Primary and Community Health Steering Group minutes: April 2025

Attendees and apologies

• Co-Chair of the Primary and Community Health Steering Group and Director of Primary Care Directorate, Scottish Government
• Co-Chair of the Primary and Community Health Steering Group and Deputy Chief Medical Officer, Scottish Government
• Professional Nurse Adviser for Primary Care and Chief Nursing Officer representative, Scottish Government
• Delivery Director, Preventative and Proactive Care Programme, Scottish Government
• Director of Allied Health Professionals, NHS Fife
• Director of Pharmacy, NHS Borders - Member and deputy attended
• Director of Midwifery, NHS Western Isles
• Executive Medical Director, NHS 24 - Deputy attended
• Chief Executive, Scottish Ambulance Service - Deputy attended
• Director of Psychology NHS Borders and Chair of Heads of Psychology Scotland (HOPS) - Deputy attended
• Chief Officer South Lanarkshire Health and Social Care Partnership (HSCP) and HSCP Chief Officers Representative
• National Strategic Lead for Primary Care, Health and Social Care Scotland
• NHS Board Optometric Advisor, NHS Greater Glasgow and Clyde - Deputy attended
• Interim Director, Primary/Community Care, Strategy, Performance & Service Transformation, National Services Scotland (NSS) - Member and deputy attended
• Head of Digital Services, Practitioner Services Division, National Services Scotland (NSS)
• Interim Director of Nursing and Systems Improvement, Healthcare Improvement Scotland (HIS)
• Chief Executive, National Education for Scotland (NES) - Deputy attended
• Director of Digital, National Education for Scotland (NES)
• Out of Hours (OOH) Oversight Group Representatives
• Chair, Scottish General Practitioners Committee of the British Medical Association (SGPC BMA)
• Chair, Royal College of General Practitioners Scotland (RCGP Scotland)
• Associate Director, Royal College of Nurses (RCN) - Deputy attended 
• National Director, British Dental Association Scotland (BDA Scotland)
• Chair, Optometry Scotland    
• CEO, Community Pharmacy Scotland
• Director for Scotland, Royal Pharmaceutical Society (RPS) - Deputy attended
• Professional Adviser for Scotland, Chartered Society of Physiotherapists (CST)
• Policy & Public Affairs Lead Scotland, Royal College of Occupational Therapists (RCOT)
• Chief Executive and Nurse Director, Queen's Nursing Institute Scotland
• Chief Officer of Development, The ALLIANCE 
• Chief Executive, Voluntary Health Scotland

Apologies

• Chief Allied Health Professions Officer, Scottish Government
• Head of Health and Social Care Analysis, Scottish Government
• Director of Dentistry, NHS Shetland
• Associate Medical Director, NHS 24 and Primary Care Clinical Leads Group representative
• Associate Medical Director Primary and Community Services, NHS Borders and Primary Care Leads Group representative
• Director of National Centre for Remote and Rural Health and Care
• Scottish Executive Nurse Directors (SEND) Representative and Executive Nurse Director NHS Ayrshire and Arran
• Head of Audiology Services, NHS Tayside and Board Member of the British Academy of Audiology
• NHS Board Digital Leads Group representative
• Nurse Director, Angus Health and Social Care Partnership
• Director of Place and Wellbeing, Public Health Scotland (PHS)
• Director, Royal College of Midwives (RCM) and National Staffside Representative
• General Practice Managers Network representative
• Professor of Medical Education, University of Glasgow and Co-Director of the Scottish School of Primary Care
• Professor of Health Economics, University of Glasgow

Items and actions

Please note: views expressed during the meeting include working positions under development, which are not reflective of current Scottish Government policy.

Welcoming Remarks - Co-Chairs

The Co-Chair welcomed attendees to the meeting. The Co-Chair emphasised that the voice and views of this group are being taken into account directly in the health and social care reform plans under development, and the level of engagement to date has been greatly appreciated.

