2 The Role Of GPs In Scotland – Expert Medical Generalists
- The GP as expert medical generalist will focus on undifferentiated presentations, complex care and quality and leadership. All are equally important.
- GPs will lead and be part of an extended team of primary care professionals.
- GPs will have more time to spend with the people who need them most.
The Scottish Government and the SGPC share a vision of the role of the GP as the expert medical generalist in the community. This is not a new role – generalism has always been at the heart of general practice: holistic care that sees the person as a whole in the context of their community is the very strength of general practice that we wish to enhance.
However, the context that GPs now work in is changing - multi-morbidity is more common; people are living longer and the demands on GPs have been growing. The challenge is ensuring GPs have the space and the time to carry out the expert medical generalist role that their communities need.
We intend to meet this challenge by focusing the role of the GP on activity that requires the skills of a doctor. The GP will be supported by an extended multi-disciplinary team that will be responsible for some of the activities currently being performed by the GP, where that is safe, appropriate and improves patient care. Practice workload will be more manageable, with patients consulting with the most appropriate professional in the team. Chapter four describes how we will tackle rising GP workload in more detail.
We anticipate that an enhanced role for the GP as senior clinical leader in the community will lead to greater professional esteem. It will remain a challenging role, and a rewarding one.
The GP As Expert Medical Generalist
In the previous chapter we introduced Barbara Starfield’s four Cs of primary care - contact, comprehensiveness, continuity and co-ordination. Her pioneering research clearly demonstrated the benefits of strong general practice for the population and for the wider health and care system. The international evidence is clear – health and care systems with strong primary care demonstrate better population health outcomes, more equitable outcomes and better cost efficiency than systems with relatively weak primary care. The aim of this contract – and wider primary care transformation – is to strengthen general practice for the benefit of all in Scotland.
Successfully addressing the health needs of individuals and communities requires an approach that makes the best use of the unique skills and experience of GPs and of other professionals in primary care. We expect that a modernised role for GPs will encourage recruitment and retention and strengthen the crucial role of general practice and primary care within the wider health and social care system.
We are proposing a refocused role for the GP from 2018. This will incorporate the core existing aspects of general practice and introduce a renewed focus on quality and the sharing of system wide clinical knowledge. It will acknowledge the GP’s expertise as the senior clinical leader in the community, who will focus on:
- undifferentiated presentations
- complex care in the community
- whole system quality improvement and clinical leadership
A key change in the contract offer is the proposal that GPs become more involved in complex care and system wide activities, necessitating a refocusing of GP activity. As we refocus the GP role, we expect GPs to be less involved in more routine tasks, with these tasks being delivered by other health professions in the wider primary care multi-disciplinary team. To achieve this, the training needs of GPs and members of the wider primary care multi-disciplinary team will need to be considered, developed and delivered. The National Health and Social Care Workforce Plan: Part 3 Primary Care will set out plans for the development and training of GPs and this wider primary care multi-disciplinary team and is due to be published early 2018.
Seeing patients who are unwell, or believe themselves to be unwell, will remain a core part of general practice as it is the basis for the continuous development of the clinical skills required of a generalist and is essential for good patient care.
GPs are, however, a limited resource and their capacity to see patients is finite. There needs to be a balance between access to GP appointments, access to other health professionals where that is more appropriate, and encouraging patients to seek self-care advice, where appropriate. This will enable GP time to be available when really needed by patients.
The key direct clinical care role for the GP as expert medical generalist is in undifferentiated presentations which require the skills of a doctor trained in risk management and holistic care with broad medical knowledge. Often this care is delivered through the continuity of consultations over time.
People are often able to self-differentiate in their own presentations. For example, a person presenting with shoulder pain may choose to see a physiotherapist as a first point of contact if such a service is as responsive as their GP practice. This is also the case for minor illness and injury, where, if there is an advanced practitioner or other service available locally, patients may choose that practitioner rather than seek a GP appointment.
