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SRG 3 - Primary Care

The third Stakeholder Reference Group (SRG) for the Moving Forward Together (MFT) Programme took place on Tuesday the 9th of January. The Group of 14 patient, service user and carer representatives (details at the end) heard a presentation and engaged in discussion about the key role that services in the Primary Care setting will have in transforming the delivery of healthcare and social care services.

The Chair, Dr Ian Ritchie, opened the meeting and welcomed everyone, thanking them all for their participation and input. He said that as a non-executive Board member he really valued this opportunity to work with everyone and hear their feedback as it will help how we can best deliver services for all the people of Greater Glasgow and Clyde. Following this Lorna Kelly, Head of Primary Care Support and Development; Richard Groden, a GP in the East End of Glasgow and Clinical Director; Willie Wilkie, Lead Optometrist for NHS GGC and Alan Harrison, Lead Pharmacist for Community Care delivered presentations about the changing role of Primary Care services.

Lorna Kelly, spoke about Primary Care services providing detail about how they are currently structured across Greater Glasgow and Clyde (GGC) and recognising some representatives from Inverclyde welcomed them as they might be able to comment on the pilot work looking at new ways of delivering these being piloted in the area. She said Primary Care is often the first point of contact and that 90% of people visit their GP practice resulting in over 5 million GP consultations across GGC per year. This plus contact with people through optometry, dentistry and pharmacy means that Primary Care can be gateway to a wide range of community based health, social and voluntary services and the main route of referral for hospital based services. This means that Primary Care will play a crucial role in how we transform healthcare and social care services to ensure people are able to live independently in their communities and international evidence shows us that health systems with strong, well organised primary care are more efficient and have better outcomes.

Richard Groden said that there are 237 GP practices across Greater Glasgow and Clyde offering universal access and that, unless there are reasons to close a list, patient choice dictates where people attend. He said that the average practice list was about 4500 people and there was a range of core services offered; however as independent contractors  and essentially small business there was some variation services e.g. smaller practices don’t have the demand or resource. Their contract stipulates that they must see people who are or think they are ill and that they advise, treat, refer and manage episodes of care, but how routine or urgent appointments are offered and accessed and the range of other services is largely determined at a practice level. He said that one way for practices to be able to locally offer more in a geographic area was for them to work together in clusters to serve a bigger population.

He said that, although a success story, an aging population is placing greater demand on GP’s and that the deprivation prevalent in parts of Glasgow means that patients are becoming far more complex. This has resulted in a 15% increase in demand for appointments and this means that there are time pressures and discussed the difficulty in having to try and see people with multiple complicated conditions in 10 minutes. As a consequence many GPs are choosing to retire early and trainee doctors are not choosing general practice as a profession leading to challenges nationally to recruit enough GPs. However, he said that new ways of working to enable staff to work to the ‘top of their licence’ were being looked at and as an example spoke about being able to directly access the person with the most appropriate skills bypassing the GP. As an example he said that if you have an eye problem then you are better seeing the person who spent more time studying to qualify in that area with the right equipment– this being the optometrist.

He said that the aim is to try and free up GP time to focus on those with complex conditions and some of this was a goal of the new GP contract. This would see more different roles in Primary Care and some restructuring to provide new ways of accessing them in local areas. Some of this was already being piloted and tested successfully across GGC and included:

  • Anticipatory Care Planning with patients and wider multi-disciplinary team
  • Pharmacist as part of Practice Team
  • Physiotherapist attached to practice
  • Community Link Worker attached to practice supporting individuals
  • Community Respiratory and Rehabilitation Teams
  • Community Rehabilitation Teams
  • Direct access to some services - Podiatry, Physiotherapy, Midwifery

He said that more could be done in the community, but they need to look at how it links to general practice and that people need to know where to go, who to see and how to access services and that importantly people need timely access to core services.

Willie Wilkie spoke about the changing role of optometry and that training, investment and equipment has allowed them to work to the top of their licence. He said that with 178 high street optometrists across GGC most people have easy access to a highly trained eye specialist in their local area.  They should be the first port for all eye problems that can often be treated with no cost to the person and as well and being able to assess eye problems an increasing number are able to independently prescribe and can completely treat more complex conditions without having to visit a GP or hospital. However, if someone presents with more serious problems they can directly refer to hospital eye services for both urgent and routine appointments and in the future there are plans for them to be able to be more involved with patients being discharged from the hospital eye service.