Referencing the First Minster’s recent speech on reform, the Co-Chair stated that there are areas of short term focus including waiting list backlogs but these are being addressed against an absolute commitment from the First Minister and this government to shift the balance of care into the community and to achieve a long term and positive focus on prevention. Primary care plays a pivotal role in both those short-term and longer-term objectives.

The Co-Chair described the Operational Improvement Plan, Population Health Framework and the Service Renewal Framework and the intended scope of these publications, noting as above the work of this group to date is informing the government’s approach to reform.

No corrections to the draft minutes from the previous meeting were provided in advance and no objections were raised to the minutes being an accurate record. 

The second Co-Chair reiterated the importance of this group and the wealth of feedback it has provided to date and set out the aims of the forthcoming presentations.

Overview Presentation - Primary Care Strategy Unit

The Strategy Unit said that the First Minister's statement on improving public services and NHS renewal at the end of January 2025 set out key actions that bridge across both shorter term and longer term reform intentions and it set out the Scottish Government's intention to publish three reform publications that the Co-Chair described in the opening remarks. 

The Strategy Unit described the Service Renewal Framework’s (SRF) intention to set out the Scottish Government's strategic policy intent for health and social care services in Scotland in the next ten years. 
This will be built around the vision that the Cabinet secretary laid out to Parliament in June last year, which is a Scotland where people live longer, healthier and fulfilling lives. With the four components within that of access, quality, prevention and  people. 

The SRF will set out some of the primary care reform that the steering group has been developing particularly as they pertain to the cross health and social care reforms required to realize that shift to prevention in the community. Primary care reform will be detailed further in the Primary Care Route Map that will be published after the SRF. 

The Strategy Unit set out the timescales for the development of the SRF, the Primary Care Route Map and meeting schedule for the steering group. 

The Strategy Unit presented the draft vision and outcome areas developed with the steering group sub-group including a draft outcomes diagram has been developed by analysts in the Scottish Government. A final deadline for views of 8 April was set, after which the vision and outcomes will be finalised.

Officials have started to undertake some mapping work with wider frameworks such as the Scottish Learning and Improvement Framework (SLIF) to ensure that we've got clarity around alignment and we'll be setting out further detail on potential next steps around monitoring evaluation at the meeting in June. 

The Strategy Unit provided a summary of the ‘workforce’ and ‘policy, frameworks, and standards’ drivers  that will be discussed in breakouts.

The workforce paper provides an overview of our existing workforce and its performance against the current Route Map Vision and Outcomes, and suggests  the following approach to improve the overall retention and function of the workforce within primary care:

• that the predominant model of employment in primary care – via independent contractors – should be retained
• that in retaining this model, further supporting action is needed to fully realise primary care's aims and ambitions, namely:
  • whole-system planning for the wider health and social care workforce – supporting system rebalance and underlining the importance of primary and community care services in supporting the preventative agenda and embedding person-centred approaches in health and care
  • holistic working with local and national stakeholders to understand and meet the needs of Scotland's diverse populations, and supporting equitable access in all areas
  • greater use of multi-disciplinary working to better meet that population need
• the paper also notes that while independent contracting modes of delivery do limit direct government involvement  on the Employ and Nurture elements of the NHS workforce strategy, more could and should be done to improve overall retention of staff e.g. through system rebalance, learning from existing initiatives, and linkages with other drivers (e.g. finance and data) to drive improvements

The Policy, Frameworks and Standards driver paper sets out the following approach to realise the strategic direction:

• set out and communicate clearly and with impact the strategic direction which works to clarify priorities for primary care
• set out and embed the inter-relationship between the strategic direction for primary care with wider reform strategic direction. This is particularly important with the development of the SRF, and we have a big opportunity to embed primary care priorities at the heart of health and social care reform
• this clarity will support policy development across primary care and wider health and care to embed primary care priorities and outcomes  Articulating priorities for all areas of the health and care system, including primary care, will make it easier to establish commonalities and for decision-making to support whole system reform
• we ensure Primary Care quality frameworks are cohesive and support primary care's strategic direction
• the paper also recognises the need to ensure assurance mechanisms across primary care are robust and reflect strategic priorities and outcomes for primary care
• finally, similarly to policy, we need to ensure HSC standards and frameworks are harmonized and co-designed – reflecting system wide and person-led priorities 

Members were given instructions regarding the Getting It Right For Everyone (GIRFE) and driver paper breakout groups.

