Looking Ahead: Recommendations for Rural General Practice
Preparing for the Future
The following recommendations are intended to support the Scottish Government and BMA to sustain and enhance primary care delivery across remote, rural and island communities for the future.
The Scottish Government and British Medical Association must continue to state their unequivocal commitment to maintaining the Income & Expenses Guarantee under current contractual and funding arrangements.
Rationale: The Group welcomes all efforts to reassure rural GPs that the income and expenses guarantee will be in place as long as it is needed. The Scottish Government and BMA should consider different and better ways to communicate and reinforce this message across the profession. This work should include clarity around uplifts as well as set out how this assurance will be safeguarded by both parties.
Local collaboration through the PCIP process will help improve relationships over time. The Group will also continue to promote examples of co-produced solutions through our work on Case Studies. The Scottish Government and BMA should continue to explore opportunities to reiterate this message at national, regional and local levels.
New terms and conditions arrangements, developed as part of Phase 2 or any further iteration of the GP Contract, should clearly recognise the diversity of remote and rural general practice.
This seeks to provide a long-term sustainable footing for rural practices and their communities. A comprehensive plan for consulting with remote and rural stakeholders on any wider contractual changes should be agreed as part of this process. This must include and embrace the views of the public and communities served.
Rationale: The Scottish Workload Formula (SWF) introduced in the new GP Contract favoured practices with high intensity workloads. As a result, a large number of rural practices have their income assured by the Income & Expenses Guarantee rather than by the formula. Across our engagement, this was widely regarded by remote and rural General Practitioners as a missed opportunity to show value for their role and recognise its distinctiveness.
This issue is not new. Historically, most of these practices would have received income stability through the Minimum Practice Income Guarantee (MPIG), used since the 2004 GP Contract. In the years prior to the 2004 Contract, many practices were supported through the Inducement Practitioners Scheme and had been Inducement Practices pre-2004.
The Inducement Practitioners Scheme made payments to GPs practising in areas where Scottish Ministers, after consultation with the Scottish Medical Practices Committee (SMPC), accepted that it was essential to maintain a medical practice even though the area was sparsely populated or was for some other reason unattractive to practitioners. In advising Scottish Ministers as to a practice’s “essentiality”, the SMPC considered its notional patient list size, the location of the practice, the number and location of surrounding practices, the likely level of income etc. Where Scottish Ministers accepted that a practice was essential, the GP was entitled to receive inducement payments.
The effect of the inducement payment was to underwrite the practice by the provision of a guaranteed minimum income. To calculate the level of inducement payment, allowable practice expenses were deducted from the GPs gross income (from all professional sources) to arrive at net income. The amount by which the net income fell short of the guaranteed income (the inducement yardstick) was the inducement payment.
The GMS Contract in 2004 radically changed the method of payment for rural GPs and brought them in line with other practices. The “Red Book” and the concept of an intended average net income (and hence the yardstick for Inducement Practitioners) was abolished. This signalled the end of the Inducement Practitioners Scheme.
Payments under the new Contract were based on the needs of the population i.e. the Global Sum and Minimum Practice Income Guarantee (MPIG), the Quality of Outcomes Framework (QOF) and the wide range of directed, national and local Enhanced Services, some of which were specific to rural areas. GP income, therefore, was largely determined by the efficiency with which the practice provided these services. Ex Inducement practices tended to have a large MPIG due to small list sizes.
In addition, practices were eligible for an increasing range of Health Board administered payments including reimbursement for the costs of covering maternity, paternity, adoption, and sickness leave. Some historical payments relating to annual leave, study leave and other forms of leave continued for ex inducement practices in some areas.
Through consideration of these historic examples, and the present dissatisfaction with the current formula, it is very likely that no national formula can ever be developed that will equitably respond to the needs and circumstances of very small remote and rural practices.
Future funding arrangements should be cognisant of areas of complexity across rural, urban and deep-end practices i.e. multiple sites, dispensing practices, levels of deprivation and other factors. It should also be cognisant of the specific impacts of national pressures, such as issues related to pensions, and their specific impacts on rural primary care – ‘rural proofing’. Future models of provision and resource allocation should also take account of international experience, drawing on the reviews commissioned by the Group from HIS, SSPC and Rossall Research & Consultancy.
