Cabinet Secretary speech to SLMC 1 December 2017
Health Secretary Shona Robison addresses conference of the Scottish Local Medical Committee representatives of the BMA.
Many thanks Teresa, and congratulations on your first conference as chair.
We took a big and historic step on 13th November, when the Scottish Government and the BMA jointly published the terms of the proposed 2018 Scottish GMS contract. This is the first time we have worked together in this way - it is ground-breaking and it is novel.
The fundamental aim of the contract is to ensure that the core values of general practice are sustainable and that general practice in Scotland is secure for the future.
The sustainability of general practice is an essential part of our vision for better healthcare and improved health for the People of Scotland.
I genuinely believe this is a strong contract offer.
It balances the short term and the long term. The national and the local. It builds on the familiar, and promotes the new. It offers secure income, reduced workload and reduced risk. It offers a step change in sustainability. It enables you as GPs to do the role you train to do and to spend longer with those patients who most need your skills and your time.
It is a contract jointly created with the SGPC.
I’d like to pay tribute to the professionalism of the SGPC’s negotiating team.
Thank you to the doctors on the team - to Andrew Buist, Andrew Cowie, Colette Maule, who Andrew recently replaced, and to Chair, Alan McDevitt.
Thank you also to the supporting officials – Gillian Simpson, David Prince and Carrie Young, who is retiring in style today. Carrie – your knowledge, wisdom, and invaluable support to the negotiations will be sorely missed.
As a team each and every one of you contributed significantly to the final offer – on stable income, on risk, on workload, on premises, and on core values.
We don’t have to look too far in these islands for an example of a negotiation where trust seems lacking, objectives seem unclear, and progress seems absent. The challenges facing general practice do not afford us the time to waste in unproductive negotiation.
Scotland’s GPs are considering a new contract negotiated solely with the Scottish Government. This is an historic moment. It is worth taking a moment to recall the journey to this point.
That journey began with the imposition of the GMS contract in England in 2013. Seniority pay was abolished, the minimum practice income guarantee ended, and QOF continued with quality assurance driven by the CQC.
The Scottish Government does not agree with imposing contracts. That is why we asked the SGPC to consider negotiating a unique contract for Scotland. They agreed that we should.
Negotiations since 2015 have been intense, productive and collaborative. They have resulted in an offer of a distinctive, better future for general practice in Scotland.
This contract matters to you all, at all stages of your career.
It will affect those medical students who have still to decide their speciality, and those of you in the early years of your GP career. It will affect those of you in the middle of your careers, perhaps considering leadership roles, though understandably concerned about workload and risk . And also those of you who have already worked for decades as GPs – decades of service for which I am enormously grateful.
At its heart, the purpose of the new contract is to ensure that the core values of general practice are sustainable for the future. That means designing a contract that is attractive not only to all existing GPs, but also to new generations of GPs, to help deal head on with the recruitment challenges we face.
We need more GPs across Scotland. I recognise that increasing our GP workforce is fundamental to the success of this new contract.
I can announce today our ambition is to increase the number of GPs working in Scotland by at least 800 over the next ten years.
This will require us to not only encourage more people to enter the profession, but also to support those of you already working in general practice to remain.
How we do this will be set out in the third part of the National Workforce Plan, focussed on primary care. This will be published early next year.
In advance of that, I am delighted to announce additional investment of £7.5 million pounds to fund a number of important proposals to recruit and retain more GPs.
The negotiations were distinctly collaborative, and we now have a distinctively Scottish contract offer. This offer – of stable income, reduced risk and reduced workload – will enable a more sustainable service in Scotland.
This distinctive path will be attractive to existing GPs in the rest of the UK and overseas. We will launch a new marketing campaign in 2018 to capitalise on that interest and attract more GPs to work in Scotland.
We will continue the current bursary scheme to increase the attractiveness of GP specialty training posts. Over half of these bursaries will be attached to training posts in rural areas.
We are actively considering a number of other measures to increase supply.
These other measures include reviewing the sessional payment received by training practices, reviewing the GPST assessment selection process, and measures to make it easier and quicker for doctors in other specialties to switch to general practice.
These measures will increase the supply of GPs. Further details will be set out in the National Workforce Plan on Primary Care which will be published early next year.
More GP training posts have been filled this year in Scotland than at any other time since the beginning of the decade. Both recruitment rounds in 2017 attracted more doctors to general practice than their respective rounds in 2016. I believe we are beginning to see progress.
We also need to make sure that the critical early years of your careers are positive – that the experience is good, that you are doing the role you deliberately chose, and you trained to do, and that support is available to you when you need it.
I can announce that the workforce plan will include a package of support to be made available to GPs in the first five years of their career. This will include funding to allow for Professional Time Activities, and mentoring support from experienced GPs.