Presentation - Primary Care Sustainability and Improvement in NHS Lanarkshire presentation – Chief Officer South Lanarkshire Health and Social Care Partnership (HSCP)

NHS Lanarkshire did initial consultation with its populations on development of its health together strategy and what came out of there clearly is people's number one concern was around access to general practice. The Board’s general practitioners (GPs) and practices are very active, but that's not necessarily felt or appreciated in terms of the experience of many people within our populations. This is something Boards needs to resolve both for the benefit of patients in the round but also in terms of the support, motivation and finally value we attached to the work undertaken by practices. 

Key messages were:

• people very much valued GPs and that they wanted to see their GP. But they were also very open to being seen by other members of the practice team, the MDT, if they could see them faster
• there was a high level of willingness to engage through digital routes. Not everybody wanted a digital route, but enough of them to make it worthwhile for Lanarkshite to investing to improve and be more responsive for those individuals whilst also creating space for those individuals who wanted to engage on a direct face to face

The Chief Officer presented statistics on the scale of activity within the board including that ‘A quarter of the population in Lanarkshire has contact with General Practice each week’ and that there are ‘178,000 general practice contacts a week’.

Two thirds of the individuals were really happy to have an online support, and that what we need to try and meet their expectations, which should enable quicker access for those who would prefer to or in many cases need to have a face to face interaction.

The Lanarkshire Primary Care Action Plan has three improvement areas:

• meaningful Alternatives for patients
• reshape Care pathways
• refocus GP capacity

Cross-cutting and supporting enablers include: premises, digital and engagement and co-design. The improvement areas will support sustainability and recruitment and retention within general practice.

There is a Once for Scotland opportunity for the transformation of primary patient care:

• digital contact could have a substantial impact on access challenges if targeted at interactions where there is already a high degree of public acceptance
• Director-General reinforcement that NHS Boards actively engage in collaborative arrangements with other Health Boards to increase the pace of implementing improvements
• to accelerate Digital Front Door development and opportunity of Lanarkshire as an early adopter, value in exploring potential to undertake local test-of-change that contributes once-for-Scotland commitment

We should embrace that Once For Scotland approach and accelerate front door development to think about what we can do across boards and thought is being given with within Lanarkshire about the opportunity for being early adopters so we're not waiting for the full finished product.

We can start to identify some quick wins that we can progress locally to build up capacity and capability, and not just digital confidence amongst our staff, but that familiarity with using digital technology by more and more of our population. 

Presentation - Getting It Right for Everyone (GIRFE) – GIRFE Team 

Getting It Right For Everyone (GIRFE) been co-designed by six health and social care partnerships (HSCPs). 

The five thematic areas are: ‘People in prisons’, ‘People in substance use services’, ‘People registered with deep end GP practices’, and ‘Families with multiple and/or complex needs; and young people in transition from GIRFEC to GIRFE’, and ‘Older people’. GIRFE applies to any adult that has more than one professional working around them. 

People have been central to understanding what it feels like for people to access health and social care and GIRFE developed around 144 person centred journey maps which were really detailed stories that mapped out people's various touch points with health and social care and the other agencies a person comes into contact with.

Subsequent engagement generated around 500 ideas for improving access to services from the experiences of people who worked in the system, people accessing the system and professional leads and policy areas from the Scottish Government. 

GIRFE has developed a huge amount of well-informed data. People working in health and social care reform are well aware of the problems but the GIRFE engagement has taken matters from the viewpoint of a person and their family to really understand what they experience when they engage with the health and social care system. 

