We have agreed how we can build on the 2014-15 contract and how, moving forward, we can ensure that we shape the contract so that it reflects the needs of general practice in Scotland. We will do that with the Scottish general practitioners committee, so that we can develop the contract to ensure not only that it reflects our values and needs but that it tackles issues such as recruitment and retention, which Alison McInnes and Nanette Milne highlighted.
In addition, a range of work can be done outwith the contract to modernise general practice. It should be recognised that a tremendous amount of innovative improvement exercises are already being undertaken at local level. We are working with a number of practices to understand what works and how it works.
We have also provided £1 million this year to the primary care modernisation programme to look at how we can build on areas where good practice has been identified. The first stage of that programme is the strategic assessments of primary care that boards will conduct at a local level and which should form part of their local planning process for 2014-15. We are also co-funding a programme of work that is being led by NHS Highland to develop and test models of healthcare delivery that are sustainable in remote and rural areas. We have provided £1.5 million to allow the programme to test different models of how we can meet the challenge of recruitment and retention, particularly in rural areas, and assess what model of care can best meet the needs of those local communities.
Nanette Milne referred to a point that Alison McInnes made about the planning of housing developments and the pressure that they can place on local service delivery. Health boards are key participants in developing local development plans. That is to allow the planning of sufficient healthcare provision in relation to any local development plan that is being taken forward by a local authority. Scottish planning policy makes it clear that local authorities must take account of the availability of public services and infrastructure, including primary healthcare provision, when assessing sites for new housing developments. That must be seen as being part of the core purpose of carrying out the local assessment process.
Nanette Milne rose—
I congratulate Alison McInnes on bringing forward this important debate.
Obviously, I support the your GP cares campaign, which is, I think, running in tandem with the put patients first: back general practice campaign by the Royal College of General Practitioners. Actually, I learned some of the details about the your GP cares campaign from members of the Royal College of General Practitioners at a meeting some time ago.
The key thing is to look at the percentage of NHS spending that goes into general practice, which has declined from somewhere over 9 per cent a decade ago to somewhere over 7 per cent now. That, of course, has happened at a time when the number of consultations in primary care has gone up. Alison McInnes quoted a general figure of a 10 per cent increase over the same period, much of which, of course, is relates to practice nurse consultations, but GP consultations have also gone up significantly.
That is happening already, and as we look to the future, the need for more work to be done in primary care will be accentuated. We have a growing elderly population; there is the whole policy shift in the balance of care towards primary care, which successive Governments have supported over the past decade; and, as the motion mentions, there are issues relating to
“delivering preventative care and the integration of health and social care services”.
It is therefore clear that there is a big challenge for the NHS. The fundamental issue is that the proportion of resources that go into primary care will have to shift significantly. I realise that that is not easy, as we all know about the pressures that there are on hospital services as well, but it is quite clear that that shift must take place.
I know that the Government is beginning to engage with that. For example, when I wrote to the cabinet secretary about the issue, he referred to shifting £36 million from the quality and outcomes framework into the core GP contract. Although that is not extra money for general practice, it means that that money can be spent differently. Having said that, the quality and outcomes framework has been a generally positive development since the first GP contract 10 years ago.
The new GP contract, which is currently being negotiated in Scotland, also presents a great opportunity to address some of those issues. I will be interested to hear what the minister says about progress on that.
There are particular challenges in Edinburgh in that respect, including in my constituency. Alison McInnes referred to the burgeoning population of the north-east of Scotland, which I am pleased to hear about. However, I think that the part of Scotland with the most rapidly growing population is Edinburgh. I get quite a few letters from constituents who find it difficult to access a practice in my constituency, although they all find somewhere in due course. While I am glad that NHS Lothian is opening up a new practice in the Leith community treatment centre, that will not address the problem. The health board realises that and has commissioned two reports. It has said that we need 33 new GP surgeries in Lothian in the near future. We will all keep a close watch on what those reports recommend. I hope that they come up with proposals very soon.
The issue is not just the number of practices but the quality of practices. Almost a third of practice buildings in Lothian need to be extended or modernised. I am told by my GP, who is absolutely superb, that her practice is top of the list for that modernisation work. I should therefore declare a close personal interest in the issue.
