Policy responses and statements
- Name of organisation:
- Royal College of General Practitioners
- Name of policy document:
- The Future of General Practice in Scotland:
A Vision - Draft for Consultation
- Deadline for response:
- 1 October 2010
Background: General Practice is the jewel in the
crown of the NHS, as described by Professor Gordon Moore. It provides
effective and efficient medical care through the singular status of
the GP as an independent ‘contractor’.
This makes GPs experts in managing risk and living with uncertainty
in a way that is markedly different from other areas of healthcare.
90% of patient contact in the NHS Scotland happens in general practice,
with over 90,000 consultations held every day in more than 1000 practices
across the country, from inner city areas to the highlands and islands.
On average, most patients see their GP four times a year which makes
general practice exceptionally good value, at about £28-35 per
consultation. All this is delivered free at the point of use and funded
centrally, covering approximately 90% of patient contact for just 10%
of the overall health budget.
This document seeks to embrace the challenges of the NHS in the future.
General practice is a dynamic profession and the model of GP partnerships
allows us to be nimble and respond to change in a way that is unique.
However, we must not throw away our core values, clearly described
in our opening chapter, ‘Essence of General Practice’.
Professor Don Berwick in his John Fry Lecture of 2008 described how
we are ‘guests in our patient’s lives’, there at
their invitation to share ‘the dark and tender places of their
lives’.
We must help to ensure that the Scottish general practice of the future
is fit to face the vital challenges which include an ageing population,
rapidly developing technology, a feminised workforce and portfolio
style careers, set alongside an economy of funding pressures. We must
look beyond the historic criticisms of the Quality and Outcomes Framework
(QOF), chiefly that it creates a ‘tick box’ culture, and
focus firmly on jointly-created outcomes for the patient.
Much of what we wish to achieve has been laid out in the Scottish
Government’s Quality Strategy and quality must continue to underpin
everything we do in general practice. Quality of care and service;
quality in training and education and maintaining quality through continuous
professional development. By driving up quality we will improve patient
safety and move to a culture where we get it right for every patient.
We all need to aspire to care which is safe, clinically effective and
person-centred. The key themes that have come through in this strategy
include:
- Empowering patients to play a part in the management of
their own health
- The integration of all care service to fully meet the needs
of patient
- Care that is clinically effective, safe, delivered in the
most appropriate way and within clear, agreed pathways
- Primary care playing an essential role in the effective
use of scarce public resources.
General practice is part of the primary care family including pharmacy,
dentistry, allied health professionals (AHP) and nursing. We must find
new ways of working co-operatively with other professions to deliver
integrated care we strive towards.
General practice is the gateway to secondary care so it is paramount
that we work together with our secondary partners to improve access
to services and deliver the best balance of care in the most efficient
way. However, any change in the balance of services must be accompanied
by a re-allocation of resource and training if is to be successful.
There are a number of areas not covered in this report, many of those,
including out- of-hours, are covered in the recent document by the
Scottish General Practitioners Committee of the BMA entitled “General
Practice in Scotland: The Way Ahead”. We intend these documents
to complement each other and ensure the essential elements are covered.
General practice in Scotland has a positive future as part of a strong
NHS. We must aim for excellence in all we do for our patients and make
Scotland a world leader in health care.
COMMENTS ON
ROYAL COLLEGE
OF GENERAL PRACTITIONERS
THE FUTURE OF GENERAL PRACTICE
IN SCOTLAND: A VISION
The Royal College of Physicians of Edinburgh (the College) is pleased
to respond to the Royal College of General Practitioners Scotland (RCGP)
consultation on The Future of General Practice in Scotland: A Vision. The
College commends the RCGP for producing a document that encourages
consistency in general practice in Scotland.
The College welcomes the opportunity to provide a secondary care perspective
and offers the following comments:
Interface between primary and other healthcare areas
The College understands that primary care is the focus of the document
and notes that an opportunity exists to highlight the interface between
primary and other healthcare sectors such as secondary care and community
and voluntary healthcare services. This may promote understanding
of how general practitioners interact with other key players and support
the notion of continuity of care.
The Chair’s introduction stresses the importance of general
practice working together with its’ “secondary partners” to
improve access to services and balanced care in the most efficient
way. The College strongly supports this statement and notes that
the document may benefit from a broadening of this theme in the body
of the paper. Additional references to the development, implementation
and audit of referral pathways between primary and secondary care may
also be helpful.
