Cabinet Secretary for Health: Speech to BMA Local Medical Committees
Clydebank, 10 March 2017
Thank you Mary, and congratulations on a successful Conference as Chair. Thank you to Alan too, and to all of the Local Medical Committees represented here today.
I want to start with a personal thank you to you all, for the work you do, day-in, day-out.
Many of you in the room will know our Deputy Chief Medical Officer in Scotland, Gregor Smith. He is here today. He wrote a blog a couple of years ago – a really honest piece, rightly critical of the experience he’d had at medical school when he was told he ‘lacked ambition’ in choosing general practice.
He said we need to:
"appreciate and marvel at the work done in general practice across Scotland every day, and to celebrate it, and respect it".
I agree. And I’d go further. We need to value it and show how we value it. General practice is indispensable. Without strong general practice, our health and social care system can’t and won’t work. It is how people get the care they need.
I value general practice, and I value what you do as GPs, that no other part of the system does. The Scottish Government is committed to reinvigorating the core strengths and principles of general practice.
That’s why today I want to focus on three things:
How we attract more people to work as GPs in Scotland
How we make working in general practice better now
How we value, invest in and build general practice so it has a thriving future.
Our manifesto made clear, we are committed to increasing the number of GPs working in Scotland. We talk often of the multi-disciplinary primary care future – and we need that – but that is not instead of more GPs. We need both.
Last year we increased the number of general practice training places in Scotland by a third. And, for the first time, we made a recruitment bonus of £20,000 available to attract trainees in traditionally harder to fill posts.
This year we increased to 76 the number of training programmes advertised with bursaries. We are starting to see the impact of these efforts. The 2016 GP Year one training recruitment fill rate was up 19% compared to 2015.
These measures are only the start of our efforts to increase GP numbers. We know we also need to fundamentally influence the balance of medical training, so that Scotland produces more GPs each year.
That is why, in June last year, I confirmed a new Graduate Entry Medical School will be established – delivered by partnership of Dundee University Medical School, St Andrew’s University Medical School, and the University of the Highlands and Islands.
This new school will focus on primary care, with community experience a central feature of the curriculum. This is deliberate. We know exposure to community settings during training increases the likelihood of graduates choosing careers in primary care. I am encouraged by the progress the partnership are making in establishing the school which, subject to GMC approval, will be open in 2018.
And there is more we can do – especially to attract more people to general practice in those places where it is traditionally challenging – in our more deprived communities; in remote and rural areas.
The GP Recruitment and Retention Scheme is making inroads here. To take just two examples:
The Deep End GP Pioneer Scheme is up and running. It is designed to both attract new GPs to practices in deprived areas, and retain experienced GPs in those practices by involving them in leadership roles.
The Scottish Rural Medicine Collaborative is now expanded to include ten rural health boards across Scotland, developing a unified recruitment strategy and operating as a community of mutual support.
These inroads are promising – but we need to do more. That is why today, I am announcing the GP Recruitment and Retention Fund will increase five-fold - from £1 million in 2016 to £5 million in 2017.
This increase will:
fund GP training bursaries;
help us expand the GP Returners Scheme; and
mean we can increase the GP Retainer reimbursement rate from £59.18 per session to £76.92 per session.
And of course we will need to look beyond Scotland. That is just one reason why Brexit is so damaging to Scotland’s interests. Brexit has made recruiting medical students and qualified doctors and other staff more difficult at the very time we need them most. The NHS in Scotland has a proud history of welcoming colleagues from Europe and the rest of the world.
These issues – training, capacity, supply – are all critical elements of improved workforce planning. When I spoke to you here at conference last year, I said we needed a workforce plan. We have made progress on this.
A discussion document has been published which seeks views on how we improve planning for our health and social care workforce. I would urge you to give your views before the consultation period closes on the 28th March. They will help inform the development of the National Plan to be published in Spring 2017.
Better workforce planning in primary care requires better data. I recognise that compiling your practice workforce information for the Primary Care Workforce Survey takes time, and often falls to your already busy practice manager colleagues.
We will reimburse an additional £150 per practice for the return of workforce data in this year’s workforce survey.
Of course, attracting new people, and retaining people early in their career, is only half the challenge. We need to retain experienced GPs – you are the mentors, the professional leaders, the community medical leaders and the family doctors with many years of continuing care with your patients.
The challenges faced now by general practice are significant and complex. At this conference last year I announced the establishment of a working group on Improving Practice Sustainability.
The group has concluded the first stage of its work – their report is in your conference packs today. It is full of practical solutions on workload, on reducing bureaucracy, and on improving sustainability; and has recommendations for action at a number of levels.
I know current pressures – in particular workload pressures – are real. I am convinced we can retain GPs, in the same way we can attract more new GPs, by demonstrating with our actions, not just our words, that GPs in Scotland are valued. The Sustainability group has helped us identify where more action is needed now.