We also have more general issues, such as the difficulty in recruiting GPs and the time lag for training. There are clearly many challenges there, and addressing those major issues must be a priority for the Government.
12:47
I start by thanking those MSPs who supported my motion and enabled it to be debated today.
The British Medical Association’s your GP cares campaign emphasises that general practice is the cornerstone of the national health service and is at the heart of every community. The service provided by general practitioners and primary healthcare teams—from professionals covering vast remote areas to those working in large city practices—is appreciated the length and breadth of the country and admired across the chamber.
Amid a wealth of specialisms and the involvement of departments across the health service and beyond, GPs are often the only constant during a patient’s care, identifying symptoms, assessing needs, signposting to other services and co-ordinating a joined-up approach to the patient’s care. That continuity means that GPs are capable of developing the most acute understanding of individuals’ overall health.
Providing more than 24 million consultations each year, GPs are integral to improving Scotland’s health and wellbeing and to the objective to shift the balance of treatment and care away from hospitals towards primary settings.
The your GP cares campaign highlights the need for that patient shift to be accompanied by an appropriate transfer of resources to and investment in primary care team personnel and practice infrastructure. It draws our attention to the challenges posed by patients’ changing needs.
In the gallery today is Dr Alan McDevitt, chairman of the BMA’s Scottish GP committee. He tells us:
“There are more patients to see, more test results to read and more paperwork. Yet there are still the same number of hours in the day and many GP surgeries are simply overwhelmed.”
ISD Scotland data shows that the number of patient contacts with GPs and practice nurses has increased by 10 per cent during the past decade. Twelve per cent of registered patients now visit their local practice 10 or more times a year. The intense workload can, in part, be attributed to our growing ageing population and the need to support people who are living longer with complex, chronic or multiple health conditions. Long-term conditions already account for the majority of consultations, but the prevalence of conditions such as dementia will soar as the number of people aged over 75 doubles during the next 20 years.
The demands on general practice are particularly acute in my own North East Scotland region, and there is real concern that they are affecting GPs’ ability to best care for their patients. Official statistics show that six of the biggest 20 practices, by patient list size, are in the north-east. Many serve areas with burgeoning populations and two possess more than 20,000 patients. Facilities are already creaking and yet the third national planning framework, which was published this week, reminds us the north-east’s population will grow by 23 per cent by 2035.
A question mark still hangs over the provision of a medical centre for the new town of Chapelton—a development that will provide up to 8,000 homes. That has caused my constituents to fear that the nearby Portlethen medical centre, which is already one of the busiest in the country, could soon be overwhelmed. Elsewhere, staff at Ellon health centre are striving to provide for a growing community, but they are hampered by premises that are no longer fit for purpose, having been built when the town was a fraction of its current size. NHS Grampian says that it will be “some years” before it is replaced. Such situations are common across Scotland.
The Scottish Liberal Democrats believe that communities know best how to run locally responsive services. It would therefore be remiss of me not to note that the Scottish Government seized control of health boards’ capital budgets, stripping them of powers to tackle infrastructure problems as they see fit. This year, NHS Grampian will receive less than 2 per cent of non-formula capital spend for specific projects.
This week, the Cabinet Secretary for Health and Wellbeing confirmed to my colleague Jim Hume that the proportion of the NHS budget that is spent on primary medical services has fallen under this Government. It peaked at 9.1 per cent under the Liberal Democrat-Labour Administration and has fallen to 7.5 per cent this year.
General practice is the gateway to the wider NHS. Clinical decisions that are made in general practice commit more than half of total NHS expenditure. The Scottish Government must therefore ensure that general practice is sufficiently resourced to take the right decisions and that opportunities to build relationships with patients, understand their needs and effectively communicate what is happening are enhanced, not diminished, as care shifts from acute to primary settings.
Indeed, GPs’ workloads have already soared as the profession struggles to attract and retain talent. Young doctors appear to be pursuing other specialisms. In the Aberdeenshire community health partnership, the number who are working part time has increased by 9 per cent in the past five years alone. Worryingly, I have been told that early retirements are up, with more than a third of staff in their 50s. Others are emigrating in search of a better work-life balance.
