Primary and Community Health Steering Group minutes: February 2025

Attendees and apologies

• Co-Chair of Primary and Community Health Steering Group and Director of Primary Care Directorate, Scottish Government
• Co-Chair of Primary and Community Health Steering Group and Deputy Chief Medical Officer, Scottish Government
• Chief Allied Health Professions Officer, Scottish Government          
• Professional Nurse Adviser for Primary Care and Chief Nursing Officer representative, Scottish Government    
• Head of Health and Social Care Analysis, Scottish Government         
• Director of Dentistry, NHS Borders - Deputy attended
• Director of Allied Health Professionals, NHS Fife
• Associate Medical Director, NHS 24 and Primary Care Clinical Leads representative
• Director of National Centre for Remote and Rural Health and Care  
• Director of Pharmacy, NHS Borders - Attended and deputy attended
• Scottish Executive Nurse Directors (SEND) Representative and Executive Nurse Director NHS Ayrshire and Arran      
• Executive Medical Director, NHS 24
• Chief Executive, Scottish Ambulance Service - Deputy attended
• NHS Board Optometric Advisor, NHS Greater Glasgow and Clyde 
• Director of Psychology NHS Fife Psychology Service and Vice Chair of Heads of Psychology Scotland (HOPS) - Deputy attended
• NHS Board Digital Leads Group representative
• Chief Officer South Lanarkshire Health and Social Care Partnership (HSCP) and HSCP Chief Officers Representative     
• Nurse Director, Angus Health and Social Care Partnership   
• National Strategic Lead for Primary Care, Health and Social Care Scotland        
• Head of Digital Services in Practitioner Services Division, National Services Scotland (NSS)
• Interim Director of Nursing and Systems Improvement, Healthcare Improvement Scotland (HIS) - Attended and deputy attended
• Chief Executive, National Education for Scotland (NES) - Deputy attended
• Director of Place and Wellbeing, Public Health Scotland (PHS) - Deputy attended
• Out of Hours (OOH) Oversight Group Representative 
• Out of Hours (OOH) Oversight Group Representative 
• Chair, Scottish General Practitioners Committee of the British Medical Association (SGPC BMA) 
• Chair, Royal College of General Practitioners Scotland (RCGP Scotland) - Deputy attended
• National Director, British Dental Association Scotland 
• Chair, Optometry Scotland
• CEO, Community Pharmacy Scotland
• Director for Scotland, Royal Pharmaceutical Society - Deputy attended
• Professor of Medical Education, University of Glasgow and Co-Director of the Scottish School of Primary Care
• Chief Officer of Development, The ALLIANCE  

Apologies

• Delivery Director, Preventative and Proactive Care Programme, Scottish Government        
• Associate Medical Director Primary and Community Services, NHS Borders
• Director of Midwifery, NHS Western Isles
• Head of Audiology Services, NHS Tayside and Board Member of the British Academy of Audiology Interim Director, Primary/Community Care, Strategy, Performance & Service Transformation, National Services Scotland (NSS)     
• Director of Digital, National Education for Scotland (NES)
• Associate Director, Royal College of Nurses (RCN)
• General Practice Managers Network representative
• Professor of Health Economics, University of Glasgow
• Chief Executive and Nurse Director, Queen's Nursing Institute Scotland
• Chief Executive, Voluntary Health Scotland

Items and actions

Welcoming Remarks

The Co-Chair welcomed group members and shared introductory remarks.The purpose of this meeting of the steering group was to continue discussions around Primary Care reform and the route map for primary care, with a focus on identifying the practical changes needed to help realise the agreed strategic direction. Discussions at this meeting covered two route map drivers: ‘infrastructure, data and digital’ and finance and funding mechanisms’. The Co-Chair welcomed members and deputies. The Co-Chair covered a number of key issues ahead of the orientating presentation and discussions:

