General Practice Week
The final item of business is a members' business debate on motion S3M-5469, in the name of Dr Richard Simpson, on celebrating the first-ever general practice week in Scotland. The debate will be concluded without any question being put.
Motion debated,
That the Parliament notes that more than 21 million patient consultations take place in general practice in Scotland every year; is proud of the high quality service provided by GPs and their practice teams every day, and welcomes the first ever General Practice Week in Scotland, from 8 to 14 February 2010, hosted by the British Medical Association Scotland in partnership with the Royal College of General Practitioners Scotland, which aims to celebrate the very best of NHS general practice in Scotland.
I am grateful for the opportunity to praise the fantastic work that general practitioners and their staff do all over Scotland. I thank the members who signed the motion in my name and who have remained to speak in the debate.
Throughout Scotland, from single-handed rural one-person GP surgeries to busy multipartner practices, which are mainly in our cities, the whole range of practices provides an excellent service to us. I make no apology for approaching the debate from a rather biased perspective as, in a former life, I was a GP for 30 years. I declare that I am a member of the British Medical Association, which promotes general practice week, and of the Royal College of General Practitioners.
Many MSPs have had the opportunity to visit GP practices in their constituencies in conjunction with the BMA and have found that useful. General practice week aims to build on the positive feedback that was received about those visits.
Last year was busy for general practice, not only because of the recent prolonged cold weather, but most notably because of the increased pressures from the swine flu vaccination and pandemic. That is just the most recent demonstration that GP primary care has proved over the years to be the part of the national health service that is most capable of a rapid and flexible response.
The BMA's document "General Practice in Scotland: The Way Ahead—Final Report", of which members should have a copy, spells out a clear vision for the future of general practice. From about 120 responses to the association's consultation, the BMA felt that six key areas needed to be addressed to ensure that general practice meets the aspirations of patients in the community. Those are access, out-of-hours care, health inequalities, workforce planning—the right workforce as it is called—the balance of care, and infrastructure in terms of premises and information technology. I will try to touch on some of those issues.
Don Berwick, the noted American academic, has called general practice
"the jewel in the crown of the NHS",
and, in a recent paper in the British Medical Journal, has said that, if we were to lose the core values of general practice, we would all live to regret that loss. It is hard to disagree with the sentiment.
An effective GP service not only provides rapid diagnosis in an emergency but, by providing continuity in a trusting relationship between the patient and primary care team, is the bedrock for prevention, supported lifestyle changes, self-management of long-term chronic conditions and family support.
Access is a matter for discussion. When I became a consultant psychiatrist, I found that too many practices had used the Scottish flexible approach of the 48-hour target for the time within which a patient has to be seen by a health professional to introduce unacceptable appointment systems. Patients had to phone at 08:00 to get an appointment and sometimes then spent an hour on the phone only to be told that, unless it was an emergency, they had to call again the next day.
It is very important that the Government works with the BMA and the Royal College of General Practitioners to reward continuity and good access systems that suit individual localities. We must tackle the injustices that will arise from responses to poorly validated access questions in the current quality and outcomes framework survey. The QOF survey has done us a disservice in that regard; it has created—reasonably and appropriately—a lot of resentment among general practitioners.
In the main, health mostly does not happen in hospital; it happens at home and in the workplace, school and community. Health is not just about the absence of disease. It is not even just about fitness. It is about the mental and physical wellbeing that gives us the energy, hope and self-esteem to achieve what we want to achieve. Looking after the health of the whole community is the job of general practice, primary and community health services and social services, working together to provide genuinely holistic health services close to home. Health professionals need to be well connected to the other services that are provided in their area, particularly local council services.
There is too much division between health and social services sectors. Indeed, divisions between GPs, hospital consultants, social care workers, public health officials and allied health workers have all deepened. Those divisions have shifted the focus of the professional from the patient as an individual to the part of the patient that the professional is servicing. That does not make it easy for the professional to consider the whole health and wellbeing of the person. I wish the Government success in its integrated resource approach, which is the latest Government effort to achieve integration. I hope that it is more successful than the joint future programme with which the previous Government wrestled over a number of years.