A set of criteria for the use of the Rural Fund should be developed, recognising and supporting the distinct role of rural GPs and multidisciplinary teams.
Rationale: The Group has provided advice about how the Rural Fund should be used for a number of projects in 2018/19 and 2019/20. These projects seek to address themes emerging from across our engagement as well as from analysis of enablers in the Primary Care Improvement Plans. These projects are intended to help create positive momentum around regional and national initiatives that will over time shape and inform policies that will determine the future of General Practice in remote, rural and island communities.
We suggest that the Group should be invited by the Scottish Government to develop a set of criteria based on formalising this approach. If agreed, the Group will develop criteria that considers the cost, scale and timeframe for delivery for its current and future projects. It will also consider whether to support medium-longer term projects that go beyond the 3 year implementation period (to April 2021 and beyond). This should include comprehensive impact analysis of supported projects and join this work up with other intelligence driven projects and stakeholders. The Group will also consider possible criteria for extending the projects it supports, including further support for multidisciplinary team roles.
A package of support for dispensing practices, should continue to be developed through the Dispensing Working Group that will protect and enhance the sustainability of Scotland’s dispensing practices.
Rationale: Dispensing GP practices are located in remote, rural and island communities and are invaluable to the communities they support. They are located in communities who do not have access to Community Pharmacy services largely on account of lack of commercial viability. Practices can be required to dispense by their health boards following a decision by the Area Pharmaceutical committee (APC). This is not discretionary and is subject to judicial review.
A GP dispensing practice not only prescribes patients medicines but has to stock and dispense those medicines to patients in a safe and timely manner. This has both financial, commercial, training and patient safety implications to the practice, GP and practice staff.
The Dispensing Group, was formed to consider a number of issues relating to dispensing practices including the impact of implementing the new GMS Contract, including the role of pharmacists and pharmacy technicians delivering a pharmacotherapy service. The Group has worked to identify opportunities to develop and support dispensing practices to continue providing a high quality, safe and sustainable service. This includes areas such as IT provision, staff training and patient safety initiatives.
Currently there are no agreed national guidelines around how a Dispensing GP Practice should operate. The group has commissioned NHS Highland to develop draft national guidelines, based on work previously done in Highland to support 2C practices, and building on the work of the Dispensing Doctors Association to support Scottish dispensing practices. Early discussions have also begun on developing a bespoke Scottish training package for dispensing practice managers and administrative staff.
The Group has encouraged the Scottish Government to support GP dispensing practices from the Rural Fund (£500,000 in 2018/19 and £301,080 in 2019/20). Funding has been used to support Dispensing Staff Training and to help implement the Falsified Medicines Directive in all GP dispensing sites.
The Scottish Government should continue to support the Rural Group to continue this work, and to extend its scope to how future funding models will better support dispensing practices to provide informed guidance to the Scottish Government and BMA negotiating teams.
Refining Rural Enablers
These recommendations are focused on enablers that will support primary care redesign and GP Contract implementation across remote, rural and island communities.
A National Centre for Remote and Rural Health and Social Care should be established to foster and promote innovation and excellence in Scotland and internationally.
Rationale: The time is right to support not only general practice, primary care and clinical practice in Community Hospitals and Rural General Hospitals, but also the wider project of health and social care integration by creating a National Centre for Remote and Rural Health and Social Care. The Centre should serve as a platform for inter-professional sharing that should promote and foster rural innovation both nationally and internationally.
The Centre should be developed to deliver against a number of priorities:
- To be a multiplier for rural innovation - It should provide strategy and leadership for stakeholders working to improve remote and rural health and social care for patients and service providers. It should cover a broad range of fields including care quality, quality improvement and assurance, health and social care integration, recruitment and retention, training and education of clinicians, and e-health, digital technologies and telehealth care. Its role should support linking individuals and groups to develop and deliver collaborative projects and distil lessons to allow application of the learning to other areas of Scotland – rural and urban - and to deliver models at scale.
- To spread and contribute to Scotland’s Rural Healthcare story using data to show that our rural clinicians and service providers are exemplars - It should coordinate with groups such as the Primary Care Evidence Collaborative, the Remote and Rural Healthcare Alliance (RRHEAL) and the Scottish Rural Health Partnership (SRHP), to utilise the growing evidence base of innovation in remote and rural settings, explore projects to address unwarranted clinical variation in rural areas, and provide intelligence driven evaluations and recommendations to the Scottish Government and other stakeholders.