Last year, I announced three measures to get more of the basics right – new Occupational Health provision; new non-discretionary rates for cover for maternity, paternity and adoption leave; and a new emergency oxygen service.
I am pleased all three measures are now fully up and running.
And today I want to announce further measures to improve the health and wellbeing of GPs and general practice staff.
First – we will improve sickness pay. We will raise the maximum amount that can be claimed for locum cover due to a GP partner’s absence from illness or injury to £1,734.18 per week, matching the payments for maternity leave.
We know the workforce is changing, with more GPs working part time or flexible hours.
To help GPs maintain practice stability when partners are off due to illness or injury, we will extend eligibility for those increased payments to internal staff working additional hours to cover for absent GPs.
We will also simplify the discretionary rules around eligibility for payments. They will no longer be linked to the number of remaining GPs or the GP/Patient ratio. Payments will be available for all practices with GP partners absent for over two weeks.
We also recognise the amount of time and effort that you put into preparing for your annual appraisals. We will therefore invest a further £200,000 to reimburse the increase in the costs of completing appraisals for GPs, including sessional GPs.
The Sustainability report contains practical recommendations for reducing workload by improving interface working. These include following up test results. There is an important principle here. Whoever orders the test should follow up the result.
The SGPC and Consultants’ Committee of the BMA are clear on this, and I am too. It is a patient safety issue. The clinician who requests the investigation is responsible for acting on the results.
The report also touches on indemnity, and I know many of you will be concerned about the recent discount rate change in England and Wales and what that may mean for indemnity costs. Scottish Ministers are consulting with the Government Actuary Department on the basis for any movement in Scotland, and once a decision has been made, we will carefully assess the position at that point.
Getting more of the basics right also applies to the tools you have to do your jobs. At this conference last year I announced an additional £2 million to improve your information technology and systems.
I know this is an issue which matters to you, and that you need systems and IT that support you in your practice.
GP IT reprovisioning offers opportunity for future systems enhancement, but we also want to ensure that your IT remains fit for purpose now.
Our investment needs to be sustainable and integrated, so we undertook a deep analysis of GP systems and processes. This gave us real insight into where the pressure points are for you. This money is already being used to increase mobile working, single sign on, electronic test requests, practice wi-fi, and other initiatives, according to local need.
This week sees the launch of the public information campaign on SPIRE. The roll out is now well underway and we expect to see the benefits of this new system for practices, clusters and the wider population in the months ahead.
I am keen to see further opportunities develop including working with NHS 24 to support people with information and advice. Putting people in control of their own health.
And physical infrastructure matters just as much as digital. Premises are clearly a concern for many GPs - you have had motions already this morning on this.
Premises matter when planning your future, they can cause recruitment challenges, and fitness for purpose can lead to service delivery and sustainability issues.
That is why last year I established a Short Life Working Group on premises which reported to me in December. The group recommended that the Scottish Government recognise and support a long term shift that gradually moves with general practice towards a model which does not presume GPs own their practice premises.
This model lowers the risk to general practice and it allows for better financial planning and risk management by NHS Boards.
Change will involve a range of approaches, depending on the circumstances of a GP practice, the needs of GP partners and local needs.
We are working in conjunction with the BMA to produce a national Code of Practice for NHS Boards when a contractor wishes the Board to acquire property or take on the contractor’s responsibilities under an existing lease.
This would ensure a more consistent approach across Scotland, protect general practice from the Last Person Standing scenario, and allow NHS Boards to more quickly respond to these situations.
Multidisciplinary workforce in practices, clusters and localities
Finally, some of the things we need to do to make general practice better now are also the key to long term stability. Increasing the core multi-professional team, working in your practices, working in clusters and in wider localities, will make a difference to GP workload and ultimately to better patient choice and care.
We have already started with the Pharmacy in GP fund. Already 120 whole time equivalent pharmacists have been appointed to posts with one third of GP practices across Scotland now having direct pharmacist support.
The initial results are promising. The sixteen practices in our Inverclyde test of change have been receiving additional prescribing support since last summer.
GP workload on the relevant activities – Immediate Discharge Letters; Outpatients Requests; Special Requests and other medication related issues – has decreased by 50% over this period.
Imagine that at scale, in every practice, improving the care of all our patients and reducing the workload of all our GPs? That is our ambition.
That is why I can announce today that we will expand the GP Pharmacy fund – from £7.8 million in 2016 to £12 million in 2017. Funding more pharmacists to work in more practices to reduce GP workload and improve patient care.
Pharmacy is just the beginning.
We need to develop our nursing and allied health professionals.
For instance, there is enormous potential for community paramedics to do more in general practice – particularly on falls and unscheduled house calls. The Scottish Ambulance Service and BMA have already started the conversation on how best to develop this community paramedic role.