I read this recently:
"Hospitals, as most GPs will tell you, are foreign countries; they do things differently there … Hospital specialists still routinely refer patients to one another without any reference to the patients' GPs, whilst the tendency of hospitals to call patients back for further outpatient consultations repeatedly, even though there is no obvious medical benefit for doing so, is still too prevalent. Encouraging hospitals to do less will require more than just a review of their funding arrangements therefore; it will require a re-examination of the fundamental ethos that governs the working practices of hospitals."
Sadly, we still have a situation in Scotland where the poorer someone is, the less healthy they are. Scotland has pockets of real poverty. Poorer people tend to fall sick more often and have long-term illnesses and long-term poor health. As Professor Graham Watt has urged, if we want everyone to be healthy and if we want to improve the quality of care in our hospitals, we need to ensure that GPs in poor areas are given extra resources with which to do their job well.
Primary care needs modern premises. With capital budgets being restrained, there are serious concerns about the future premises replacement programme. Primary care needs modern IT systems. The demise of the general practice administration system for Scotland—it was almost a national system for Scotland—reflects very badly on our ability to make public sector IT software work. I am concerned that the replacement system may prove as inadequate to the task as GPASS proved to be.
In England, Labour has chosen a combination of approaches, based on patient choice, underpinned by commissioning or purchasing—initially by primary care trusts and then by GPs—and linked to foundation hospitals, which have achieved a level of service and governance, both clinical and financial, that allows them freedom that is not afforded to ordinary NHS hospitals. In Scotland, we have chosen a quite different approach. The challenge will be, with that approach, to match the progress that the NHS in England is undoubtedly making. The intention must be that, eventually, people will expect rarely to see the inside of a hospital. Hospitals will be seen no longer as the centre of the health service but as an essential high-quality—and, no doubt, high-cost—but increasingly smaller backstop for things that cannot be accommodated in the service that is provided in local communities, which is the front line for the new NHS. Everyone will understand that the local services that the primary care team provides bind together—or should bind together—the whole NHS around the individual's personal needs.
It is disappointing that Audit Scotland has been unable to identify much in the way of a shift in the balance of resources to match the intended shift in care. In England, primary care trusts are required to define and finance such a shift in their annual plans. I ask the minister whether there is anything comparable in Scotland.
I commend to members the BMA's final report on general practice in Scotland and look forward to the report by the Royal College of General Practitioners in the autumn. I hope that all of us can work together to resolve issues relating to access, out-of-hours services and the workforce and to create systems that support what all of us seek—a continuing rise in the quality of primary care, so that it remains the jewel in the crown and a world leader.
I congratulate Richard Simpson on securing this important debate. He described general practice as the jewel in the crown of the national health service, and rightly so. A health service in which every citizen is registered with a GP practice and receives top-class primary care and appropriate referral, if necessary, is one that many envy and which acts as an exemplar for health services elsewhere in the world. It is also a trailblazer in other ways. When I started out in general practice years ago, the only experience that I had before seeing patients was 12 months in hospital jobs—I had to learn the trade as I went along. Now, rightly, many years of training are required before entry into general practice, and regular continuing professional training and assessments ensure that standards are maintained thereafter. Nowadays, patients can be confident that the GP caring for them is experienced and up to date.
Having said that, I think that there are some areas of concern. The first relates to the changing role of the GP in the health service. Once that role was obvious. He or she—I will use the word "she" from now on, as most GPs today are female—was the patient's advocate; loyalty was entirely to the patient. However, now the GP has an increasing responsibility to the community, too. She must bear in mind not just whether a medicine will help a patient but whether the public purse can afford it. There is also the growing public health role, which can cause conflicting loyalties. For example, I can envisage circumstances in which the lifelong prescription of a statin for raised cholesterol may be recommended if population studies are taken into account but not when the needs and preferences of the individual patient are considered. I wonder whether all patients realise that a doctor's income may suffer if they decide, on perfectly reasonable grounds, to refuse a prescription. Will that affect the way in which doctors counsel patients? I think that it could.