- To lead on promoting Scotland’s Rural Healthcare on a national and global stage - It should transform this work into a platform for engagement with regional, national and international stakeholder networks to promote Scotland’s success in delivering high quality healthcare. In collaboration with Universities, other academic and research groups such as the Scottish School of Primary Care, the nascent Faculty of Remote and Rural Healthcare of the Royal College of Surgeons of Edinburgh and others. It should help build networks that gather and disseminate the learning from other countries with successful rural healthcare delivery models.
The Centre will support delivery of a stronger response to the concerns of stakeholders in rural primary care and rural communities. The Centre should be developed in line with the Scottish Government’s National Performance Framework vision for Health and use evidence intelligently to continuously improve and challenge existing healthcare models and have a focus on resolving needs in order to achieve positive health, care and wellbeing outcomes.
This approach is supported by studies commissioned by the Rural Group to compare current models of MDT working in rural primary care provision in a range of developed countries. Health Improvement Scotland carried out a rapid review that indicated there is much value in further study of international solutions to delivering primary care services in remote, rural and island communities. The Group also commissioned research from Rossall Research & Consultancy, led by Dr David Heaney: to identify and compare current models of multi-disciplinary team working in rural primary care provision in a range of countries. The research comprised 20 interviews of healthcare experts across 8 countries. Dr Heaney’s work concluded that the culture and context of rural communities has motivated innovation in health service delivery across the world. The report is available on the Rural Group website.
Efforts should be renewed to make maximum use of information technology and digital connectivity in the provision of remote and rural primary care.
Rationale: The Group recognises the need for IT developments to support multidisciplinary working, through better-connected systems, remote consultation and virtual services. Alongside national initiatives to enable uptake of technology and improve digital connectivity, there is a need for a wider cultural shift across Boards, HSCPs and Practices to embrace technology enabled health and social care. During our engagement programme, we encountered examples of effective local collaboration to implement digital solutions, such as NHS Near Me that have been helpful to support effective implementation of MoU work streams.
To better address challenges at practice level, HSCPs should work closely with GP Sub Committees to support the deployment of new systems. In addition, engagement beyond primary care is needed to better understand how technology and connectivity can address the needs specific to local populations.
The Group welcomes the Scottish Government’s national investment of £3,085,000 to Health Boards to improve IT infrastructure within GP Practices. This is intended to improve the basic infrastructure, such as hardware and software, used by GP practice and multi-disciplinary team staff and to enable the development of the services set out in the MoU and the subsequent Primary Care Improvement Plans developed by HSCPs and Local Medical Committees. The Scottish Government has also set out plans to establish a primary care digital programme board to improve governance and the Rural Group should have opportunities to feed views into that developing work.
The Group recommends that the Scottish Government consider what further work can be done to support these national measures in rural areas. Through the Rural Fund, the Group has supported initiatives targeted at smaller, remote, rural and island Health Boards. In 2019/20 an additional £200,000 has been allocated to NHS Borders, Dumfries and Galloway, Highland, Orkney, Shetland and Western Isles.
A further £200,000 from the Primary Care Rural Fund is being allocated to Health Boards to assist with the deployment of Attend Anywhere (NHS Near Me) to remote and rural general practices. Attend Anywhere (NHS Near Me) is increasingly being seen as a viable tool to support GP practices and the wider multi-disciplinary team and the development of primary care services in rural areas. NHS Ayrshire and Arran, Borders, Dumfries and Galloway, Grampian, Highland, Orkney, Shetland, Tayside and Western Isles have each received £22,000 for the deployment of Attend Anywhere (NHS Near Me) in 2019/20 to support the roll out to rural practices.
Digital Connectivity as well as Health and Wellbeing are strategic priorities in the recently published (October 2019), Scotland’s Islands: Proposed National Plan.
More effective collaboration with Health Boards and HSCPs is necessary to improve pressing physical infrastructure issues across remote, rural and island general practice, to better support multidisciplinary working, training and education.