Similarly Alan Harrison spoke about pharmacy and that with 291 community branches everyone in GGC could access one within 10 minutes without needing an appointment. He said that many people didn’t realise the skills that trained pharmacists have and there was work required to challenge the perception of them being ‘pill counters’. They are able to offer advice on common ailments and over the counter medication for things like coughs, colds, sore throat and stomach upsets. In addition they also offered support to stop smoking, dispense prescriptions and supply emergency contraception. With over 24 million dispensed prescription items per year in GGC many people with lifelong conditions regularly see and can build a relationship with their pharmacist and through the Chronic Medication Service they can directly monitor and prescribe.

He said that the pilots in Inverclyde and other areas of; Pharmacy First with community pharmacy prescribing prescription-only medication for specified conditions; and the advice and supply of treatment for Minor Ailments was so successful that the Scottish Government have rolled these out wider. These and future developments looking at; the Supply of specialist treatments for oncology through community pharmacy rather than hospital; and wider involvement in Out of Hours service will all contribute to reducing the burden and pressures elsewhere in the system.

Lorna Kelly then summarised the presentations by stating that there are changes across all services in Primary Care, but there are opportunities to do more and work needs done to look the what, where, who and how this will be delivered. Overall the aim is to ensure that, from the user’s perspective the system is easy to understand and use and that people get to see the right person with the appropriate knowledge and skills the first time. She then welcomed questions and asked the SRG to think about how Primary Care links with the rest of the MFT programme and the key messages for the wider public.

Ian Ritchie then opened the discussion and asked members about their understanding of the services available and how what is offered and by who might be better communicated to the wider public. Karen said that, for the pilot in Inverclyde, a lot of work was done such as giving talks in schools and targeting patients with long-term conditions with information. She said that there were some initial barriers with people wanting to see their GP, but with positive promotion and use people started to see the advantages. Thomas asked if the pilot had been evaluated and whether people had perceived improvement in care and care offered and was informed that early findings suggested that it was improving access to GPs.

Several of the group said that they were unaware of the services available having never noticed any of the promotional materials or been informed by staff when using them for other purposes. The group discussed potential issues that might prevent people accessing them such as; not understanding what is provided free of charge; some apprehension about confidentially and safety when visiting pharmacies; and that there might be some concerns around governance and assurance i.e. the GP is the expert and knows best. This led to further discussion that culturally people have become used to going to and reliant on their GP and that this will be hard to change.

 

Margaret said that people used to turn to family members for advice, but they no longer do this and with a shortage of GPs they need to realise they are not always the expert and gave a personal example where this was the case. The group felt that using real life examples and patient stories to illustrate benefits to both people and other health staff would be good to help raise awareness and increase confidence to use other services. It was felt that most people simply not aware of community services or the ability to directly refer for some things and that, until you need them, they are out of sight. This was why posters and leaflets often have limited impact, but in some areas targeted promotion at a community level lead could lead to endorsement and change via word of mouth.

The group also felt that those with complex long-term conditions who regularly use services need easy, timely access to the right person. There was talk about link workers or expanded district and specialist nursing roles, Betty recalled how home visits had been something she had done when she was nursing, but there was acknowledgement that resources and new ways of working were required to meet current and future demand. Stacey asked if voluntary services that provide self management or physiotherapy could be used to help reduce waiting times. The Group acknowledged the excellent work done by the Third Sector across health and social care, but also recognised the pressures that many are under to meet demand.

 

Talk of demand also led to discussion about what is available to people across different geographic areas with many services being provided by independent contractors. Morag Cullen asked if pilots had been Scottish Government funded how they could be rolled out elsewhere and how and Morag McIntosh spoke about consistency and will every GP practice be able to offer the same services and work to similar protocols. Ian closed the meeting by reiterating feedback from the group members that; services and system must be easy to use with the person at the centre; that there needs to be clear and consistent messages to begin to change people’s expectations and use of services.

 

In Attendance

Dr Ian Ritchie (Chair)

NHSGGC Non Executive Director

Liz Porterfield (Co-Chair)

NHSGGC - MFT Core Team

John Barber (Facilitator)

NHSGGC - MFT Core Team

Deirdre MacLean

NHSGGC – Admin Support

 

Presenting

Lorna Kelly

NHSGGC - Head of Primary Care Support and Development

Richard Groden

GP and  NHSGGC Clinical Director;

Willie Wilkie

NHSGGC - Lead Optometrist

Alan Harrison,

NHSGGC - Lead Pharmacist for Community Care

 

Patient, Service User and Carer Representatives

Anne Marie Kennedy

 

Anne McDougall

 

Barbara Barnes

 

Betty Graham

 

George Brown

 

Janet Nicholls

 

Janice Woodburn

 

Karen Haldane

 

Margaret Telfer

 

Martin Brickley

 

Morag Cullen

 

Morag McIntosh

 

Stacey Highfield

 

Thomas Cassidy