That brings me to the subject of targets in primary care. No one can doubt that the introduction of the quality and outcomes framework has been beneficial. The systematic search for hidden chronic disease has vastly improved standards of health care. However, I wonder whether the use of targets is becoming slightly counterproductive. I say that for two reasons. First, there are many conditions that, although important, do not lend themselves to the development of targets and therefore risk being treated as of lesser importance. Secondly, targets that are applied nationwide, without attention to the individual needs of different communities, risk disadvantaging practices that serve areas of deprivation, for example, where targets often take superhuman efforts to achieve and divert attention from more important problems.
A suggestion is that some of the QOF structure should be replaced by a system in which individual practices negotiate development plans with health boards that are specific to the needs of the area that they serve, and progress is charted in regular follow-up meetings. If GPs were remunerated for that rather than for meeting all the QOFs, that could be a way of channelling resources to deprived areas in the way that Dr Simpson requested.
My last point is concern that we have concentrated over recent years on the accessibility of primary care at the expense of continuity—Richard Simpson also made that point—which is a feature that has been so valuable to patient and doctor in the past. The theoretical idea of one doctor being responsible for a patient 24 hours day, 365 days a year, is obviously undesirable. However, in our haste to develop targets, have we made it more difficult for a patient, when feeling unwell, to access care from someone who knows them and whom they trust? Does the fact that general practice is the only service sector to reduce its hours of availability to the public mean that it risks losing the public support that has sustained it so well in the past? The profession must take care that short-term gain does not become its long-term loss.
I could have dwelled on many other points, including the changing role of the nurse in primary care—
You are over your time, Dr McKee.
—but time does not permit, so I will sit down.
The appointment is over.
I thank Richard Simpson for securing the debate during general practice week in Scotland. I thank him, too, for organising the briefing last night at which I had the opportunity to meet two GPs from the Highlands, Dr Miles Mack and Dr Susan Hussey.
My starting point in preparation for the debate was my members' business debate in national general practice week in September 2002, when we were meeting up the road. The motion recognised
"the importance of primary care",
appreciated
"the vital role GPs play",
and supported Malcolm Chisholm's statement that
"if it can be done in primary care, it should be done in primary care".
In that debate, I stressed the nine years of training that GPs had and the fact that over 90 per cent of NHS contact was in primary care. I stated:
"There is no doubt that general practice and the primary health care team is the heart and the cornerstone of the NHS in Scotland."
That was eight years ago, before the introduction of the new general medical services contract, about which Malcolm Chisholm, who was then Minister for Health and Community Care, said:
"The contract gives renewed focus to quality and outcomes".—[Official Report, 25 September 2002; c 14090, 14104.]
There is no doubt of the benefits of QOFs to patients, but there is also no doubt that the contract can be reviewed and improved. There is also no doubting the excellent service in general practice, including that provided by nurses, health visitors and podiatrists. However, it is a bit difficult to relate the benefits of the new contract to the out-of-hours service, from which 95 per cent of our GPs have opted out.
In this context, I place on record my thanks to the good people of Kinloch Rannoch whose petition to Parliament prompted an inquiry by the Health and Sport Committee into the provision of out-of-hours care in Scotland. Although the committee has not concluded its report and recommendations, there is no doubt that the inquiry has highlighted many issues in out-of-hours services that need to be addressed. Audit Scotland has confirmed that there is
"a lack of clear quality standards"
for out-of-hours services, and NHS Quality Improvement Scotland gave the committee an assurance that it will look at that issue.
The committee was told during the inquiry that, since the introduction of the new contract, calls to the Scottish Ambulance Service have increased by 35 per cent during GP working hours and by 42 per cent out of hours; that presentations to accident and emergency departments have increased; and that there is greater utilisation of NHS 24. I look forward to NHS 24 making more use of telehealth and working with GPs on that issue throughout Scotland.
We now have a very good emergency response service, but many people in Scotland are rightly concerned about the corresponding loss of clinical care and the previous excellent access to the diagnostic skills of the GP. We must thank the folk of Kinloch Rannoch for raising their concerns about the difference between emergency response and quality clinical care. One thing is certain: the Ambulance Service, NHS 24, A and E, minor injuries units and GPs must work in much closer partnership, although I appreciate that that is already happening in many areas.