The GIRFE team Around The Person Toolkit has been published which can be used by professionals individually or collectively to provide holistic care around a person, depending on their need.  The intention around designing these tools is that we would see improved outcomes for citizens and people working in the system, but also importantly improved system outcomes and better coordination. 

Better understanding of preventive care needs and being able to identify that need earlier through communication between professionals rather than referring people around the system. 

The team illustrated the application of GIRFE within case studies of alcohol dependency and addiction, and physical disability.

A GIRFE approach was highlighted as fundamental to the reform of health and social care reform and improvement of outcomes for people.

Feedback from driver paper breakout rooms - Primary Care Directorate Officials

Workforce 1 

Question 1. What is working well now?

• foundations of a strong primary care system, which other countries seek to emulate inc. strong education base, and contextualised understanding of population need (e.g. rurality)  

Question 2: What is missing and needs to happen?

• mobile/agile workforce to support resilience both geographically (education centralised) and in working practice e.g. MDTs but also generalist approach for rural areas
• funding and resource to support primary care and tackle health inequalities/inverse care law (including plans which support retention not just attraction, and embedding of piloted initiatives)
• recognition of Board-run services (e.g. PDS) in planning

Question 3: what practical actions can be taken?

• balance of investment, aligning to strategic vision – shifts in activity require investment. Funding is critical
• cross-system working, including better consideration of workforce/diversification within education and training 
• improving flow through local engagement and reducing burden on patients to navigate the system
• Managed Clinical Networks – provide peer support and work across boundaries

Question 4: Reflecting on this conversation, do you think there is anything worth highlighting to allow for greater integration?

• huge interdependencies between drivers – need to look holistically across the Route Map to ensure coherence
• are independent contractor models supported enough?

Workforce 2

Question 1. What is working well now?

• MDT working supporting coordinated care e.g. SAS, OOH

Question 2. What is missing and needs to happen?

• lack of equitable investment in wide MDT workforce across professions (e.g. beyond GP, resourcing in practice learning for some professions)
• equity and connection, interface and flow of workforce, including between Boards, e.g. listings, particular rural challenges
• imbalance in education and training systems towards specialist training
• time, workload and infrastructure limitations on in practice learning and training

Question 3. what practical actions can be taken?

• radical approach to rebalancing workforce - thinking about how we plan, invest in and redeploy our workforce from Acute to primary care and community healthcare.  Think about the entire healthcare workforce
• training and value of primary care education in all of health – more primary care academics, and training rebalanced to ensure everyone exposed to primary care. Teach more generalism and person-centred care
• improving connection, flexibility and collaboration – across and beyond primary care, closer working with/ support to Boards on primary and community healthcare challenges, cultural changes, and improving interfaces – local and national
• redesigning key levers to incentivise more equitable access (e.g. contract mechanisms & other arrangements) include consideration of rural issues

Question 4: Reflecting on this conversation, do you think there is anything worth highlighting to allow for greater integration?

• population-based planning critical for workforce – evidence-based approach to how many and what roles do we need based on need?  Good example from optometry
• measurement and broader incentives to move towards preventative workforce planning – focus tends to be on access and waiting times, but link to broad PC outcomes important, e.g. around quality, CoC, to ensure health outcomes & sustainably reduce demand

Policy, Frameworks and Standards

Question 1. What is in place currently that supports the approach proposed in the paper?

• well trained and dedicated staff
• mechanisms: GP quality clusters, the steering group, interface groups (surfaces & addresses policy disconnect)
• able to change and delivery rapidly in general practice – where there's the right direction

Question 2. What makes it difficult to support the approach proposed in the paper, now or in the past? What can we learn from this?

• too much policy – 'spaghetti junction'
• gap between intent at policy level and reality at the delivery level – understanding how/if policies are followed through.  More policies are a response to issues but aren't 'solving' them. Policies existing doesn't mean winning hearts and minds of those needed to implement
• need measure outcomes, currently measuring inputs
• need to manage expectations, recognising people are delivering in a complex system.  Not just trying to implement multiple policies, but addressing multiple challenges at the same time
• lack of permission in the system – waiting for direction, or for others to change, rather than doing

Question 3. what practical actions can be taken?