This morning, The Scotsman reported that more than 30 practices across Scotland are operating an “open but full” policy and are accepting registrations on a limited basis only. However, Dr McDevitt has told us that many practices
“wouldn’t be able to take on a new doctor even if they wanted to.”
The Scottish Government must therefore intensify its efforts to attract and retain GPs and reverse the losses that have been experienced during the past three years.
We cannot expect GPs and practice staff to spend more time with patients and provide more appropriate care closer to home without sufficient resources, additional staff or appropriate facilities. As the nature of primary care changes, it is imperative that health boards and GPs are capable of responding to local needs and demands. They must be empowered to provide integrated and sustainable primary health services that are rooted in communities, focused on every aspect of patients’ health, delivered in a fitting environment and of the highest quality.
I would be grateful if the minister could therefore tell us whether he considers the current distribution of total NHS expenditure to be appropriate. Will he hand back some power over capital spending to boards or ensure a fairer allocation? I would welcome details of how he intends to attract and retain the staff who are required to deliver shared objectives, including those of enhancing preventative care, reducing hospital admissions, tackling the unacceptable number of delayed discharges and integrating adult health and social care services.
I congratulate Alison McInnes on securing the debate.
BMA Scotland’s your GP cares campaign highlights a number of important issues. However, it has shone a light on an issue that it perhaps did not intend to. The future delivery of services in our communities, especially our rural communities, is worthy of consideration, not least because it is beyond any doubt that fractures have developed in the relationship between the general public and general practitioners. If my mailbag is anything to go by, the principal cause of that is the difficulty that people encounter when they seek to secure surgery-based appointments, let alone home visits.
Having spent half a day shadowing in a busy GP practice in Carnoustie last year, I am not without sympathy for some of the challenges faced by those charged with delivering the services. There is unquestionably an issue over attracting locums and indeed the next generation of GPs. Demand for appointments in Carnoustie is 50 per cent higher than the national average. Ironically, up-and-coming GPs encounter a greatly reduced workload in surgeries that are based in some deprived city areas in comparison with surgeries in more affluent rural areas, such as Angus. That draws many GPs to the conurbations.
The likes of Carnoustie and nearby Monifieth also have a growing ageing population, with the service demand that that presents. NHS Tayside responded to that with a pilot project over the winter months, which aimed to assist in dealing with dementia sufferers and prevent avoidable hospital admission. However, although the pilot was so successful that it is to be extended, those issues will not go away.
There is also the bane of any GP practice: the patients who want a doctor to remove a splinter from their finger or provide antibiotics for a cold, or who insist on seeing a specific GP.
It is worth noting that GP numbers in Scotland have gone up by 5.7 per cent under this Government and that the sum invested in primary care services in 2012-13 was 10 per cent more than in 2006.
In the interests of balance, it must be said that while additional resources, if available or practically redeployable, could and would alleviate the situation, so too would doctors working the same kind of hours as the wider public. I met a GP practice partner recently after they contacted me about the campaign. They pointed out the levels of depression, stress, divorce and alcoholism in the medical profession and told me that if we politicians would answer one plea from medics it would be not to ask more of GPs because, as a profession, they simply cannot cope and would be put in a position where mistakes would be made. At the same time, they readily acknowledged that their present contracted working week consisted of just eight clinical sessions, with a further session set aside for paperwork.
General practitioners play a vital role in the health service, where they act as gatekeepers. We would not want them to be placed under such strain that they were making errors, but are we really saying that that sort of working week represents an appropriate return on what, for partners in a GP practice, is a substantial salary, especially when there is an increasing demand for access to services, which somehow has to be met?
There is a case to be made for the redeployment of financial resources as more services are delivered in our communities, but there has to be give and take on that because the Scottish Government cannot somehow magic up additional sums of money for GP practices.
I welcome the debate, and congratulate Alison McInnes on securing parliamentary time for it.