With this early career support, a renewed focus on general practice in Scotland’s medical training, and a new GP contract, my message to Scotland’s medical students is this -
now is the time to choose general practice in Scotland.
We also need to retain our existing GPs – we need your experience and contribution now more than ever.
To this end, I am pleased to announce a series of additional measures designed to increase the retention of experienced GPs.
We are currently working with NES to create a new ‘Staying in Practice’ scheme.
Compelling evidence also suggests retention is improved when GPs are supported through tailored coaching. We will fund 100 coaching places each year for the next 3 years.
I’m aware that annual appraisals can be an onerous process. I’ve heard your concerns and your requests for support. I can announce we will fund tailored support for the GP appraisal process from 2018. This will give GPs dedicated time and support to navigate the SOAR website in real time to complete their appraisal paperwork.
In the roadshows on the contract offer since its launch, many of you have commented that it is an aspirational contract. I’m going to hold my hands up to that one. It is aspirational – and intentionally so. I’m hugely aspirational for general practice in Scotland. I want us to be world leading.
I want us to be the place that has got the balance right. That has retained autonomy and reduced risk. That has safeguarded continuity and improved coordination. That has enabled a clear role for GPs as expert medical generalists and built an improved multidisciplinary team to support that role. That moved away from old eras of mistrust to a new era of better relationships between clinicians and managers for better patient care.
I know and I understand that you need details too. Aspirations don’t help you run a business. They don’t answer your concerns about who takes on the lease when your partners retire. And they don’t answer your questions about when exactly your day will feel less pressured as your workload reduces.
There are legitimate questions about workforce. I hear you when you ask: “Where are all these people coming from?”
There are three things I wish to emphasise on workforce and on building the multidisciplinary team:
1) We are not starting afresh.
2) Workforce groups are different.
3) Developing existing staff is key.
I’ll take each in turn.
Firstly – we are not starting from scratch. The Scottish Government has invested in pharmacy in general practice since 2016. Figures updated just this week tell us there are already 198 pharmacists and 47 pharmacy technicians providing support to over a third of practices across Scotland.
We are going to expand this service, and by April 2021 under this contract every practice will receive pharmacy support - at no cost to the practice.
These pharmacists will become the first point of contact for patients with pharmaceutical, prescription or medicine related requests. They will directly reduce your workload by taking on core tasks such as acute and repeat prescribing, medicines reviews and reconciliations, and monitoring high risk medicines, freeing up as much as an hour of your day.
Secondly – not all workforce groups are the same. Capacity varies across the different groups.
Continuing with pharmacy as an example. At a UK level, there is an oversupply of pharmacists. Concerns are expressed about where these professionals will find opportunities to use their skills.
I am not complacent – that does not guarantee supply in all parts of Scotland, in our rural communities, our towns and our cities. That is why we are introducing Scotland specific measures.
I was delighted that the contract offer includes investment to increase the number of pharmacist pre-registration training posts from 170 to 200 per year from 2018. We will explore tying this expansion to a return to service in general practice.
We are also acutely conscious of the need to rural proof our workforce plans for the wider multidisciplinary team. I am pleased to announce we will test a programme of longitudinal clerkships with pharmacy undergraduate students which will give them more exposure to working in general practice in remote and rural settings.
The final point on workforce is that developing our existing staff is key.
Much of the service redesign priorities proposed in the new contract will require an expansion of our healthcare assistant and nursing workforce in the community.
We know from the Primary Care Workforce Survey that Scotland has already successfully expanded the nursing and healthcare assistant workforce in general practice over the last decade – without displacement in other parts of the system. Much of the service redesign priorities identified in the new contract will require an expansion of that workforce.
General Practice Nursing is an integral part of the core General Practice Team. There is huge opportunity here for general practice nurses to become expert nursing generalists - better equipped and working alongside GPs and other team members to meet the increasingly complex needs of patients.
A newly developed career framework will support the profession’s career development, creating opportunities for improvement and making it easier for patients to access the right person at the right time.
To enable this change I can announce the Scottish Government will invest £3 million over the next three years for additional training for general practice nurses.
We will play our part nationally – in ensuring that the workforce supply is right – not just now but for the future. Getting that right will be critical in supporting local changes.
This will require sensitivity to the huge variation in our communities in Scotland. We need to recognise the different needs of urban areas with high levels of deprivation, of affluent suburbs with high numbers of frail elderly residents, and of remote communities, where the GP role has always been a critical and a wide ranging one.
We are committed to expanding the Community Links Worker Scheme – prioritised for practices in deprived areas. We have already recruited 43 Link Workers working across Scotland, and will provide 250 by the end of this parliament – at no additional cost to general practice.