• content: balance between national consistency and local responsiveness. 'Golden thread' needs to be outcomes and experience for people
• focus on process rather than content e.g. taking an iterative approach, co-production
• culture: permission to 'do' and change
• Supporting change: 
  • reflect/learning both in terms of policy implementation and implementation of successful models of care
  • align incentives, needs based support 
  • strengthen existing mechanisms – e.g. clusters and reporting – declutter and align. Currently perpetuate siloes

Question 4: Reflecting on this conversation, do we think the overall approach set out is sufficient, does it need to be tweaked or added to? 

• needs to strengthen process for developing policy, frameworks and standards
• need for all points to be evidence-based

Breakout Groups Summary

GIRFE 1

Question 1: What does delivery using GIRFE principles look like?

• N/A

Question 2: What are the conditions that need to be in place for primary care to embed GIRFE principles in delivery of healthcare, and to work as part of a ‘team around a person’?

• collaborative environment, good communication, leadership, and time to embed needed. In addition, need to have appropriate structures and management in place. Need to be aware of ‘professions within the professions’ and overcoming silos that can be exist as a result of that
• need to think about how we apply GIRFE to whole populations. Also, need to think about what decisions can be done at the lowest level e.g. teams, but also make sure that there is consistency

Question 3: What steps can we take to create those conditions?

• very well to have planning integration and local dialogue but is there a case for greater integration management and coordination? GIRFE is good for cases outlined but how do you embed practical management improvement coordination to make this a reality? What is working well and what needs to be improved?
• the principles but then how they are applied and assured at local context to discuss at IJBs, health boards and fed into operational delivery in the future. Need to challenge ourselves to make sure that if we don’t have the right permissions in place to get them locally. Need to agree that we need to uphold this for the people we work for. Maturity, authority and how we do assurance are key
• what we have from GIRFE in 'wrap around the person' is deep learning and practical experience of what works for people. If we plug that into the reform work and more community based services how do we stop fragmentation of new service initiatives to prevent disparate service management. It cannot be single component or provider

GIRFE 2 

Question 1: What does delivery using GIRFE principles look like? 

• additional capacity (a supported and sustainable workforce) is required in primary care to deliver GIRFE
• initial hesitancy about seeing someone other than GP overcome with support to understand that they’re seeing the most appropriate member of the team
• takes time and trust to build a whole system approach
• help work with people to help with information
• need an acknowledgement that you can't have discussions around access or GIRFE without tackling capacity, provided by a supported and sustainable workforce 
• there needs to be one system of communications - primary care practitioners have no access to secondary care notes, care portal, sky stores. e.g. an eye scan done through a diabetes clinic cannot be seen by a primary care optometrist

Question 2: What are the conditions that need to be in place for primary care to embed GIRFE principles in delivery of healthcare, and to work as part of a ‘team around a person’?

• there needs to be an agreed set of metrics to be able to measure progress and collect data in a systematic way to allow proper evaluation
• capacity and time required, for example for effective co-ordination with the general practice MDT
• need well supported services, ability to allow episodes of care where needed, and responsive to delivering quality relationship-based care
• integrated team meetings are helpful to create the conditions for GIRFE. People are looking for a workforce with training and professional development in person centred care, focusing on equality, inclusion and being trauma informed. Community hubs can be valuable, where the continuity of care is provided in places where there is trust and familiarity. And ease of communication with services is important.

Question 3 ‘What steps can we take to create those conditions?’

• nothing in GMS contract about workforce & capacity – contract needs to reward enhancement of workforce
• here should be a focus on improving the number of GPs per population across the country to bring down patient lists, and so be able to spend more time with those that need it. This will then allow delivery of the GIRFE principals in ordinary care to ensure that the right people are being involved at the right time
• need for easier IT interface to allow the sharing of info through patient-focussed info systems making it easier to follow up on engagement (e.g. find out results) and ensure that patient interface is easy to use & follow
• utilise community relationships and infrastructure – community empowerment on this is really strong
• need clarity on what doing GIRFE means within professions and different parts of the workforce
• helpful to have more national solutions (rather than spilt into health board areas). For example, national solution for primary care optometry to access DES photos, national IG sign off on products e.g ECS/KIS

GIRFE 3 

Question 1: What does delivery using GIRFE principles look like? 