New models of care will require other health professionals to be more involved in meeting immediate patient needs as part of a wider team (see chapter four for further details). Working alongside GPs, other health professionals need to be able to efficiently assess and treat patients, within their clinical competence. It will be essential that they are able to complete episodes of care without recourse to the GP on a significant number of occasions.
GPs will retain oversight to ensure the service, as a whole, is working and patient needs are met. Other clinicians will work independently within their competencies as part of the extended team with mutual decision support.
GPs will be of particular importance in supporting and managing people with undifferentiated presentations especially in the context of multi-morbidity and complexity and will maintain longitudinal patient contact to support that role.
GP practices act as a patient gateway to ensure that people can access the right care. Patients should experience contacting the practice, either in person or remotely, as a way to obtain advice on how best to have their needs met safely, effectively and efficiently by services. GPs should oversee and manage this process to ensure it is effective and that patients can see the right person at the right place at the right time.
Complex Care In The Community
As workload capacity is freed up, a key part of the GPs expert medical generalist role will be leading a primary care multi-disciplinary team to deliver care to patients with, for example, multiple co-morbidity, general frailty associated with age, and those with requirements for complex care (e.g. children or adults with multiple conditions, including mental health problems, or significant disabilities).
What do we mean by complex care?
Complex Care is most commonly the clinical care of patients who have multiple disease presentations. Such patients may have two or more diagnoses which, as they occur in the same individual, are therefore connected and interacting. Evidence based guidance and decisions which may be appropriate for one diagnosis may not be appropriate or may conflict with those for the other conditions. This uncertainty requires shared decision-making with patients and carers. Complexity can occur in the context of mental and/or physical ill health, at any age including end of life. The GP acts, as the expert medical generalist, giving advice on managing and treating these uncertainties to increase the likelihood of achieving the agreed outcomes.
The system, with the contribution of GPs and GP practices through cluster quality improvement, will be focused on knowing its population and assessing where there is potential to achieve better outcomes. GP clusters were introduced in Scotland with the 2016/17 GMS agreement between the SGPC and the Scottish Government. In professional groupings of five to eight practices, clusters enable peer-led, values-driven quality planning, improvement and assurance.
Each GP practice will be supported with appropriate information to proactively identify the cohort of patients requiring complex care and to then work with others to devise an appropriate care plan to ensure patients receive the optimum care and support.
One of the main aims of this change in focus is to provide care to patients with complex needs at home wherever this is appropriate. Where care at home is desirable and adequately supported it is better for patients. GPs spending more time on patients with complex needs would help to ensure that admission to acute care should only be to achieve a specific outcome, or for an assessment or treatment that can only be provided in a hospital setting.
GPs will also be involved in establishing care plans for patients with complex needs, including anticipatory care plans, which can be used by community teams to enable patients to be cared for in their own homes for as long as possible. As the expert medical generalist in the community, GPs will also support these community teams, when any expert GP input is required.
Whole System Activity – Quality Improvement And Leading Teams
Ultimately all GPs must have regular protected time to be able to develop as clinical leaders. The intended outcome is that they become fully involved in assessing and developing services intended to meet the needs of their patients and local communities. Currently, only Practice Quality Leads ( PQL) have access to protected time, although different GPs in the practice can perform that role over time.
The next step in this journey is to create additional protected time for each practice, to enable GPs to develop their clinical leadership role. Therefore, from April 2018, each practice will receive resources to support one session per month for Professional Time Activities. There is a clear intention to achieve, over time, regular protected time for every GP.
GPs are senior clinical decision makers and leaders. As such, and with a clear focus on outcomes of relevance for patients, they will assess the overall performance of their own practice, practices within their cluster, and the wider community team, leading to suggestions for improvement that will in turn be evaluated by them and others. This will require GPs to have influence to direct change within the wider health and social care system. Indeed, for wider health and social care to be successful, meaningful involvement of GPs is required.