It is also critical that workforce proposals are rural proofed. That is why ScotGEM – Scotland’s new graduate entry medical school – has a deliberate focus on rural medicine and on general practice. It is a vital system level intervention to ensure the sustainability of general practice in our rural communities.
I mentioned earlier that we will invest £7.5 million pounds next year to improve GP recruitment and retention - £2 million of that will be specifically to support remote and rural initiatives to attract and retain GPs in our rural communities.
We will continue to invest in the Scottish Rural Medicine Collaborative. We will develop a range of initiatives, including expanding the £10,000 “golden hello” scheme to GPs taking up post in their first eligible rural practice. This will be made available to 160 rural practices, a considerable expansion from the current 44.
Those 160 practices will also be eligible for an improved relocation package of £5000 per GP to encourage GPs to move to rural areas.
I want to make an important point about the detail. One size does not fit all. That is true now, and will remain true in the future. This contract is not prescriptive. It is enabling. It promotes flexibility in its implementation. Decisions on service change will be determined locally.
The draft Memorandum, supported by Chief Officers and Chief Executives, is clear that local primary care plans will be developed through collaboration between GPs, Partnerships, and Boards. These plans will be signed off by July 2018.
This will require mature, mutually respectful and trusting relationships between GPs as clinical leaders and the local system in which they practice.
Practice and Cluster Quality Leads, the GP Sub Committee and Clinical Directors will all have important contributions to make to ensure that service design reflects the needs of the people and the practices of that area.
I have been listening to the discussion and the debate that has followed the contract launch. Trust is a significant theme.
You are right to ask how the service redesign, the reduced workload, the increased multidisciplinary team will actually work in practice if relationships between clinicians and the local system are not trusting.
But you cannot contract for trust. Trust is two-way and it is earned and built up over time. You can, though, create the conditions that encourage and promote trusting relationships. That is what this contract aims to do.
The Memorandum also sets out the scale of the resources available over the next 3 years to deliver the change. I have already committed to increase the funding in direct support of general practice by £250 million by 2021. That additional investment is negotiated with the SGPC.
Today I can confirm that in 2018 the Scottish Government will invest £100 million to support the introduction of the new contract.
Oversight of this investment – at both national and local level – will include the GP profession.
This investment allows us to make real those fundamental objectives of stable income, reduced workload and reduced risk.
It enables us to guarantee that no practice in Scotland sees their funding reduce. And, it is worth remembering, subject to the outcome of discussions on pay following the Scottish budget, we are likely to see funding for every practice in Scotland increase.
The income guarantee to practices is not short term, nor indeed time-limited. It will be uplifted annually - an improvement on the current position.
Any changes to practice income will only be implemented on a clearly negotiated basis. As the contract offer makes clear, significant changes to how GPs are paid, including our proposals for phase two, will require a further poll of the profession.
I can also confirm that Board Allocated Funds will not be reduced. The mechanism for their distribution will not change. Each Health Board will continue to receive the share of Board Allocated Funds they currently do.
A national group – comprising SGPC, SG, Health Boards and Integration Authorities - will have oversight of the implementation of the new contract.
This oversight group will play a key role in ensuring that investment is focussed where needed to deliver the contract priorities, and that our commitment to income stability is being applied fairly and consistently across Scotland.
Crucially, local plans – where the detail on workforce and on workload will necessarily be set out – must be developed and agreed by local GPs.
The contract offer will reduce workload volume and intensity. The core role of the GPs should and will be the role that you trained to do – caring for people who are unwell and don’t know why, caring for people whose needs are complex, caring for a whole community and improving the quality of care that your community receives.
Reducing workload is one key part of this contract. Reducing risk is another.
Over the course of these negotiations I have spoken to many GPs. Premises have been one of the recurring concerns I have heard.
I am pleased to announce that as part of the contract we published a new GP Premises Code. This will be backed by £30 million pounds of new investment in GP Premises by the end of this parliament.
This investment will be used to provide interest free GP sustainability loans to practices. This will increase the profitability of general practice, make it easier for new partners to join a practice and help those of you near the end of your career properly plan for retirement.
The proposals cover GP leased premises too – setting out clear arrangements for the managed transfer of leases from GP partnerships to Health Boards.
I am confident these proposals effectively eliminate the risk of ‘last person standing’ in Scotland.
The premises proposals take effect from April 2018, should the contract offer by accepted by the profession. They are a fundamental plank of our proposals to reduce risk.
To conclude, this contract is a joint endeavour. It was created by the SGPC and Scottish Government together. The full committee of SGPC recommended this offer be put to the profession. It is a positive offer that will stabilise income, reduce workload and reduce risk.
It is a modern expression of the core values of general practice. Today my ask of you as leaders of your profession is to help us sustain those core values for the future.