• patients are more complex than they used to be. Need multiple professionals working together around a patient and requires these professionals being able to share information easily, for example every primary care professional should know when the patient has contacted another professional – there is no feedback loop between GP and other primary care professionals. Reliant on patient remembering. Also being able to make referrals easily
• Digital Front Door work may help – in prescribing for example, need info to keep patients safe and deliver best service. Need joined up clinical records. In GIRFE, patient has their own record, this means they have a programme of care wrapped around them, with patient the owner of that information. This fits with the principle of building care around the patient

Question 2: What are the conditions that need to be in place for primary care to embed GIRFE principles in delivery of healthcare, and to work as part of a ‘team around a person’?

• we need to look at systems with a GIRFE lens, not just patients. More holistic approaches work better for patients e.g. breathlessness clinics, but patients often may not be eligible

Question 3 ‘What steps can we take to create those conditions?’

• this way of working encouraged by professionals having time and capacity to consider patient needs, but also awareness of the work of other professionals e.g. shadowing 
• patients should also be empowered to know GIRFE approach is what they can expect from services

Workforce 1 

Question 1: What is in place currently that supports the approach proposed in the policy and workforce papers? 

• focus needs to be on generalism and adding more first points of contact confuses patients, especially those who are not particularly health literate. Generalism is particularly important in rural areas. Contractual frameworks are a lever for change here
• Inclusion Health Action in General Practice funding another good example in this area providing some of the capacity that those workforces need to identify those in the practice population who require further support, or who may be ‘missing’ from the practice population
• workforce mobility a big issue and sites of education can be distant from where the workforce is needed (e.g. the Borders is far from the universities of Strathclyde and Robert Gordon which train pharmacists)
• we have the numbers of pharmacists, and the numbers training to be pharmacists, but they are not geographically spread nor mobile
• retention is just as important as recruitment. Primary needs to be seen as an attractive career – in diversity of interesting work as well as in remuneration. It’s not just a numbers game – needs to be a focus to ensure that experienced professionals are retained
• workforce planning is a long-term gain, but agility also needed within the workforce to ensure short-term resilience. A key enabler is workforce development and training and creating a positive working environment
• workforce is what is impacting on the ability of dentists to see more patients and the dental access issues more widely

Question 2: What makes it difficult to support the approach set out in the approach proposed in the paper, now or in the past? What can we learn from this?

• primary care share of health spend has gone from 11% to 6.2% and will be <6% in 2025/26. Resourcing needs to be shifted to match the shift in workload. Secondary care needs to be as efficient as primary care is
• new degree placement structure for optometry established where one of the placements is to a rural area may well help issues of recruitment to rural/remote areas and it will be interesting to see the effects of this
• most dentists are in primary care rather than secondary care, so workforce needs to be shored up. Public Dental Service is a small, but very key service (who are not independent contractors)
• scottish self-management fund is envy of rUK but it’s purely piloting initiatives rather than trying to embed and sustain any
• community link workers is incredibly effective intervention but would be seen as an easy service to cut were funds to be tight
• community empowerment through social prescribing and population health frameworks need planned and designed for what we want rather than just wishing for it to happen
• more time is needed with patients who are not health literate, and in more deprived areas the more complex cases are likely to be found and these are the cases where the GP working with the the wider MDT is needed.

