access to full services. The teams will continue to implement solutions where possible with digital options and use of hub sites.
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4.6 Community Wealth Building The wellbeing of people and communities is core to the aims and successes of Community Planning. The PCIP, delivered as an integral part of the Wellbeing Delivery 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 Implementation Officer and Person to Contact: Claire McCamon Senior Manager Primary Care Services Claire.McCamon@aapct.scot.nhs.uk 01 February 2023
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DIRECTION Reference No. 20230316/(Agenda Item No.) From North Ayrshire Integration Joint Board To NHS Ayrshire Arran X Name/Contact Details Public Health Department Local Authority Name/Contact Details Both Name/Contact Details 1. IJB Report Reference No. Include hyperlink to report. 2. Date Direction Issued/Approved by IJB 16 March 2023 3. Report Author/Contact Details Vicki Campbell, Head of Primary and Urgent Care Services – vicki.campbell@aapct.scot.nhs.uk 4. Date Direction takes effect 1 April 2023 5. Does this direction supercede, amend or revoke a previous direction – if yes, include the reference numbers(s) Yes No x 6. Description of services/functions covered by the direction Sections 3.4.2 and 3.5 of covering report. 7. Full text of direction Approve the transfer of funds from 1 April 2023 from the Primary Care Improvement Fund and General Medical Services to the NHS Ayrshire & Arran Public Health Department and Direct NHSAA to deliver all vaccination workload transferring from General Practice to NHSAA mass vaccination teams as set out in Section 3.4.2 and 3.5 8. Specification of those impacted by direction. Transfer of funds will allow full transfer of vaccinations from General Practice to NHS Ayrshire & Arran for delivery to citizens via the mass vaccination model from 1 April 2023. 9. Budget allocated by Integration Joint Board to carry out direction As detailed in section 3.5 of covering report. 10. Outcomes/Link to Strategic Priorities By transferring vaccine delivery from General Practice to the Health Board, this supports the IJB to deliver on its Strategic Objective to provide early and effective support to citizens. 11. Timescales/Review/Monitoring Arrangements Funds to transfer from 1 April 2023 from the Primary Care Improvement Fund and General Medical Services to the NHS Ayrshire & Arran Public Health Department
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Once this Direction is actioned, total delivery of vaccines will be move from General Practice delivery model and resume under the continuing responsibility and accountability of NHS AA (via Public Health) via a mass vaccination model. Uptake numbers and impact of numbers will be reviewed across 2023/24. 12. Lead Partnership Arrangements The total delivery of this service will fully transfer from 1 April 2023 under the continuing responsibility and accountability of NHSAA. Once actioned, all Lead Partnership arrangements for vaccine delivery in General Practice will cease.