• Scottish Government 25/26 budget proposals were set out in Parliament on 4 December 2024
• the 25-26 budget, if approved by Parliament, contains record funding of over £21 billion for the health and social care portfolio. This includes over £2.2 Billion for Primary Care services
• the budget states that Scottish Government will prioritise, and increase access and capacity in, Primary Care, including supporting services in General Practice, and enable measures to sustainably treat more patients in community settings, particularly in eyecare, whilst continuing work on dental reform
• the First Minister set out the Scottish Government’s plans for health reform and renewal on Monday 27 January, with a statement and accompanying Government Inspired Question
• this important speech was preceded by roundtable sessions which included a number of steering group meetings
• the close involvement of Primary Care in the work around the First Minister’s speech underlines the recognition within Government of the importance of Primary Care as a whole in realising Minister’s priorities, and the critical role of this group in representing all parts of Primary Care, now and as we go into the next stage of reform
• the themes and supporting material around the First Minister’s speech also highlighted the centrality of shifting the balance of care and proactive prevention, ambitions which the Co-Chair noted are familiar and shared across the steering group
• a few key upcoming publications were trailed in this speech including: a Health and Social Care (HSC) Operational Improvement Plan, a Population Health Framework, and the First Minister also committed to publishing the Scottish Government’s medium-term approach to health and social care reform before the summer Parliamentary recess
• this will build on the vision set out by the Cabinet Secretary in June and set out how we plan our services for our whole population over the period 2025-2030.  Primary Care and Community Health will be a core part of this work on longer-term reform, as a key building block of a reformed sustainable system supporting early intervention and prevention; and care closer to home.  This is the context in which Scottish Government are developing work on reform and the Route Map for Primary Care with the close input of the steering group

The group approved the minutes from the previous meeting and the Co-Chair noted that there were no outstanding actions form the previous meeting.

A member highlighted the lack of the word ‘social’ from ‘social care’ in some of the papers, noting the importance of the social support offered through the health and social care (HSC) service. The Co-Chair noted the point and said that officials would use terminology that is understood across the system.

A member raised a distinction in how we define ‘community health/care’ within the context of this group. The Co-Chair agreed that we need to be cognisant of definitions and boundaries and that clarifying this will be part of the work of this group going forward.

The second Co-Chair thanked group members for feedback so far and highlighted that the strategic sub-group continues to meet and is considering the draft vision and outcomes for primary care.

Presentation - Primary Care Strategy Unit

The Primary Care Strategy Unit provided an overview of the health and social care reform publications that the Co-Chair referred to, describing the scope of those publications and the publication dates.

The first reform product is the HSC Operational Improvement Plan which focusses on immediate actions over the following 12 to 18 months under the headings of improving access, shifting the balance of care, digital and technological innovation, and prevention. It is anticipated that this document will focus on performance in the health and social care system within the short-term horizon, particularly work to reduce delayed discharge and improving waiting times, alongside laying the foundation for future reforms.

The second product in the 10-year Population Health Framework which is taking a cross-government/cross-system approach to improving the key building blocks of health including employment, housing, education and skills complemented by the promotion of positive health behaviours and healthcare.

The third product is the HSC Service Reform Framework will build on the Cabinet Secretary for Health and Social Care’s vision to set out the longer-term direction for health and social care (Note: at the time of the meeting the name ‘Service Reform Framework’ was in use but following the meeting the document has been renamed to ‘Service Renewal Framework’).

Primary care and community health will be a core part of this agenda. Key short-term actions that have been set out by Scottish Government included:

• access to general practitioners (GPs) and other primary and community care clinicians: increase the capacity in general practice and develop a new quality framework this year to make general practice services more consistent across Scotland
• eyecare: deliver a new acute anterior eye condition service during 2025 and support the rollout of the Community Glaucoma Service to free up 40,000 hospital appointments per year
• pharmacy: expanding the NHS Scotland Pharmacy First Service
• dentistry: targeted investment in the workforce to improve capacity and patient access in the short to medium-term, including a 7% increase in student numbers from September 2025; review existing incentives for rural practices

The delivery of key actions to shift the balance of care is going to be supported by data and evidence to monitor impact and support local quality improvement. With support from steering group members, Scottish Government are working rapidly on refreshing the primary care vision and outcomes and the monitoring and evaluation approach so that we can understand and demonstrate the impact of our actions.