Question 3: What are the practical actions we can take to better support this approach? Consider opportunities we can leverage and other actions to take

• communication and lack of cross-system between different contractor groups requires a national IT solution to resolve
• he total health and social care budget needs to be better distributed
• hort-term issues may need to be encountered and overcome to deliver long-term gain, moving away from short-term political cycles
• ontracts do not necessarily incentivise the care model properly and there is significant potential through contract reform. Contract reform needed to move more from GP-led to GP-delivered care
• potential for screening programs, diagnostics in the community, and bespoke treatments to change how care is delivered
• burden on the patient for navigation of their own care is huge. Community link workers spend considerable time helping patients navigate the system. Therefore, we need to make it simpler for the patient
• utilise community sector better– healthcare professionals don’t need to be everywhere for everyone. Vaccine inclusivity programme was an excellent template
• ensure attractiveness of the NHS offer
• enhanced skills practitioners into areas of dentistry where it is absent and shift more specific care back into primary (e.g. oral surgery or oral medicine) to make the role more appealing, interesting, and rewarding
• diversifying workforce has to be driven by need to ensure patients receive the correct level of care
• better guidance needed to ensure high level of care matches changing needs
• ensure ‘GP-lite’ doesn’t impair the quality of care being provided (e.g. through inappropriate overuse of Advanced Nurse Practitioners in place of GPs)
• transactional care does have its place and can help facilitate relational care by eliminating backlogs
• shifting from hospital to the community requires resource (e.g. community glaucoma scheme requires 10 months of training)
• optometrists don’t have patient lists in same way other primary care providers do which impacts their ability to take a GIRFE approach
• better to be able to deliver more pre-assessments, appointments, and procedures in rural communities instead of requiring patients to travel long distances into urban centres
• consequences of bringing additional procedures into primary care need to be considered (e.g. additional training costs)
• support (including with funding) to develop local networks and discussion forums to help practitioners diversify their workload and make it more rewarding

Question 4: Reflecting on this conversation, do we think the overall approach set out is sufficient, does it need to be tweaked or added to?

• interdependencies between drivers – do they coherently support each other?
• historically there hasn’t been enough time into implementation and delivery of plans and frameworks and there needs to be boundary-spanning structures to enable change.
• independent contractor model works and is cost effective to the public purse

Workforce 2 

Question 1: What is in place currently that supports the approach proposed in the policy and workforce papers? 

• the multidisciplinary team (MDT) approach makes this more achievable. 

Question 2: What makes it difficult to support the approach set out in the approach proposed in the paper, now or in the past? What can we learn from this?

• we do not invest enough in the MDT and not all of the MDT has been met with investment or a career pathway. Physiotherapy does not receive as much investment as other professions
• contract and workforce models interrupt seamless provision of care and workforce flow:
  • there are two sets of employers in primary care (the independent contractor and the NHS Board) which creates silos and invisible barriers e.g. general practice nurses can’t work in other areas without being employed by them
  • in optometry where NHS Territorial Boards have a list of optometrists, and optometrists cannot work in another board unless listed, therefore they cannot cover sickness absence for example. Contracts wedded to contract holders which restricts multidisciplinary working. A universal listing across Scotland would resolve this
• there are fewer opportunities to rotate and experience different settings e.g. out of hours. Some of this challenge is space and accommodation. Need to encourage exposure to primary care in training – needs to be valued in academic settings e.g. more PC professors
• need to teach more generalism than specialism and greater visibility and exposure to primary care at colleges and universities
• boards require a flexible workforce with generalist skillsets (e.g. catheterization, where appropriate) and flexible ways of working, e.g. more procedures in the home 

Question 3: What are the practical actions we can take to better support this approach? Consider opportunities we can leverage and other actions to take?

• need to move workforce out of acute into the community, particularly allied health professionals (AHPs)
• need to break down silos between professionals providing care within primary care but also with wider services including social work and social care
• funding needs to be in place to support domiciliary eyecare especially to support those who are vulnerable
• advantages to a consistent contract in community pharmacy to ensure areas of rurality and deprivation receive a consistent service
• the problems being faced need to be fully quantified in order to assess what the best solutions are

Question 4: Reflecting on this conversation, do we think the overall approach set out is sufficient, does it need to be tweaked or added to?