Rationale: The development of multidisciplinary teams is one of the important objectives of the GP Contract. The Group has also heard a number of rural GPs highlight the importance of space to host training and education for clinical undergraduates and postgraduates, particularly GP training. (see the ninth and tenth recommendations below) This is widely regarded as an important factor in contributing to rural recruitment as prospective GPs and MDT members are more likely to take up posts in areas where they have trained.
The Group agreed on the importance of creating additional physical space for growing teams, and training needs. Health Boards and HSCPs should consider physical space during future infrastructure and workforce planning and should commit to essential improvements and upgrades. The Group welcomes the Scottish Government continuing to develop the GP Premises Sustainability Fund to support physical infrastructure.
Closer working with HSCPs, territorial and national (special) Health Boards and Bodies is required to establish change management support and capacity for remote, rural and island communities. In turn, these endeavours should also help non-rural areas across Scotland.
Rationale: We frequently heard from GPs, and representatives of Health Boards and HSCPs in smaller rural areas that due to their smaller size they have issues with project management and quality improvement capacity and expertise to develop and deliver PCIPs.
The Primary Care Improvement Fund is allocated to Health Boards using the Scottish Resource Allocation Formula. The Formula calculates target shares (percentages) for each NHS Board based on a weighted capitation approach that starts with the number of people resident in each NHS Board area. The formula then makes adjustments for the age/sex profile of the NHS Board population, their additional needs based on morbidity and life circumstances (including deprivation) and the excess costs of providing services in different geographical areas.
Across our engagement, we have heard that very remote areas have a diseconomy of scale that means funding change management support is more costly and difficult to implement. Resources for change management also extend to effective engagement with the GP bodies. The development of strong, robust working relationships and trust is essential for the effective co-production of service delivery models. In rural areas, bringing local stakeholders together can inevitably involve long travel times, and be dependent on geographic and weather factors, or rely on often sub-optimal technological solutions that can incur an additional cost and time. The amounts allocated through this formula present challenges for Boards and HSCPs with very remote communities.
It is clear through our engagement and through the evidence of the Primary Care Improvement Plans that clinicians and managers need to understand each other’s priorities and pressures, and have time to develop strong, mutually trusting relationships. Strong clinical leadership will be required alongside robust management support.
In some cases, project management support is funded out of the Primary Care Improvement Fund (PCIF) to implement the Contract although this has not been the case uniformly, especially for smaller Boards for the reasons given above. The Scottish Government should prioritise developing measures to support change management in remote, rural and island general practice.
The Rural Group has used the Rural Fund to take forward initial work that can inform this process. In 2019/20 we established a fund of £117,252 to assist the three island Health Board/HSCPs with administrative/project management support. NHS Orkney, Shetland and Western Isles are each allocated £39,804 each.
The Scottish Rural Medicine Collaborative should continue to develop innovative solutions to support recruitment and retention of remote and rural GPs and the broadening multi-disciplinary team workforce, at all career stages.
Rationale: Across our interviews and visits there was a common view that remote and rural general practice and primary care needs to provide a wider range of services, requiring clinicians to maintain a broader repertoire of knowledge and skills. The breadth of services delivered varies across the spectrum from a small, remote practice to large urban practices. It is a continuum and the required skill sets of practitioners in two equally rural practices of similar sizes may differ. For example, one practice may support a Community Hospital and practitioners would therefore require additional skills to deliver these services. This creates specific recruitment and retention challenges that need tailored solutions to ensure the sustainability of rural general practice.
The Group welcomes the work of the Scottish Rural Medicine Collaborative (SRMC) in bringing together rural health boards and other key stakeholders including BMA, RCGP and NES to co-produce creative solutions to rural recruitment and retention challenges.
One example of this innovative approach is the Scottish Rural Medicine Collaborative project ‘Rediscover the Joy of General Practice’ which was successful in recruiting 33 GPs to its first Rural GP Support Team in 2019. When asked about what attracted them, applicants cited the project’s clear aims and vision, the emphasis on values, supportive teamwork, flexible working structures and collaboration across four Health Boards to address rural recruitment. The provision of training and a unified system for pre hospital emergency care provision allowed experienced urban GPs to consider working in rural and remote areas. SRMC will continue to work collaboratively with other organisations and stakeholders to continue to expand this work.