On this day of celebrating general practice, I highlight some points that have been made by GPs who are still providing out-of-hours care, and who made written submissions to the Health and Sport Committee—and these are in the public domain. Dr Helen Stewart of Torridon in Wester Ross states:
"My only conclusion can be that a GP is the most sustainable and cost-effective way to provide that service."
The member should wind up.
I will just give members one more example, from Shetland, which I think is an important one, and I will finish there:
"I live amongst my patients and am part of their community.
The retained fire service and coastguard services turn out to emergencies and therefore why not the doctor who lives in the community."
As other members have done, I congratulate Richard Simpson on securing the debate and, as Mary Scanlon said, on organising the very successful reception last night. Without detracting from Ian McKee's excellent contributions to the Parliament, I would say that Richard Simpson brings his experience as a GP to the chamber and the committees of the Parliament. There is no doubt that the Parliament is better for that expertise.
In preparation for general practice week I visited the local Craigallian Avenue practice in Halfway in my constituency, where I have been registered as a patient since I was nine. It was interesting to return there this week. Fortunately, I do not have to visit the practice that often, but when I do I am always reassured by the excellent service that the GPs and the team there provide.
I have young children and elderly parents. People at that stage often find themselves in and out of GP surgeries. We look to GPs for reassurance as they treat those who are close to us—and we often get it; that is why, according to the BMA survey, 82 per cent of people said that they got a lot of reassurance and support from their GPs.
I am registered at the Craigallian Avenue practice but, like a good constituency MSP, I manage to have an interest in another practice, as my wife and children are registered at a practice nearer home, in Rutherglen. As well as paying tribute to the Craigallian Avenue practice, I pay tribute to the work of Dr Colville, who is on the Scottish GPs committee, and to others who work at Rutherglen health centre.
There is no doubt that GP practices have changed over the years. When I was a youngster, one GP in Cambuslang used to chain-smoke his way through consultations. Thankfully, times have changed and we have moved on. The nature of GP practices has changed too; work is done by practice nurses and health visitors, and coverage is more comprehensive. That helps not just with diagnosis but with anticipating potential health problems, which is to the betterment of communities throughout Scotland.
GPs are the driving force of the NHS and have a big role to play in tackling many of the issues that we discuss at the Parliament, such as health inequalities. In the west of Scotland, health inequalities remain a very challenging issue, but the way in which practices are organised there allows them to tap in and track heart disease, lung disease, liver disease and cancer from an early stage and GPs are able to prolong people's lives.
I share Richard Simpson's disappointment at the demise of the GPASS IT system. I remember one of my very first jobs as an analyst/programmer a very long time ago. I was not directly involved in GPASS, but I worked in a team that worked on its roll-out. I know from that, as well as from various experiences of GP surgeries over the years, how important a system it was. IT facilities are crucial in helping GPs with their work and in helping to ensure that patients are given an appropriate service.
I congratulate Richard Simpson on securing the debate and commend the work of GP practices throughout Rutherglen and Cambuslang in my constituency.
I, too, congratulate Richard Simpson—notwithstanding the obvious bias that was demonstrated by his declaration of interests—on securing a debate on such an important issue. I also congratulate him on securing it on 11 February, which is an important date for me for two reasons.
One of the first issues that gripped me as a young politician was discrimination against coloured people. Along with many others who are now members of this Parliament, I went on anti-apartheid marches and the like. Today is important because it is 20 years since the release of Nelson Mandela.
Today is important also because it is 64 years to the day since I became a patient of the practice by which I am still looked after. Sadly, the first doctor who looked after me has passed on. Two others have retired because of the robust health they have given me. My current doctor spends most evenings wondering what on earth she did to deserve me as a patient.
As Dr McKee mentioned, the important point is the continuity of the care that is offered and provided by general practice. The motion celebrates Scotland's first ever general practice week. In celebrating the week, we celebrate the work of general practice and its contribution to society.