As the actions are developed, Scottish Government will work closely with stakeholders and members of the steering group.

With respect to longer term transformation, the work of the steering group and the primary care route map will be a critical part of the Scottish Government’s medium-term approach to health and social care reform. Officials are working closely with colleagues on the HSC Reform Framework, and we will ensure the route map for primary care align with this overall framework as it emerges.

It is anticipated at this stage that the route map for primary care will be an additional publication that will set out in more detail the specific reforms within primary care.

The Primary Care Strategy Unit set out the forward schedule and next steps, with the next steering group meeting in April 2025 to discuss the remaining route map drivers of ‘policy frameworks’ and ‘workforce’ alongside a discussion on person-centred approaches. In June 2025 the group will have an initial discussion on the full route map with a view to publishing a public product in Summer 2025.

The Strategy Unit gave an overview of the finance and funding mechanisms paper:

• the paper set out existing funding mechanisms along with rationale on their structure and form. Unlike some of the other drivers which have been discussed by the steering group, the paper proposes that the development of enhanced models of funding delivery is likely to be more iterative or narrower in focus as regards actual operation
• the paper argued that whilst on a functional level the current finance and funding models work as intended, there are a number of improvements that could be considered such as better targeting of funding to address known health inequalities driven by socioeconomic and geographic factors or moving to more community-driven models of care. This is likely to require additional investment in primary and community care
• the paper also recognised the relationship between the finance and data and digital drivers, with management information and official statistics forming key evidence of the outcomes achieved through Scottish Government’s investment in services

An overview of the infrastructure, data, and digital paper which considered existing arrangements for how it is provided to and used by primary care services, what is working well and how it can be strengthened, including:

• a person-centred approach should be taken to digital which promotes choice, supported by a core set of consistent digital capabilities available to both patients and the workforce, reducing variation in what is available nationally whilst ensuring local needs and priorities are paramount
• patients should have greater access to their own data as well as digital services and information, supporting their health and wellbeing, including self-care, building on initiatives such as the national Digital Front Door programme
• the development of digital and data tools will seek to facilitate and improve relational care including continuity of care and equity of access, and coherence through multi-disciplinary and cross-sector working (independent contractors, NHS and social care). The lack of a single electronic patient record has been reported by the steering group as a major barrier to increased use of alternative pathways to primary care. This must be addressed to support delivery of the primary care vision
• consideration to a hub approach for more infrastructure developments, promoting more integrated care across health and social care services
• some of the changes are already underway, for example the development of an integrated health and care record, improved access to general practice data for reporting and quality improvement, and the advancement of digital prescribing and dispensing. Others are yet to be committed to but appear necessary if we are to fully achieve the intended vision, and therefore may warrant further exploratory work. For example, setting of minimum standards and contractual requirements for digital capabilities, data access and infrastructure across all independent contractors that can be supported by Health Boards

Breakout groups

Members split into three breakout groups with a dedicated facilitator. The facilitator guided the conversation in line with the questions below, with the secretariat capturing key points.

1. what is in place currently that supports the approach proposed in the paper?
2. what makes it difficult to support the approach set out in the community health/ improvement/ governance paper, now or in the past?
3. what are the practical actions we can take to better support this approach? Consider opportunities we can leverage and other actions to take.
4. reflecting on this conversation, do you agree with the overall approach proposed in the paper? Does it need to be altered or added to? 

A summary of main discussion points from each group is included at Annex 1.

Feedback from breakout rooms - Primary Care Directorate Officials

Finance and Funding Mechanisms

Question 1: what is working well now?

• for general practice/pharmacy models particularly, good mix of funding to support core service provision while allowing for local discretion/flexibility
• efficient, cost-effective care, supported by good data

Question 2: what is missing and needs to happen?