Measures to secure improvement in communication between care systems,
such as the adoption of a single electronic patient record, would improve
patient safety and continuity of care and the College supports the
call for this within a realistic timeframe. This theme could
be connected to the discussion of inter-practice communication and
links on page 12. The promotion of telehealth to enable primary
care clinicians to consult specialists remotely would also assist in
this regard.
General practitioners are increasingly involved in the provision of
hospital services, particularly in emergency care. The RCGP may
wish to consider acknowledging this trend and proposing ways to support
practitioners.
In addition, the College acknowledges the importance of shared knowledge
and would be pleased to consider future opportunities for cooperation
in relation to training and development with the RCGP.
Patient safety and quality assurance
Whilst the importance of the NHS Quality Improvement Scottish Patient
Safety Programme is highlighted on page 11, it may be beneficial to
emphasise patient safety as a key theme given its significance.
The RCGP may also wish to expand on the discussion of ways that general
practice ensures service quality, in addition to the RCGP’s Quality
Practice Awards. This could include the implementation of existing
and development of new clinical guidelines; areas in which the College
would be keen to cooperate with colleagues in primary care.
Training
The vision document calls for an extension of GP Specialty Training
Programmes from 3 to 5 years, of which at least two years are based
in general practice. The College understands that this has been
rejected recently and further information regarding the nature of extended
training, such as the proposed setting and curriculum, would be helpful
in supporting a follow up approach. It may also be helpful to consider
the impact of the Collins Review into Foundation Programme once it
is published.
The College also notes the importance of training and development
of general practitioners with special interests, especially those in
rural and remote areas; for example, the pilot programme in the Highlands
to support the development of a remote and rural general physician.
Remote and rural issues
Issues relating to primary care in rural and remote areas are mentioned
briefly in relation to tailoring care to local needs, recruitment,
health inequalities and the need to develop academic support for new
and sustainable models of health care in remote and rural settings.
In 2005, the College commissioned a series of personal commentaries
from medical professionals working in rural Scotland.1 A
number of themes emerged that are relevant to general practice including
that:
- as wide as possible a range of routine medical care should be provided
locally;
- Doctors in remote and rural areas should not become professionally
isolated and should be involved in the body politic of medicine.
This could include involving general practitioners in hospital care,
making continuing medical education a combined function of rural
and district hospitals, and teaching medical students and doctors-in-training
- that longer-term attention should be given to producing enthusiastic
doctors suitable for and attuned to, the social and medical realities
of remote or rural practice
Given that a significant proportion of the population live in rural
and remote areas, the RCGP may wish to consider giving greater emphasis
to the future of remote and rural primary care in the paper.
Emergency services and Workforce Planning
Whilst it is acknowledged that the RCGP vision document is to be read
with the British Medical Association (BMA) Scotland’s document General
Practice in Scotland: The Way Ahead, issues including workforce
planning issues and emergency and after hours care are arguably of
sufficient import to warrant greater focus in the RCGP document.
The College believes that, given the impact on acute admissions and
average length of stay in hospital, addressing the challenges of emergency
demand from patients, in particular out of hours, should be included
within the vision for General Practice in Scotland.
The College endorses Dr Lawton’s references to future challenges
such as the ageing population, rapidly developing technology, an increasingly
feminised workforce and portfolio style careers and funding pressures. The
RCGP may wish to consider possible approaches to addressing some of
these challenges further within the document.
General Comments
To add greater focus to the document, it may be beneficial to prioritise
or provide a timeline for the recommended actions. In addition,
disclosure of those who contributed to the production of the consultation
paper would be helpful to readers.
The College is currently digesting the Department of Health’s
White Paper entitled Equity and excellence: Liberating the NHS and
a consultation paper entitled Liberating the NHS: Commissioning
for Patients. The RCGP may wish to consider the potential
impact for Scottish primary care of proposals to give English general
practitioners a greater role in commissioning.
The College would be happy to discuss any aspects of the above comments
further.
1 Royal
College of Physicians of Edinburgh, Personal Perspectives on
the future of remote and rural medicine in Scotland: A series of
commissioned commentaries, 2005, www.rcpe.ac.uk/publications/remoteandrural
medicine.php.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[1 October 2010]
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