In the many years since the establishment of general practice, there have, of course, been enormous changes, but despite those changes and the significant difficulties that have been faced, GPs remain at the core of the delivery of health services in our community. I pay tribute to what they have done and hope that they will continue to be at the forefront of the delivery of care. I think that GPs will continue to be at the forefront of the delivery of care, but we must recognise that the model through which that care will be delivered has altered and will continue to alter. Although GPs will undoubtedly not lose their predominant role, they will not necessarily be the only people in what will increasingly become a multidisciplinary team who will be involved in organising the delivery of care.
The issues that GPs have raised in "General Practice in Scotland: The Way Ahead" strike a chord with anyone and everyone who has read it, who will recognise that simply because GPs are in touch and understand the issues that confront us, the agenda that is set out in that document is undoubtedly one that we can all warm to, notwithstanding the fact that under each sub-heading there are issues that need to be resolved—that is admitted in the document.
Access has changed because work patterns and social habits have changed. The model of access must reflect change and respond to it. On out-of-hours care, in no way do we suggest that there should ever be a return to doctors having to work 24/7, but we need to recognise that although GPs have played and will continue to play a critical role, that must be interfaced with their delivery of out-of-hours care alongside other health professionals. That issue, which GPs highlight in "The Way Ahead", has not been wholly resolved and it needs to be addressed. Because GPs play such a central role in our communities, they are the people who will be able to tell us about health inequalities.
I hope that, in taking the opportunity that the motion gives us to celebrate GPs' success and to look forward to their continuing to be at the core of our communities, we recognise that, in future, they will be part of a team and that some of the issues that they have raised in their document need to be properly addressed.
I thank Richard Simpson for securing the debate and for arranging the reception last night, at which I was pleased to talk to quite a few GPs from across Scotland, including one from Leith, in my constituency. I also thank all the GPs and primary health care teams throughout Scotland for all the work they do—especially my GP in the Leith Walk surgery, who is simply the best and whom I would be very happy to nominate as GP of the year. However, I am sure that I am not the only person to feel that way about their GP, because the relationship between an individual and their GP is central to the NHS. Indeed, as the very great Don Berwick—I think Richard Simpson thought I was going to say "the very great Richard Simpson"—said in a recent article, it is the
"jewel in the Crown of the NHS."
It was very kind of Mary Scanlon to remind me of one of my better soundbites—one of my few soundbites, actually—when she quoted my statement that
"If it can be done in primary care, it should be done in primary care."—[Official Report, 25 April 2002; c 11239.]
I think that that embodies an important truth. There have been developments that have moved the health service in that direction over the years, but I am sure that we all agree that it could go further.
Mary Scanlon's second comment, about the contract, was not quite so kind. I want gently to challenge her on it, because I believe that what I said about giving
"renewed focus to quality and outcomes"—[Official Report, 25 September 2002; c 14104.]
was in fact one of the results of the GP contract.
Both the consultants contract and the GP contract have been subject to quite a lot of criticism. I will not talk about the former in this debate, but I have always been pleased with the GP contract, not least because of the quality and outcomes framework and the idea of rewarding health professionals because of positive actions that they take. It is a shame that most of the public probably do not know about the quality and outcomes framework, but many thousands of people benefit from it every day of the year. It was also one of the subjects that came up at the reception last night. Notwithstanding GPs' particular criticism about the way in which the access points are arrived at, they recognise that it has brought enormous benefits to patients, particularly in respect of preventive health care—especially on issues to do with heart disease, stroke and diabetes.
Obviously, the minister and the professionals will listen to some of the points that Ian McKee made, but the principle that was established is good and, fundamentally, it was a good contract. I accept that there are issues in rural areas that the Health and Sport Committee is considering but, in urban areas, such as the one that I represent, out-of-hours arrangements are working very satisfactorily.
The BMA has produced a report in connection with general practice week. Most of us are happy to go along with a lot of the recommendations in the report, which goes with the general direction of travel on health in Scotland. I think that the minister recognises that there is some continuity on that between different Administrations. It was encouraging to have that general direction of travel, particularly the importance that continues to be attached to general practice in Scotland, endorsed by the health professionals last night. In fact, they contrasted the situation here with some developments in England. I know that the minister will look at the recommendations in the report and respond positively to them. I look forward to hearing her now.