I readily acknowledge the increasing demands on primary care and the pressures that those are causing for GPs and their practice teams, leading to difficulty in recruiting and retaining new entrants. Thanks to the BMA’s your GP cares campaign, those pressures are becoming more widely known within the Scottish community. That is a good thing.
There have been issues with primary care throughout my 11 years in the Parliament. A decade ago, I was happy to support the 2004 GP contract, which removed from GPs their 24/7 responsibility for patients, because it was also very difficult at that time to recruit and retain younger doctors, growing numbers of whom were unwilling to accept the round-the-clock commitment of their predecessors.
During the ensuing years, there have been significant concerns about out-of-hours care provision, particularly in some of the more remote parts of Scotland. It took some time for NHS 24 to settle in and for the public generally to accept it. The primary care medical workforce has become increasingly part time, partly because of the predominance of female doctors who want a work-life balance that fits with their parenting role, but also because of an increasing number of men who combine general practice with other part-time appointments, such as teaching or hospital work.
In the meantime, patient demand has escalated, lists are bigger and the demographic change means that more patients are living longer with comorbidities and more complex medical conditions. All that is happening at a time of financial stringency, when spending has to be carefully planned and controlled.
The NHS in Scotland has benefited from the UK Government’s decision to protect the NHS budget and from the Scottish Government’s decision to ring fence the ensuing Barnett consequentials for the Scottish health budget. My party has not agreed with all the Scottish Government’s policy decisions on how to spend that money—for example, we disagree with free prescriptions for higher rate taxpayers who can afford to pay—but we have campaigned for more investment in primary care through the restoration of a universal GP-attached health visitor service. We therefore very much welcome last week’s announcement of 500 new health visitor posts, which will provide significant support to GPs, particularly in the more deprived parts of the country. Likewise, we were pleased with the recent changes to the Scottish contract, which removed some of the bureaucratic box ticking and allowed GPs to have a bit more face-to-face contact with their patients.
However, in the face of growing pressures on the service, the Government’s 2020 vision for more care to be provided in the community and the integration of health and social care—a policy that will require GPs to be at the heart of the primary care team if it is to be successful—a good, hard look needs to be taken at how services will be provided in the future, with the Scottish community involved at the heart of the debate.
I endorse the BMA’s concern about the need for fit-for-purpose primary care premises. In the north-east, we have seen a few excellent developments recently, such as the Calsayseat and Woodside health centres in Aberdeen, and we look forward to the approved new health centre in Inverurie. However, there are concerns in my area—as Alison McInnes has rightly pointed out—with rapidly growing populations throughout Aberdeenshire and new settlements being built, for example around Portlethen, without provision of the primary care facilities that will be needed by the increased population. There is also a need to replace buildings such as the Foresterhill health centre in Aberdeen, where my husband used to work, which was state of the art when it opened in 1979 but is now well past its sell-by date.
The motion raises some serious issues that cannot be dealt with adequately in such a short debate but which merit much fuller discussion in the chamber. I hope that the minister will pay heed to that.
Once again, I commend Alison McInnes for drawing the BMA’s campaign to our attention.
12:56
I am a little bit disturbed by the angle that the member is taking. He must understand that the GP’s workload is significantly more than the patient contact time.
I will give way to Nanette Milne.
We are quite tight for time, so I ask members to keep to four minutes, please.
12:42
As everyone in the chamber has done, I congratulate Alison McInnes on securing the debate. As every member who has spoken has also done, I recognise the fantastic job that our general practitioners do. They provide a vital service that lies at the heart of our vision of delivering an integrated health and social care system. In recognising the key role that GPs play in our system, it is important that we ensure that we have in place processes that allow them to maximise their potential in helping to shape health and social care in a community setting.
Alison McInnes and Malcolm Chisholm recognised the stark challenges that the demographic shift we face presents us with. By 2033, the number of people who are over the age of 75 is likely to have increased by almost 60 per cent, and with age, as with poverty, comes a higher chance of having a long-term illness. Many individuals will have such a condition at that point in their lives. Those are real challenges, and we need to ensure that we do the right work to support the general practice profession and the NHS so that they can meet them.
