7 Better Health In Communities
- GPs will be more involved in influencing the wider system to improve local population health in their communities.
- GP clusters will have a clear role in quality planning, quality improvement and quality assurance.
- Information on practice workforce and activity will be collected to improve quality and sustainability.
GPs, working with colleagues across health and social care, continue to be at the forefront of a wide range of improvements in the safety, effectiveness and quality of care and treatment.
For over 10 years, the Quality and Outcomes Framework ( QOF) largely defined the approach to quality in general practice. It was introduced in the 2004 GMS contract with the intention of providing improved, or consistently high, quality of care, whilst offering GP practices an opportunity to increase funding via an incentivised payment scheme.
Whilst the quality of care delivered in general practice has undoubtedly improved since the beginning of the century, the extent to which QOF contributed to this improvement is contested. There is some evidence to suggest that in the early years it accelerated the pre-existing trajectory of improvement in managing those chronic diseases that were included, and achieved greater equality in the standard of care across practices. However over time, and for a variety of reasons, this effect became diluted and perhaps had the unintended consequence of crowding out other chronic conditions not included.
A systematic review published in The British Journal of General Practice  concluded that any replacement for QOF needs to consider the evidence of effectiveness of pay-for-performance in primary care, and the evidence of what motivates primary care professionals to provide high-quality care.
Improving Together  a new quality framework for GP clusters in Scotland offers an alternative route to continuously improve the quality of care that patients receive by facilitating strong, collaborative relationships across GP clusters and localities. At the heart is learning, developing and improving together for the benefit of local communities.
As described in chapter two, GP clusters are professional groupings of general practices that meet regularly, with each practice represented by their Practice Quality Leads ( PQL). Each GP cluster has a Cluster Quality Lead ( CQL) who performs a co-ordinating role and liaises with locality and professional structures. This requires supporting measures such as the existing contractual provision for protected time. It also requires: infrastructure to support leadership; data provision and analysis; and facilitation and improvement activity within local governance structures. Clusters may be of different sizes, influenced by local circumstances and geography, but as a principle, they should be viable for small group work.
Improving Together describes the agreed ‘intrinsic’ and ‘extrinsic’ functions of GP clusters in Scotland. The intrinsic function refers to the role of GP clusters in improving the quality of care in their cluster through peer-led review. The extrinsic function refers to the critical role GP clusters have in improving the quality of care in general practice and influencing HSCPs regarding both how services work and the quality of services. The dimensions of these intrinsic and extrinsic functions are set out in the table below.
Figure 4 - Intrinsic and extrinsic functions of clusters
Learning network, local solutions, peer support
Consider clinical priorities for collective population
Transparent use of data, techniques and tools to drive quality improvement - will, ideas, execution
Improve wellbeing, health and reduce health inequalities
Collaboration and practice systems working with Community MDT and third sector partners
Participate in and influence priorities and strategic plans of Integration Authorities
Provide critical opinion to aid transparency and oversight of managed services
Ensure relentless focus on improving clinical outcomes and addressing health inequalities
As clinical leaders in the primary healthcare team, GPs will actively contribute to the clinical governance and oversight of service design and delivery across health and social care as part of the extrinsic GP cluster role.
CQLs will work in close collaboration with the already established medical advisory structure including: Medical Directors (Primary Care) (usually AMDs); Clinical Directors; Locality Strategic Planning Groups; and GP Sub Committees in NHS Boards.
The GP Subcommittee of the Area Medical Committee should be responsible and funded for local arrangements to ensure effective collaboration between the GP Subcommittee, NHS Board medical directors, and CQLs. The GP Subcommittee will be responsible for co-ordinating the agenda for this tri-partite collaboration and facilitating combined professional advice to the commissioning and planning processes of the HSCPs and NHS Boards.
GP Subcommittees need to be adequately funded to carry out these roles (as well as day-to-day advice to the Board and its representative committees). NHS Boards and HSCPs should be able to demonstrate to the Scottish Government that they are appropriately supporting these activities. It is recognised that, in many areas, the GP profession chooses to have the same members in the GP Subcommittee as from the LMC. Local discussion should enable the funding of the GP Subcommittee to be clearly seen as funding those activities separate to the LMC activities.