• gathering evidence on the number of professionals/clinicians needed for the population would support workforce planning (e.g. how many physiotherapists, Occupational Therapists etc). This could be developed with academic input. The College of Optometrists has done modelling on this for its interests, and NES is doing work on workforce demand and service which could be a first step to building this national picture. Need to establish the safe minimum level of workforce required
• Plan, Attract, Train, Employ, and Nurture are correct objectives for workforce but also need to add ‘Retain’
• wider determinants of health need to be addressed (e.g. diet, alcohol, tobacco) to prevent people requiring care. Develop existing resources such an NHS Inform to improve self-management and health literacy

Policy, Frameworks and Standards 

Question 1: What is in place currently that supports the approach proposed in the policy and workforce papers? 

• We have good staff in general practice and are training them up. 200 quality improvement projects done through GP quality clusters; there is buy-in across the system on quality improvement. Ways of working can change rapidly but need the right direction to be put in there
• groups of staff across system ready to take on change and do things better, but this is not universal. Additionally there is too much policy and it can be messy
• balance of looking for direction and permission but also don’t need to get too hung up on doing things differently in the system. 

Question 2: What makes it difficult to support the approach set out in the approach proposed in the paper,, now or in the past? What can we learn from this?

• real strength of primary care is the strength of connection between general practice MDT, other primary care partners and the connection to people. How do we make sure that access, improvement, experience is common? To mould an approach is great but how do you embed this in a way that respect clinical, profession, employment boundaries etc? Sweet spot between the two is where we need to be to get consistency and local responsiveness
• the process to get to the future is the future you’ll get. We need to set out how we will implement our approach and doing it in phases, and need broad consensus and buy-in for change to scale up. We could consider applying scrutiny at a local level, and assurance and process is determined at the Scottish Government level. We should discuss whether we need a longer-term programme board to oversee progress
• we need cultural change to see the borders between different parts of the system as thresholds rather than barriers
• gap between intent at policy level and reality at delivery level an issue. When the policy does not work we just get a new policy rather than looking at why it is not working at the delivery level more. We are measuring inputs now not outcomes e.g. how many people get fillings not whether that activity is actually improving oral health of nation
• policy implementation is failing because sufficient engagement is not there and nor are the hearts and minds at the development of policy, so tribalism becomes entrenched and people don’t change or make things different
• many policies have said that primary care is going to be a focus but it never happens because sufficient funds are not allocated to primary care to meet the ambition of the policy
• we operate in complex, adaptive system so when different policies come along we think there should be straight forward solutions, but they need time and capacity to implement. This set of priorities is quite broad and is therefore open to interpretation and may contradict or come into conflict with one another, which itself undermines implementation. Need bureaucratic and financial incentives to progress implementation e.g. streamlining and aligning reporting

Question 3: What are the practical actions we can take to better support this approach? Consider opportunities we can leverage and other actions to take?

• need to create space for blue sky thinking and challenging some of our own assumptions. There’s an expectation that someone else needs to be the one to change, but what can we do and what can we learn from models that show they work. Need to understand the psychology of why people are not taking steps towards making change
• it is challenging to find the headspace for change when the workload is so high. Quality frameworks need to go beyond “is everyone doing what they are supposed to be doing”
• incentives aren’t there to improve anything beyond just reporting. Need to incentive improving results not just good results with no improvement - support practices that are likely to fail rather than just letting them fail
• fear of giving clusters work to do but giving clusters more guidance on continuity might help but they also need to be listened to as they have good ideas that could improve the system.

Question 4: Reflecting on this conversation, do we think the overall approach set out is sufficient, does it need to be tweaked or added to?

• the golden thread needs to be service design around the needs of people
• need decision-making to be grounded in evidence and an evidence base that can articulated to people. Policy needs to be user friendly, explaining why things are being put in place. If there’s gaps in the evidence base, then we need Scottish based research
• there are subtleties around access where there is need and demand which aren’t always the same. Need to work with patients on this distinction and supporting practices to do this. Inverse here that practices that don’t engage with this won’t be doing a good job of access.