I am happy to be closing this debate about general practice week and the vital role that our GPs and practice staff play in providing patient care. I congratulate Richard Simpson on securing the debate.
The Scottish Government is, of course, firmly committed to general practice. As has been said, GPs and their staff are the cornerstone of primary care, which accounts for 90 per cent of all NHS contacts with patients. They provide the dedicated professional service and continuity of care that we know patients value hugely. I pay particular tribute to GPs for the role that they have played over the past year in two specific areas: first, in helping—as Richard Simpson mentioned—to combat the threat of swine flu, and, secondly, in respect of the BMA's high-profile role in supporting our efforts to tackle Scotland's problem with alcohol.
The Government has shown its commitment to GPs in particular by devoting record resources to primary medical services and by promoting legislation to enshrine their traditional role. I am sure that everyone is aware of the Tobacco and Primary Medical Services (Scotland) Bill, which was passed by the Parliament just two weeks ago. Part 2 of that bill strengthens the way in which primary medical services will be provided in the future in support of our public health priorities. It is an endorsement of the model of general practice that we see in Scotland today—a model of which we can justifiably be proud. Malcolm Chisholm made the important point that that has been our direction of travel since before 2007, but general practice must keep moving, evolving and modernising.
General practice is often cited as one of the areas of the health service that is most valued by the public: the relationship that patients have with their practice is based on trust and confidence. It is right to recognise the valuable contribution that general practice staff make to improving the health and wellbeing of the people of Scotland.
Our knowledge of the current state of general practice in Scotland has been enhanced by the recent publication of the results of the national primary care workforce survey, which was developed to address gaps in information about the GP and practice nurse workforce. The figures show a profession that has reasons to look to the future with confidence. The latest survey shows that the number of GPs in Scotland has risen steadily since 2004 and, crucially, that the number of GP trainees has increased by 67 per cent. That shows that a career in general practice continues to be attractive. With women GPs outnumbering men GPs, as Ian McKee pointed out, it is also seen as a flexible career choice that can especially suit those who have caring responsibilities. In addition, there is clear evidence that numbers of other practice staff, such as nurses, have risen in recent years, and I am encouraged by that trend.
Earlier this week, the Cabinet Secretary for Health and Wellbeing announced her commitment, through a new quality strategy, to the implementation of a shared approach to achieving world-leading quality in our NHS. It is an ambitious strategy with the key aim of involving everyone in Scotland in making a real difference to the quality of health care provision. In preparing for the new approach, we have listened carefully to what patients, carers and the people who are delivering health care services across the NHS have said they want. They want a compassionate health service and real partnership between clinicians, patients and others with clear communication. It has been said on a number of occasions that the patient-doctor relationship was very different 20, 30 or 40 years ago from how it is now. That is absolutely right and proper.
People also want services to be provided in a clean and safe care environment, with continuity throughout their journey, and they want clinical excellence so that they can continue to have confidence in our NHS services. The quality strategy will achieve those things by building on the good foundations that we already have in place, with a shared vision of health care quality that is supported by the right measures.
Along with many others, I welcome BMA Scotland's report "General Practice in Scotland: The Way Ahead", which was published on Tuesday. GPs are at the heart of health care in Scotland, providing dedicated professional service and continuity of care. Nicola Sturgeon and I are encouraged by the BMA's commitment in the report to work with us to address the challenges that all parts of the NHS face and, in particular, to improve the outcomes and quality of the primary care that is delivered to patients. That is at the core of the quality strategy that I just mentioned. There are also some specific recommendations in the report—for example, on out-of-hours standards and on local support for improving access—which we strongly support. Like many others in the chamber, we look forward to discussing the report with the BMA so that we can work together for the benefit of Scotland's patients.
I add my personal thanks to all those who are involved in general practice for the part that they play in improving the health of Scotland's people, and I am grateful to Richard Simpson for highlighting that in this afternoon's debate.
Meeting closed at 17:49.