I want to outline some of the actions that we are taking to support our GPs in meeting those challenges. We have been working closely with the profession to modernise the GP contract and to transform our approach to the delivery of primary care. The 2014-15 general medical services contract in Scotland has been negotiated and agreed with the Scottish general practitioners committee. As well as bringing direct benefits for patients, it will reduce bureaucracy for GPs through a 30 per cent reduction in the QOF, which Malcolm Chisholm referred to. The transfer of around £36 million from the QOF into the core contract will help to provide greater financial stability for practices and will give GPs a greater opportunity to make judgments about how that resource should be used. It will also give them greater flexibility to make clinical judgments on how they can best meet the needs of their patients.
The contract enables each GP practice to become involved in integration planning and decision making through a lead GP who will link with the local partnership organisation. That is a key element of the role that general practice needs to perform in the future. As part of the contract, each practice will undertake a review of access and will participate in a programme of quality improvement.
The 2014-15 contract also places greater trust in the professionalism of GPs. I believe that it gives us a good platform for some of the further development work that needs to take place if we are to create sustainable general practice provision in Scotland. Overall, the Government’s ambition is for a GP contract that gives GPs the time to do what they really want to do—to work with individuals to ensure that their medical care is right for them, their families, their carers and the local environment.
Briefly please, as the minister is in his final minute.
I am simply reflecting the experiences that I have had of talking to GPs in my own constituency.
The next item of business is a members’ business debate on motion S4M-10122, in the name of Alison McInnes, on the your GP cares campaign. The debate will be concluded without any question being put. I would be grateful if those members who wish to speak in the debate would press their request-to-speak button as soon as possible.
Motion debated,
That the Parliament notes the launch of the Your GP Cares campaign by the British Medical Association (BMA) Scotland; considers that this new campaign highlights that GPs are facing unsustainable pressures, with larger patient lists and growing demand for their services for reasons including demographic changes and the increasing prevalence of more complex health needs; notes that the campaign is calling for sustainable investment in GP services to attract, retain and expand GP numbers, strengthen the practice staff team and ensure that all GP premises are fit for purpose; is concerned that some GP practices in the North East region, already possessing patient lists that are among the largest in Scotland, are ill-equipped to serve communities with burgeoning populations; commends what it considers the outstanding work of GPs across Scotland; believes that they will become even more important to their patients with the shift to delivering preventative care and the integration of health and social care services, and considers it essential that they have the capability to respond to local needs and meet the demands placed on them.
12:35
Does the minister accept that there is a time lag between the developments that we are currently faced with and the projected medical facilities, because they will arrive some years down the line? There is going to be a significant time gap in the middle, which is what is worrying Alison McInnes and me.
Could the minister clarify whether the contract has been finalised? He referred to the 2014-15 contract. Are negotiations continuing, or is that it for the foreseeable future?
Given what he has just said, would the member suggest the number of hours in a GP’s working week? How should GPs work in his world?
I am simply making the point that there has to be compromise if we are going to make progress, and we have to look at the issues in the round.
The BMA is quite entitled to speak out on behalf of its members, but so too is the Royal College of Nursing in Scotland. It was interesting to note from the briefing that the RCN provided ahead of the debate that although the number of visits to GP practices has increased from around 21.7 million in 2003-04 to 24.2 million in 2012-13, there was an increase in GP consultations of just 3.9 per cent, in comparison with an increase of 31 per cent for practice nurse consultations.
If we are to consider how health services should be delivered locally, we also need to look at the roles played by other organisations. An example is the community drop-in service that being provided by Action on Hearing Loss Scotland. Since that service started in Angus in 2010, the organisation has re-tubed 2,700 hearing aids, carried out 2,200 interventions and distributed 25,800 batteries, all of which reduced the workload on the NHS. That was evidenced by reviewed figures that show that, during the past three and a half years, service users have been spared a trip to Ninewells or Stracathro, travelling 17,000 fewer miles, yet, as things stand, that is not matched by funding moving from the NHS to Action on Hearing Loss—although the organisation will shortly be chapping the door of NHS Tayside. Meanwhile, one local GP practice has announced that it is no longer willing to dispense hearing aid batteries because staff do not have the time.