• more focus on third sector involvement especially longevity of interface and ethical commissioning
• weighting on age not other known determinants of inequality, for example, deprivation

Question 3: what practical actions can be taken?

• intelligence-led linkage to investment – related to need, outcomes, quality assurance
• 'Missingness' - how do we fund wider engagement for population outreach
• recognition on increasing complexity of care

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

• building sustainable funding in all contractor groups
• choices within available funding – more money in health and social care means less money for other services/root determinants of health inequality
• need to be led by data – return on investment in primary care is slow but important

Infrastructure, data, and digital

Question 1: What is working well now?

• examples such as Emergency Care Summary (ECS) and Key Information Summary (KIS)
• development of key skills and experience in the digital and data space (clinical informaticians)

Question 2: what is missing and needs to happen?

• interoperability between legacy systems
• infrastructures that support care delivery, training and healthy working lives (i.e. active travel)
• challenge with speed of development

Question 3: what practical actions can be taken?

• review of national data and digital programmes and establishment of the priorities for primary care
• remove barriers between organisations
• consideration of local versus regional versus national

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

• integration and better use of existing data, across the system (including Community Care)
• improve sharing of data to reduce duplication, maximise the value of what we already have
• wider focus on information governance as well as information security, records management and technical standards to comply with Cyber Assurance Framework (NIS) and Information Commissioner’s Office (ICO) Accountability
• investment plan

Plenary Discussion - Members

• we should not be solely driven by data that we already have - we may need to seek out additional data and understanding to answer the questions of where we might best target future investment 
• the quality of data input needs to be improved and standardised. Our digital systems should be set up so that data input is easy to do correctly and efficiently and not add significantly extra time to do so as it currently does.
• improving data collection on protected characteristics is welcome, but also needs to be wider than this and take an inclusion health lens - taking into account other indicators such as being an unpaid carer, being affected by homelessness, care experienced, being a refugee etc. 
• the ALLIANCE are compiling learning from its digital links worker service on how people can be enabled to be digitally included and the digital inclusion programme more widely has good learning on this. 
• a question was raised on whether there has been work to properly define the problem around capacity issues and what are the actual capacity issues we’re trying to fix? The member raised that, as part of the Review of Sustainable Services, significant work was done with the Territorial Boards in identifying the root cause of the problem. The Co-Chair responded that looking at capacity issues is an important part of the work to develop the Primary Care Route Map. Alongside capacity and service design, we also need to ensure that the reform proposition is realistic and deliverable in terms of public expectations and the model of care we intend to pursue.
• the ALLIANCE have gathered learning about the role of digital tools through their Discover Digital programme, with tools available to enable people's self-management and access to services. In addition to this, the work of the Connect Me programme is a good example. 

Any other business

• The Co-Chair invited further questions or feedback to the secretariat inbox.

Actions

• Secretariat to analyse the outputs from the discussions (including practical actions for change) and draft them into a set of next steps, follow up questions and discussion points and for members to engage with.

Annex 1: Breakout Groups Summary

Group 1 – Finance and Funding Mechanisms

Question 1:  What is in place currently that supports the approach proposed in the finance and funding paper (consider service/local/national)? 

The Global Sum and General Medical Services payments provided to general practices enables them to provide services to a wide range of people in the community and provides a stable income for business planning, if funded adequately in proportion to/relative to the workload faced by general practices.

Enhanced services model in general practice allows specific targeting of patient populations (within contractual arrangements) and can be used as a mechanism to address nuanced challenges for example issues within rural localities, the impacts of social and economic deprivation, and the needs of the elderly.

The current arrangements for general practice allow practices to respond in a flexible and agile manner to the needs of their registered patient population and can, in theory, be an enabler to providing more equitable care in comparison with a ‘one size fits all’ approach.

2C/health board-run general practices currently exist and these are more expensive to operate than practices run through the independent contractor model.