The Group recognises the SRMC’s achievements and recommends that the Scottish Government support the SRMC to expand its work into efforts to improve MDT recruitment and retention. For example, nurses within small Rural Primary Care Teams undertake functions that span Practice Nursing, Community Nursing and Emergency Care Nursing. Elements from all these separate nursing career options in urban areas are required by rural nurses and needs to be recognised, delineated and supported.
The Group has supported the SRMC and other initiatives to help rural recruitment and retention with the 2019/20 Rural Fund. We have supported the allocation of:
- £342,218 to NHS Highland to support the Scottish Rural Medicine Collaborative.
- £69,450 to NHS Shetland to support the Rediscover the Joy of General Practice Project.
- £200,000 to continue support for Rural Relocation expenses reimbursements for GPs taking up posts in rural areas, and £400,000 to fund Golden Hello recruitment incentives for rural GP posts.
Further promotion of the recruitment of medical, nursing, pharmacy and allied health professional (AHP) students is required. This includes more opportunities for student rural replacements and support for the expansion of training practices and training opportunities in remote, rural and island areas.
Rationale: Training of GPs and the MDT is an essential component of recruitment and retention. Practices that already struggle to recruit often lack capacity to take on trainees. Mechanisms need to be established to support GP and MDT training in rural practice.
The Group recognises the vital importance of bringing students into rural areas and notes the evidence base that increasing training in rural areas has a strong positive impact on trainees choosing to work in rural areas in their future careers.
The Scottish Government’s policy is to support a significantly greater component of undergraduate medical education within the community, in general practice and primary care. As mentioned before, the Increasing Undergraduate Education in Primary Care Group Report, led by Professor John Gillies, published in October 2019, made a number of recommendations to achieve this. Other disciplines are following suit, for example more clinical attachments for pharmacy students are being piloted. This also has relevance to digital connectivity (Recommendation 6) and premises/physical infrastructure (Recommendation 7), and the role of SRMC (Recommendation 9) discussed above
Further work is needed to identify funding required to support the expansion of training practices in rural areas. It should also be aligned with wider work to improve capacity, personnel and space to enable this. This work should include MDT students, and should look at discovering successful training initiatives and exploring ways to upscale and transfer those to other clinical roles.
A better understanding of the different elements of care and the skill sets required to deliver them would allow Rural Primary Care Teams to describe the work they undertake and through this the training they require. Significant work in this area is already underway. The Remote and Rural Education Alliance (RRHEAL) has developed training programmes to support rural practice and this work could be further developed to offer greater clarity and accessibility to training programmes and an improved understanding of what other training programmes are required to allow comprehensive educational support to Rural Primary Care Teams. NHS Education for Scotland (NES) undertook some in depth work looking at the skills and competencies required of GPs providing services within community hospitals. This work was used to establish the Acute Care Rural Fellowship. The RCGP developed additional curricula requirements for rural GP training which forms the basis for the Rural Track GPST programme.
Recognition of the broader skill set required of rural practitioners along with resources to allow easy access to training would improve connectivity of rural practitioners, retention and resilience as well as helping rural practitioners to feel valued. This could also include provision of funding to allow rural practitioners to attend educational events and for the provision of videoconference training programmes with the facilities for both synchronous (live) participation and asynchronous (watching recorded educational sessions at times convenient to practitioners). See also Recommendation 6 regarding digital connectivity.
The method of funding allocations to territorial Boards with significant remote and rural areas, including Island Boards, should be reviewed, in light of changing demographics and evolving models of care provision.
Rationale: Throughout our engagement programme and in discussions of the Group, we heard queries expressed as to whether the current method of funding allocations to remote, rural and Island Boards remained reliable, taking fair account of remote and rural characteristics. These include: demographic changes, evolving models of care provision, digital innovation, sparsity, deprivation, excess supply costs, travel costs and the logistical impact of having the sea separating communities.
Proportionate mechanisms should be in place to assess and evaluate new models of care provision in remote and rural areas and to assimilate and disseminate best practice.
Rationale: In the past some areas of governmental policy have been implemented locally, without adequate evaluation of impacts and outcomes, both foreseen and unforeseen. Such assessment must be proportionate and would be helpful in determining what works, does not work and what should be considered best practice. We would envisage that the proposed National Centre for Remote and Rural Health and Social Care (Recommendation 5) would have a key role in this.