Whilst some GPs may not see themselves attracted to broader leadership roles and responsibilities, all will need to be involved in improvement activity in both their practice and the wider system through cluster working. Any significant improvements in patient outcomes are only likely to be achieved if every senior clinician is engaged in these activities at some level.
The evolution of primary care will require training for doctors wishing to become GPs to have a renewed focus on the skills required to be an expert medical generalist: in leadership, multi-disciplinary team working and peer-led quality improvement. Increased time and wider expertise may be required for training practices, with review of funding for training to ensure appropriate support for the necessary expansion of medical training in the community.
Essential Services, Additional Services And Enhanced Services
The refocusing of the GP role to expert medical generalist has implications for the current contracted service elements of Essential, Additional and Enhanced Services.
We are proposing the following service refinements in the new contract:
Essential Services will remain unchanged in the proposed new contract. The fundamental core principles of general practice – care based on the registered practice list, generalist care of the whole person and sufficient consultation time for patients according to their clinical needs – align with Essential Services.
The agreed direction of travel is to reduce the over-specification of services in the contract wherever it is safe to do so. That will begin with the proposed new contract.
For instance, latest evidence  suggests there is no longer a requirement for a separate Additional Service for minor surgery. GPs may still provide treatments which would have previously fallen under the Additional Service at their clinical discretion under core services. The Enhanced Service for minor surgery will continue.
Out of Hours
There will be changes to arrangements for out of hours services. Instead of the current opt-out arrangement a new opt-in Enhanced Service will be developed for those practices that choose to provide out of hours services.
The new out of hours Enhanced Service will have a nationally agreed specification, building on the quality recommendations within Sir Lewis Ritchie’s out of hours review Pulling Together  and covering areas such as record keeping, anticipatory care planning, key information summary, use of Adastra and NHS24.
This will contribute to a consistency of approach to the provision of unscheduled care services across Scotland where practice-based service level agreements are in place. There is also an opportunity to develop a nationally agreed quality and person-centred specification which could be used by all NHS Boards to test and benchmark their current local service level agreements.
We have agreed a general principle (with the exception of the new out of hours approach) against the expansion of the number of Enhanced Services under the proposed new contract.
Chapter four describes the Vaccination Transformation Programme which will transfer responsibility for the delivery of vaccinations from GPs to NHS Boards. On completion, to the satisfaction of the SGPC, Scottish Government and local delivery and commissioning partners, the relevant Additional and Enhanced Services for vaccinations will no longer be included in the Scottish GMS contract. In rare circumstances it may be appropriate for GP practices, such as small remote and rural practices, to agree to continue delivering these services through locally agreed contract options.
The current direction of travel on maternity medical services – where responsibility already largely lies with other parts of the community team – is expected to continue. Similarly, for contraceptive services, current provision by other professionals and teams is expected to continue.
There is, at this stage, no real alternative to delivering many of the current Enhanced Services provided by practices and no intention of reducing the funding to practices. Any further changes will need to be carefully planned with a rate of change that ensures patient safety, quality of service and practice stability.
The continuation of locally determined Enhanced Services is for NHS Boards and local practices to agree. The expectation nationally is that Enhanced Services funding is not removed from practices as services are transitioned to NHS Boards over 2018-2021, as doing so could be destabilising to the system. As mentioned previously, there is an intention to reduce the transactional business elements of the relationship between GPs and the rest of the system. These at times, have worked against the development of the collaborative relationships in health and social care necessary for good outcomes.
At the start of this chapter we set out our belief that the enhanced role of the GP as senior clinical leader in the community will lead to greater professional esteem and that while the role will remain challenging, it will be a rewarding one. The cornerstone of this enhanced role is the GP’s skill and expertise in dealing with undifferentiated presentations, complex care in the community and whole system quality improvement and clinical leadership.
We also recognise that GPs should be appropriately remunerated for their work. Chapter three sets out our proposals for pay and expenses.