The global sum element within community pharmacy is well understood across the sector, providing medicine supply for long term conditions, Pharmacy First, and some public health activity, supporting a consistency in service provision across community pharmacies.

There is an element of local service provision that is determined by health boards, which allows some adaptation to local population needs.

Individual community pharmacies procure medicines themselves on behalf of the NHS and this operates very efficiently, and costs would be higher if this procurement was done on a national basis. There is an degree to which the cost savings made here cross-subsidise other aspects of delivery in community pharmacy.

Current models of funding and finance are well understood, well established and stable, this is a strength in of itself and means that more focus can be directed towards management or reform of other aspects of the system which are not operating well.

Consideration needs to be given that the length/time-span of funding can impact on ability of contractors to adapt to changing need or policy, with longer periods providing more scope.

Current commissioning does not enable ethical commissioning nor sustainable service provision and there is a gap in the oversight between Scottish Government who provide the funding and HSCPs who commission the services.  

Primary care improvement plan funding has enabled some really good examples of primary care and 3rd sector working. 

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

Contracting of the third sector to deliver health services is not as developed in comparison to contracting with social care.

There are different silos of funding across primary care, not just for the funding of independent contractors but also bespoke programmes such as the Community Link Worker (CLW) programme. Consideration needs to be given to how the funding mechanism used supports longevity and sustainability of programmes and workstreams.

In General Practice, current funding through General Medical Services and the Scottish Workload Formula is likely to be overly weighted towards the age of patients and not weighted enough towards deprivation, as frailty in groups under 65 and over 80 years old varies significantly relative to the socioeconomic status and the SIMD of the practice’s population. Additionally, funding does not adapt to increases in the prevalence of conditions and increasing multimorbidity within patient populations, for example the elderly, or in line with population growth.

Flexibility and autonomy for general practices in how they use funding is a strength but it can also be a weakness of the current arrangements as it can lead to inequities in care provided between localities/practices, and this can make general practices more or less attractive places to work and can then have impacts on workforce recruitment and retention.

Our approach to data collection within primary care needs to move towards being more outcomes-focussed to enable an outcomes-based approach, and we need to embed a culture that is receptive to this change. A lot of the data currently captured in community pharmacy is transactional.

Alongside what money if paid, we need to understand what money is for (purpose, delivered by whom, and the desired outcomes).

A transparent and accessible mechanism of external assurance is needed alongside our funding mechanisms.

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

Quality and the outcomes we are seeking to achieve needs to be established first of all, and from there the appropriate funding mechanisms can be established.

Current funding mechanisms do not recognise the role of the primary care workforce in improving population health. When looking to future funding mechanism, we need to account for delivery of current activities and enabling preventive and proactive care and meeting population health needs.

Funding mechanisms need to enable and not undermine the sustainability of the third-sector and their role in improving population health.

Need a funding mechanism to support continuity and relationship-based care (enabled through aspects incl. data sharing), achieved through funding for general population services and targeted outcome focussed enhancements to funding.

The desired outcomes and what 'quality' looks like needs to be understood to understand the impact of funding/payment mechanisms. We cannot just look at funding/payment mechanisms to assess quality.

Question 4: Reflecting on this conversation, do you agree with the overall approach proposed in the paper? Does it need to be altered or added to? 

Need to use data and population-level and local-level insights to understand population health needs and consequently drive decision-making and resource allocation in the present and future-proof the funding of our services in anticipation of forthcoming change. Currently we tend to make isolated decisions to fund individual projects and then retrospectively evaluate our decisions. We need to keep track of the overall balance of funding.

There needs to be recognition that as we increasing the funding going into health and social care service provision, this takes funding away from addressing the underlying determinants of health. We need clarity on what money is being spent on and the outcomes we’re driving with that funding. The system is unaffordable currently, and demographic changes makes this position more challenging. Funding must be linked to outcomes.

Existing data is problematic to access and there are issues with the quality of data inputted. There is no financial incentive for good coding, and consideration needs to be given to how we incentive the ways of working we wish to see.