GP Cluster Working And Local Population Health
GP practices participate in cluster working through their PQL. The PQL engages with the CQL, the rest of the GP cluster and attends GP cluster meetings. The practice will provide agreed local and national data extractions to enable intelligence led quality planning, quality improvement and quality assurance.
Cluster working will contribute to the development of local population health needs assessments undertaken by public health and local information analysts. They will also provide professional clinical leadership on how those needs are best addressed.
The NHS National Services Scotland Local Intelligence Support Team ( LIST) service has been supporting GP cluster working in Scotland since April 2017. This analytical support to clusters will continue and expand under the new contract.
Case Study – List analytical support for clusters
LIST analysts have already been working with clusters and practices across Scotland to help analyse data and introduce improved ways of working. These have included:
- safely reducing the number of home visits through the use of telephone triage
- analysis of appointment demand to inform staff scheduling
- analysis of data to create a health needs assessment for homeless patients
- gathering evidence to assist plans for GP services in relation to new housing development
- using data to help identify High Health Gain patients, to facilitate anticipatory care planning and additional preventative support measures
These initiatives help to both reduce GP workload and improve patient care.
“The main thing we want to take forward is a more in depth analysis of our frequent attenders, looking at who they are seeing, when, why and how often, and looking at interventions which may help them to better self-manage and use the service as appropriately as possible. We are hopeful that this could free up some capacity in the system and improve the right person right time goal”. GP Inverclyde
“ LIST have analysed our appointments data - we have now made some changes which has improved capacity and helped us to prioritise the patients. The DNA rate has also significantly reduced”. Practice Manager – Lothian
There is enormous potential for improving local population health, including mental health, through GP clusters, better data on population health needs and better intelligence and facilitation through LIST analysts. The aim is for GPs to have a bigger impact on public health as an expert medical generalist than they do as service providers for services that can be safely delivered by other health professionals.
NHS Boards, as the lead agency for protecting health, will continue to be responsible for planning and responding to public health incidents. Operational management locally will remain the responsibility of NHS Boards, drawing on the expertise and support of a range of local partners, including GPs and NHS Board staff. NHS Board staff will support with screening, prescribing, prophylaxis and nursing as appropriate.
Quality Planning is a structured process for designing and organising services to meet new goals and patient needs. This includes setting aims, identifying practice populations, identifying patient and carers’ needs, developing plans to meet that need, and developing measures to ensure that the aim is met.
Agreement will be needed on the balance between local and national priorities for GP clusters to focus their quality improvement activity each year. GP clusters themselves will be critical in identifying priorities locally with the inclusion of regional/national priorities as required. The former will primarily lead the improvement agenda with the latter playing in on an as required basis only.
Thus GP clusters must decide the majority of their own clinical priorities in their own locale using both information gathered by analytical support and their own deep knowledge and understanding of the communities they serve.
GP clusters working and quality planning
GP practices will participate in cluster working and through cluster working will contribute to the development of cluster quality improvement plans.
Cluster quality improvement planning will be supported by training in quality improvement if required.
2018/19 – quality improvement planning and activity for many clusters will be based on existing Transitional Quality Arrangements ( TQA)  information. This activity will be better enabled, as more analytic and public health support goes on line. Clusters will initially review comparative data between cluster practices on areas such as disease registers, referral, prescribing, access and use of unscheduled care to identify variation, peer-based learning, and areas for improvement supported by external resources. Maintaining comprehensive disease registers will remain critical to underpin activity in quality planning, quality improvement and quality assurance.
Quality Improvement is a continuous process. On an individual level doctors have a professional responsibility to maintain their skills and knowledge and contribute and comply with systems to protect patients.  GPs will continue to be registered with the GMC, undergo annual appraisal, learn from Significant Adverse Events, contribute to confidential enquires and comply with NHS Complaints procedures and Duty of Candour legislation.
GP practices will engage in quality improvement activities as agreed through GP cluster quality improvement planning. Practices will supply information to HSCPs and NHS Boards on their workforce and demand for their services to improve sustainability and facilitate service redesign. GP clusters work with the wider system, in particular HSCPs, to achieve whole system quality improvement.