And the teams we build will need to reflect the needs of the local population they serve. There is more we can do, for example, to meet the needs of our poorer communities.
The Scottish Government has committed to increasing the number of community Links Workers in disadvantaged areas to 250 by the end of this parliament, and we expect to have the first 40 in place by September 2017.
And of course, you already work in teams. I know general practice nurses are core to your team and critical to good patient care. I am pleased to announce today we will invest £2 million in 2017 in training for GP nurse practitioners and practice nurses. You are debating motions on this later today – I hope this announcement will be welcome.
I have spoken about how we attract more GPs. And I have spoken about how we make working in general practice better now. Let me turn to how we make general practice thrive in the future.
We do this by investing in general practice. In October, the First Minister made clear the scale of our ambition in shifting the focus of health investment to the community. It is worth quoting her exact words:
"To make our NHS fit for the future we must reform as well as invest . . . The NHS of the future must be built on a real shift from acute care to primary and community care . . . By 2021 . . . half of the health budget will be spent not in acute hospitals but in the community".
There have been efforts to shift the balance before. Some of you might be feeling sceptical. I understand that.
The First Minister talked about "primary care" – what does this mean for general practice?
Let me be clear. While the full £500 million invested in primary care will benefit general practice, by 2021, the investment in direct support of general practice will reach an additional £250 million per year. There will be year on year increased investment between now and then.
This is a critical part our commitment to increase overall annual funding for primary care by £500 million by 2021. This is a direct result of the negotiations with SGPC.
This investment has already started. This year, investment in direct support of general practice will be £60 million. This is on top of the uplift to your contract. Subject to DDRB recommendations, I can confirm I will be adding £11.6 million to the GP contract next year to cover pay and expenses. A total of over £71 million this year – in direct support of general practice.
Investment is needed. Without a clear vision for the role of the GP in our future community health service, it is not enough.
I look back at the history of general practice in recent decades, and I see times when investment increased without a clear vision for the unique role and unique contribution of general practice.
I look back and wonder if the focus was too much on increasing activity, on increasing services, on increasing bureaucracy. I wonder if we lost sight of the core principles of general practice.
We spoke about these core principles in the Joint Memorandum the Scottish Government and BMA published in November – contact, comprehensiveness, continuity and co-ordination.
I value these core principles and am determined they are front and foremost in our work to develop the new contract.
What does this mean?
It means I recognise the decisions you make every day – whether to treat; how to treat; whether to refer – are critical to the sustainability of the NHS in Scotland.
You manage uncertainty and manage demand by expertly distinguishing that which genuinely needs investigation and treatment, and that which simply needs explanation. You practice Realistic Medicine – just the right amount of medicine for the best outcomes for your patients.
It means making sure you have the time to practice these core values. This is why we are focussed on increasing the multi-disciplinary teams in your practices so, for example, the practice pharmacist is responsible for repeat prescribing, freeing up your time.
It means building on your skills and the early promise of GP clusters so that you play an even bigger role in anticipatory care and proactively supporting the health of your communities.
Giving you the time to be clinical leaders in your practice, in your cluster, in your community. Engaging, planning and delivering better outcomes. A more proactive approach ranging across conditions, communities and professional boundaries.
To give you this time we need to look carefully at the balance in the new contract between GPs fulfilling a critical role and as providers of services. Let me give you one example.
We are starting a programme of work to review how we deliver vaccinations. Our intention is to move away from the current position of GP practices being the preferred provider of programmes on the basis of national agreements.
We want to find ways to enable other parts of the system to be responsible for the delivery of vaccination programmes, and we want to work with you and NHS Board colleagues to do that.
Be reassured, the Memorandum is clear that historically associated funding will stay in practices. This is not about reducing GMS, but re-focussing GMS so it funds the new role of the GP – in complex care; in managing uncertainty; in quality and local medical leadership.
The Vaccination Transformation Programme will draw in expertise from across the NHS and will take around 3 years to complete. This is a complex piece of work impacting every person in Scotland.
It will require engagement from us all to ensure that Scottish vaccination programmes continue to be delivered to the same high standard as they are now.
I opened by recounting Gregor’s memory on ‘lacking ambition’. I hope it is clear how ambitious I am for general practice in Scotland. I hope it is clear how I value general practice, and I hope GPs feel valued in Scotland, perhaps more than elsewhere in the UK.
I sense a difference. When I consider winter pressures, and how to improve our resilience, I am not interested in kneejerk responses that blame one part of the system. I am not interested in explanations that wilfully fail to see how the whole system is connected. I am not interested in scapegoating GPs.
General practice is not the problem, it is a critical part of the solution.
I need your help though, and your ambition – to be medical leaders in the community; to take on this new role of the GP; to be hopeful and work together. With this help, I am confident the future of general practice in Scotland is bright.