GMS contract in Scotland: speech by Professor Sir Lewis Ritchie

Professor Sir Lewis Ritchie, Chair, Remote and Rural General Practice Working Group speech on the General Medical Services (GMS) Contract in rural Scotland: funding, tackling resource needs and addressing recruitment and retention issues.

Thank you for very much Chairman for your welcome and kind words. Firstly I must apologise, I will have to leave just shortly after my talk because of another urgent commitment elsewhere. My colleague Fiona Duff, has kindly agreed to deputise for me in the Panel Session.
For remote and rural areas, one of the problems clearly has been described as the “tyranny of geography” - the distances, waiting for (urgent and emergency) care and increasing uncertainty about professional isolation.
Winston Churchill once said, “the further back you look the further forward you can see”, in other words…. learning lessons, reflecting on why we haven’t done what we said we might do, as well as what we have achieved.  I think it’s always important to do that and perhaps one of the most important things in relation to that is the Dewar Report (published 1912) , which looked at the poor provision of care in the Highlands and Islands. That Report provided a template which informed the creation of the NHS in Scotland and in the UK.  
In other words, good rural things are not just about helping rural communities, but helping others too, and that’s a point which was also made by John Montgomery earlier this morning about the Deep End Practice experience.  That work is helping people (both patients and health professionals living and working) in (deprived) deep end areas, but it will also help other settings throughout Scotland.
This particular slide shows a lifeboat leaving Fraserburgh Harbour (at the turn of the 19th/20th centuries).  That lifeboat was crewed by volunteers.   They all came from different backgrounds, with different professional (multi-disciplinary) expertise and skills – but pulling together as a team was essential for success.  In that same lifeboat was a leader - the Coxswain.  Going forward, strong teamwork and leadership will be required, in relation to transformation in remote and rural areas - but as we’ve already heard today, transformation will be neither easy nor quick.  
When undertaking a difficult journey it is essential to have hope and a set of guiding principles (a clear sense of direction) - that’s reflected symbolically in this picture with Kinnaird Head Lighthouse in the background.
Looking to present challenges: 
Current models of care are unsustainable, particularly in remote and rural communities. Recruitment and retention, mentioned earlier today, is particularly difficult. We’ve also heard from Carey Lunan about the significant demographic changes in train and the large scale transformation that will be required - existing models of care will no longer be sustainable and suitable.  However, that does not translate that everything is broken and needs fixing… there are many good things happening in remote and rural communities.
In this slide, (kindly borrowed from Andrew Buist, Chair SGPC, BMA) the (triangular) diagramme represents the ambitions of the new GP Contract, framed to support and diminish inappropriate workload, reduce risk, increase financial stability by supporting GPs and primary care team members.  The GP Contract is not just about GPs (their terms and conditions and more), it’s also about nurturing and sustaining primary care services into the future to meet the needs of the people of Scotland and all care providers.
So what are the specific challenges of remote and rural general practice?
Diversity of rural practice underpins the need to support and maintain a broader range of skills.  - Working longer hours, including out-of-hours (OOH), (most GPs don’t have a commitment OOH, but a number of GPs in remote and rural areas in particular continue to do so).  Vulnerable situations – where GPs are often single handed.
- Difficulty to travel away from the practice for training (because of locum cover constraints)  - Professional isolation.  
All of these things will need to be tackled going forward and the new and evolving GP Contract must address these.
Moving forward:  Where are we going? 
During the preparation of Primary Care Out-of-Hours Review (Pulling Together: Transforming Urgent Care for the People of Scotland – 2015), a set of guiding principles for new models of urgent care was developed.   
New and existing models of care should be: 
Person-centred-  both for those who receive and those who deliver care services Intelligence-led - making the most of use of information Assets-optimised – making best use of all resources Outcome-focused – achieving the best for care services for our people
Future services should be also be: 
Desirable  Sustainable (and ‘rural proofed’) Equitable (fair and accessible to all according to need)  Affordable (funds are limited - best use of public funds essential).  
The Remote and Rural Short Life Working Group was established to support the introduction of Phase 1 of the new GP Contract in remote and rural areas. Our purpose (remit) is to: 
(a) Meet and engage with colleagues (working in remote and rural areas) and to hear their views and concerns (from June 2018,  a number of remote and rural practices throughout Scotland, meeting colleagues and we have communi – this programme will continue; (b) Promote best practice to address the challenges and opportunities.  (c) Help and provide support and advice to integration authorities boards, the SGPC and the Government about re-shaping services, and:  (d) Support rural practices and how they can fully benefit.
In our membership (our people) we’ve incorporated a broad range of GP stakeholders, with the advice of the BMA; public involvement (RCCGP P3) and multi-disciplinary team engagement (and that door remains open - we want engage with groups that are relevant for this endeavour).      Progress to date: We’ve had three (quarterly) meetings, we’ve travelled to a number of remote and rural locations in Scotland and that programme of visits will continue.  We’ve met with the Rural GP Association (RGPAS) and the Scottish Rural Medicine Collaborative (SRMC).  A website has been developed and newsletters produced and disseminated.
A Dispensing Sub-Group has also been established, chaired by Fiona Duff.  In addition, Scottish Government is deploying £2 million from a Rural Fund in 2018/19, £850,000 of which will go to support re-location for GPs.  
We are also looking at best practice, not just in Scotland, but keen to learn about the international dimension - we can and must learn from others, elsewhere.  We want to prepare and promote case studies of good practice and share them throughout Scotland. One of the most pressing issues about good practice is we don’t often spread it very well – that needs to change.
We also hope to organise a conference later this year and to publish a 1 year progress report.  
In summary:  We are at the beginning of a journey of transformation, but we have many miles still to travel.
In terms of our findings to date from our engagement programme: What’s wrong - what’s the diagnosis?  
Colleagues working in remote and rural areas are highly committed, working hard and at times in very difficult circumstances. During our engagement programme we have heard fears expressed for the present (Phase 1 of the GP Contract), including a feeling/perception of being undervalued, sustainability issues, planning and uncertainty concerns.  Some, not all, also expressed fears about the future (Phase 2 of the GP Contract - in development) including (potential) loss of independent contractor status and (potential) loss of income. The Scottish Government has repeated its commitment to preserving and supporting income for all practices in Scotland - no loss of income has been experienced by any practice.  We also found, encouragingly, that all colleagues were keen to support desirable, sustainable solutions.  
So as a Group we’ve formed a provisional diagnosis, but we now need to move to find effective treatments for the future.  These treatments (prescriptions) will include: Supporting the expert medical generalist role, developing multi-disciplinary teams (as we’ve heard earlier today), getting income and expenses right (informed by actual income and expenses data being collected in 2019/20), manageable workload, premises and information technology infrastructure and more..  We should look anew at how best to reduce risk, better care for patients, to go upstream and promote greater health for all of our communities in Scotland.  We have some way to go... but we must press on. 
While it’s always important to hear about and to resolve present difficulties, we must now expend more energy and focus thinking about the future - what we need to do and how best to do it.
In the first phase of our work, we have attempted to hear about, discuss and define the issues.  In the next phase of our work we need to be seeking out and helping to implement sustainable solutions - for the benefit of the public we serve and for those who serve them.
Thank you.

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