GP clusters and quality improvement
GP practices will engage, as agreed in GP clusters, in quality improvement activities, including providing comparative data  and sharing best practice.
GP clusters will work with the wider system, in particular HSCPs, to achieve whole system quality improvement for patients.
GP practices will participate in a cluster quality peer review process, whereby their quality improvement activity and quality data will be reviewed by their local GP cluster. Support will be offered as appropriate.
The Healthcare Improvement Scotland Quality of Care Approach will involve an increased emphasis on local systems of assurance. Service providers will use the quality framework domains to evaluate the quality of care they provide and identify areas for local improvement work. As GP clusters mature, practices and clusters will be expected to take part in the peer-led values driven assurance process. The methodology for this will be negotiated by the Scottish Government and SGPC.
GP clusters and quality assurance
GP practices will participate in a cluster quality peer review process, whereby their quality improvement activity and quality data will be assessed by their local GP cluster and support will be offered as appropriate. That support could take the form of written advice and/or a supportive practice visit from peers and a local manager.
Supporting Information For Quality And Sustainability
GP clusters will need information to support their intrinsic role of peer-led quality work and their extrinsic role with wider systems. Some of the data for the new quality arrangements has already been identified in the TQA. To fulfil both intrinsic and extrinsic functions GP clusters will need a combination of nationally agreed information and locally agreed data.
The new quality arrangements will be supported by new technologies, such as the Scottish Primary Care Information Resource ( SPIRE). Currently SPIRE software is being rolled out across practices in Scotland - this is expected to be complete by April 2018.
Nationally and locally agreed (by SGPC and the clusters respectively) datasets will be supplied by practices and the use of automated extraction tools, such as SPIRE, is recommended as good practice. Practices will not be contractually required to use SPIRE and may choose not to use it at all. In those circumstances, practices must still provide the information required by the national and local datasets.
The existing dataset for the TQA will be the starting point for an agreed national dataset under the new GMS contract. This will enable clusters to build on their experience under the TQA to date, and on the existing work by NHS National Services Scotland Information Services Division to develop easily accessible data dashboards to support quality improvement in general practice.
GP practices and clusters will continue to be supplied with information on prescribing, outpatient referrals and admissions to hospital to support quality activity in these areas.
To contribute to the sustainabillity of general practice and primary care, GP practices will engage in the collection or extraction of information on activity and capacity. This information will be used transparently to inform and influence the development of the extended primary care teams.
To support GPs to identify individuals with more complex needs and to deliver anticipatory care planning more consistently, practices will continue to be supplied with risk predictive information based on the current High Health Gain Potential predictive tool. Work is ongoing to assess the value and to improve the predictive power of this and other case finding tools.
GP practices have reported a considerable increase in workload over the last five years, with more patient contacts, more clinical letters, more results and a higher proportion of consultations with people who have very complex problems who require more time.
Since the cessation of the Practice Team Information survey in Scotland there has been a lack of comprehensive national information on changing rates and complexity of GP consultations.
This information needs to be made available to the practice, the cluster, the HSCP and collated nationally to support sustainability, planning and the evolution of the extended multi-disciplinary team.
In addition, practices will be required to supply regular information on the workforce employed in their practices. This dataset will be used to triangulate locally with other sustainability factors, such as GP vacancies, increasing deprivation, and local house building. The purpose is to support GP practices, GP clusters, NHS Boards and HSCPs to identify and address sustainability challenges using a whole system approach.
GP cluster working, data extracts, and supporting sustainability
GP practices will provide agreed information on consultation rates, consultation types, health care professional being consulted and complexity within consultations. This will be done using SPIRE electronic extraction unless the practice wishes to collect the information itself.
GP practices will participate in assessment of capacity using the third available appointment method. Support will be provided to allow this to be undertaken electronically  .
GP practices, through cluster working, will be involved in discussions about, and provide advice on, sustainability issues using activity, demand and workforce data.
This chapter describes the proposed arrangements for continuous quality improvement in general practice in Scotland. The next chapter summarises proposed changes in the role of the practice and changes in other underpinning regulations.
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