There are choices to be made on what treatments are funded (e.g. prioritisation of novel, expensive treatments which could jeopardise service provision within and beyond health). Medicalisation versus a social/wider determinants of health approach.

Data coding doesn't always tell you much about the burden of care. What data do we need to tell us about the care/outcomes we are looking to deliver. Constrained by existing data and need to not be driven overly by the data we currently have.

There is huge potential in the expansion on the multidisciplinary team in primary care, but how that is currently funded can be challenging and there needs to be a focus on future need.

Sustainable funding for educating the future workforce is required.

Group 2 – Infrastructure, Data and Digital

Question 1: What is in place currently that supports the approach proposed in the finance and funding paper (consider service/local/national)?

ESC (Emergency Care Summary) and eKIS (electronic Key Information Summary) are particularly useful for sharing info between pharmacy, out of hours and NHS 24. Work is planned for Out of Hours to create a national digital platform visible to primary and secondary care.

Near Me (video appointments) are available for patients, although this technology is being under-utilised.

To utilise the expertise to build new systems, investment and a digital roadmap/strategy is required. We need a stocktake of the digital systems and assets in use across the community, the suppliers, owners, and users of assets.

Right Decision Service (RDS) is a great platform but there is now extensive duplication of topics and guidelines.

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

The variety of legacy IT systems in use across the community present a number of challenges including:

• lack of interoperability between systems / inability for these systems to interface and communicate with one another;
• providers under to access patient records held by another provider
• inability to share sufficient or optimal data between community providers and community providers and secondary care (e.g. with respect to community eyecare, the SCI gateway data limit is small and allows JPEG and PDF files only. Ideally, providers want to share video of scans which allow much better clinical decision making and reduce referrals to secondary care).
• hinders innovation
• suppliers can be hesitant to do work in Scotland

Different digital languages are used. While we have scrabble between codes, without SNOMED (Systematized Nomenclature of Medicine Clinical Terms) coming in soon, we will still be translating without appropriate tools.

Lack of adequate resource and funding to deliver digital development which can be expensive, with potentially lengthy delivery timescales, and the need to train staff on using new systems.

Available space within existing infrastructure to deliver person-centred care, training, and computers.

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

Local and national digital innovation need to work in harmony and support one another, providing sufficient flexibility for adaptation to suit local needs and circumstances. Sharing local digital innovation, and the lessons learned, at a national level requires a supporting governance structure and processes.

Increase the use of virtual consultations for those who have digital access and capability, and this can be particularly useful in the provision of preventative care.

Review digital infrastructure within Health Boards, determine if reprovisioning is required, and record within a register when procurement decisions are due. Review digital priorities across health and social care, commit to a number of priorities, and deliver them fully.

Collaborate with UK Government and devolved administrations across the UK on establishing a cross-UK digital infrastructure. Creating a single UK market for digital will be more attractive to suppliers. The existing situation and requirements within Scotland mean that suppliers need to adapt to Scotland and make it an unattractive place.

Consistent deployment of Community Health Index (CHI) across all settings.

Ensure that digital products are accessible including that the language is accommodating of the range of reading ages across Scotland

Need to ensure that effective and high-quality digital systems are rolled out across primary care and the community including in prisons and care homes.

Question 4: Reflecting on this conversation, do you agree with the overall approach proposed in the paper? Does it need to be altered or added to?

Alongside information governance requirements the approach needs to adhere to information security, records management and technical standards to comply with Cyber Assurance Framework (NIS) and ICO Accountability. This is preventing a more unified approach, particularly beyond general practices to community pharmacy, General Dental Services and community optometry.

Sharing of data from interventions across the system could help to reduce unnecessary appointments.

The health and care issues people face are not one dimensional or transactional, and person-centred approaches rely on relationships being established and maintained between service users and the workforce. We need to ensure digital solutions effectively facilitate these interactions and are person-centred.