There is a debate to be had on the subject, but it needs to be a balanced debate that sees all sides willing to compromise in the interests of ensuring that the needs of the patient are met in the best way.
12:52
That is why the planning of primary healthcare provision is a key part of local authorities’ local planning processes, which look years ahead. It is covered in Scottish planning policy to make sure that it is being done effectively. If local authorities are not doing it—Alison McInnes appears to be indicating from a sedentary position that they are not—the matter must be pursued vigorously with local authorities to ensure that the planning of primary healthcare provision is taken account of and is part of the local development plan. However, I recognise that local authorities are experiencing specific pressures.
I am conscious that the Presiding Officer is keen for the debate to finish on time, so I will just say that we are taking forward work in a range of other areas and providing resource support to general practices in Scotland. However, I hope that I have set out some of the challenges that we as a Government are seeking to take forward as part of our delivery of the 2020 vision for health and social care. Members can be assured that we see general practices as key to delivering the best possible quality of healthcare for individuals at a local level. We will continue to work with partners in the BMA and in the healthcare sector overall to ensure that we continue to deliver that healthcare in the years to come.
13:07 Meeting suspended.
I congratulate Alison McInnes on securing the debate.
As we heard at First Minister’s question time, on Monday, Brian Keighley, the well-respected outgoing chairman of the BMA in Scotland, gave his farewell speech to the conference. In it, he compared the NHS to the Titanic and said that it is teetering on the brink. Highlighting a range of issues from cancer treatment to the care crisis and hospital food, he said:
“What I have seen over the past five years is the continuing crisis management of the longest car crash in my memory—and it is time for our politicians to face up to some very hard questions.”
Mr Findlay, can you relate your speech to the your GP cares campaign?
I am about to do so, Presiding Officer.
I put on record my thanks to Dr Keighley both for his commitment and service to the BMA and for his willingness to be so frank. He agrees with what we have been saying for the past two years. It is simple—the NHS in Scotland cannot go on as it is, and the Government cannot continue to pretend that it can gloss over deep-seated problems with spin and bluster.
One of those concerns is GP provision. GPs are on the front line of the system. With people living longer with multiple complex health problems, and with rising demand and expectation, the pressure on our community GP practices is growing by the day. According to NHS Lothian, 26 GP practices in my region have either completely or partially closed their lists and patients cannot get access to their local doctor. We have recruitment problems, especially in rural areas, and budgets have been cut by 2 per cent, as we have heard.
It is in our most deprived communities that the pressures on the NHS and GPs are at their most pressing. I recently met some Glasgow GPs who operate in one of the deep-end practices. They told me of the vast number of complex and extremely time-consuming cases that they have to deal with, yet that practice had gone without a health visitor for over a year and they had never met the social workers who deal with their clients. I find that both astonishing and thoroughly depressing. They also raised the issue of the inverse care law, which entrenches health inequalities by giving similar levels of funding to wealthy, healthy areas and to areas of deprivation and poor health.
I welcome the work of the deep-end GPs and the your GP cares campaign, which highlights the need to develop premises, strengthen practice teams and attract new entrants. It is vital for all our constituents that we do those things. As a councillor, I drove through a project in my community that brought together two GP practices, sports facilities, a library, a dentist’s, a cafe and a pharmacy. It also brought together Jobcentre Plus and a range of services in a new, purpose-built facility. That is how I see community services developing. The GPs who work there now prescribe swimming or gym sessions rather than drugs. They refer on to housing and the jobcentre and have immediate access to dental and pharmacy services. Those GPs are working collaboratively to deliver better outcomes for patients. That is the service integration that we are seeing in West Lothian, and I recommend that others follow that example.
I was surprised to hear Graeme Dey imply that GPs are not working flexibly or for an appropriate number of hours. I ask him to reflect on that argument. It is like people observing the Parliament and asking why MSPs are paid almost £60,000 a year when we are here for only three afternoons a week. I think that the irony of his argument has passed him by.
12:59Previous
First Minister’s Question Time