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PRIMARY CARE SERVICES
Policy overview
The White Paper Designed to Care set out a vision of a National Health Service based on co-operation and collaboration, providing equal access to high quality care for all the people of Scotland. In pursuit of this, in 1999, responsibility for primary care will move from being a health board function to become a function of new primary care trusts (PCTs), organisations charged with delivering integrated, seamless care across the range of primary, community and long-stay health services. In addition to their responsibility for primary and community-based health care, PCTs will typically include community hospitals and mental health services as well as networks of local health care co-operatives (LHCCs). The aims of PCTs and LHCCs will be to develop primary care, integrate primary and community services locally, and provide specialist support to primary care teams. The fact that LHCCs will include general practitioners (GPs), and other health care professionals, will strengthen and support practices in delivering care to their local communities. During 1998 health boards across Scotland have been working with groups of GPs and other health care professionals towards the formation of LHCCs.
The principles of clinical effectiveness, quality assurance and clinical governance developed in Designed to Care and the Acute Services Review Report are as applicable to primary care as to the acute services. Developing these principles will continue to be a high priority for SODoH, in consultation with professional bodies and service providers.
Prevention of fraud
The NHS is determined to detect and deter fraud and sharp practice and to seek full redress where appropriate; a number of relevant measures were put in place during 1998. In April, guidance was issued clarifying aspects of general ophthalmic service procedures and new forms were introduced in August which include a new section in the sight test claim form requiring optometrists and ophthalmic medical practitioners to provide a clinical or other reason for early re-test.
In October, health boards were advised of the phased introduction of redesigned prescription forms printed on coloured paper with serial numbers, UV-sensitive markings and microwriting to prevent and detect forgery and theft. In addition, checks on the eligibility of patients for free NHS prescriptions were introduced at community pharmacies.
Activity in primary care
Child health surveillance
The percentage of general practice principals registered to monitor the development of children under five years of age rose slightly from 77% in 1997 to 78% in 1998, the latter figure representing coverage of 76% of Scottish children, compared with 68% in 1993.
Immunisation and cervical cytology
Higher and lower target payments are made to general practitioners who achieve specified levels of uptake of primary immunisations, pre-school booster immunisations and cervical cytology. Current levels are set at 90% and 70% for primary immunisations and pre-school boosters, and 80% and 50 % for cervical cytology. The proportion of general practice principals achieving the higher target levels remained high in 1997/98, representing a major contribution to public health by primary care teams. Between 1991 and 1997 the proportion of the target population receiving primary immunisation rose from 82.9% to 95.2%; pre-school booster immunisation uptake rose from 87.6% to 96.9% and cervical cytology rose from 85.4% to 91.3%. In many health boards, notably Western Isles, Orkney, Borders, Highland, Grampian, Greater Glasgow, Forth Valley, and Dumfries and Galloway, primary and pre-school booster immunisations are provided almost exclusively in primary care.
Continuous Morbidity Recording
The Continuous Morbidity Recording project began in 1993 and now extends to 60 general practices, around 6% of all Scottish practices. The patient population covered is representative of the Scottish population as a whole in terms of age, rurality and deprivation, and participating practices cover all but two health board areas (Orkney and Western Isles). The data recorded provide a useful insight into demand for GP services and can be extrapolated to provide estimates of workload at national level.
In Scotland in 1997/98 an estimated 16 million contacts took place between patients and GPs; on average, patients consulted their GP just over three times in the period with highest consultation rates for those aged 64 and older, followed by children under five. During 1997/98, 31% of males did not visit their GP at all, compared with 15% of females, while 4% of males and 8% of females attended ten or more times. The estimated 16 million GP contacts were associated with only 2,369 reported complaints, a rate of 0.015% or one complaint in 6,750 contacts.
Figure 8.1 shows categories of diagnoses made during 1997/98, based on data from 43 practices; the most frequently recorded single category was 'respiratory system diseases', accounting for 15.5% of contacts, although 21.1% were categorised as 'history, symptoms and ill-defined conditions'.
Prescribing in primary care
Provision of drugs and appliances continues to play an important part in treatment and long term health care: approximately 12% of NHSiS resources are used to support prescribing by GPs, nurses and dentists. Expenditure on drugs and appliances in Scotland in 1997/98 was around £514m, an increase of about 9.6% on the previous year, and ranged from £88.7 per capita in Orkney to £117.18 in Argyll and Clyde, with a national average of £105.65. The rate of generic prescribing continued to rise nationally from 64% to 65.9%, ranging from 48.9% in Shetland to 73% in Lothian. Patient expectation and demand for drugs continues to grow and recent reports have highlighted the dangers of inappropriate prescribing of antibiotics, hypnotics and anxiolytics. There is a continuing need for improved public and professional education on the benefits and dangers of prescribed drugs.
Antimicrobial resistance and the use of antibiotics
There is growing national and international concern about the increasing development of resistance by micro-organisms to antimicrobial agents, and recognition of the need for more concerted action to prevent, delay and control such resistance. Unnecessary and inappropriate prescribing of antibiotics is acknowledged as a contributory factor. In recent years, there has been little reduction overall in the total volume of antibiotics prescribed, as measured by defined daily dose (DDD) to obtain a standardisation of quantity prescribed (Figure 8.2). However, within the total volume, the proportion of older, more established antibiotics (such as penicillin) has steadily decreased as more and more newer antibiotics are dispensed, potentially undermining our ability to fight new forms of infection.
Hypnotics and anxiolytics
These drugs, in particular benzodiazepines, have well established risks and are perceived as being over-prescribed, with repeat prescriptions being issued inappropriately. Benzodiazepine dependence and misuse are well-recognised problems both medically and socially; the consensus of medical opinion supports a reduction in their use with increasing emphasis on non-drug management of anxiety and insomnia using methods such as advice, counselling and relaxation therapy. This has led to a decline in number of prescriptions for hypnotics and anxiolytics from 66.7 million DDDs in 1992 to 60.4 million in 1998 (Figure 8.3).
Quality and clinical effectiveness
A number of initiatives addressing quality assurance and clinical effectiveness in primary care demonstrate the benefits of joint working and collaboration. These involve a wide range of organisations including the Royal College of General Practitioners (RCGP), the Chief Scientist Office, the Clinical Resource and Audit Group, the Scottish Intercollegiate Guidelines Network (SIGN), the Nursing Board Scotland and the Scottish Council for Postgraduate Medical and Dental Education. The RCGP already has a Quality Practice Award and Directors of Postgraduate General Practice Education have developed, and are consulting on, a system for introducing clinical governance in general practice.
Clinical guidelines summarise research evidence on specific areas of clinical care and provide recommendations for best practice but, inevitably, will not improve patient care unless they are implemented. Various local and national multidisciplinary initiatives are in place in Scotland to help primary care teams use guidelines in the management of asthma, diabetes, heart disease and mental health. Nurses are particularly involved in implementing guidelines for the management of leg ulcers. Summaries of key messages in SIGN guidelines for use in primary care, developed by the RCGP in collaboration with nurses and pharmacists, are being distributed to all general practitioners and practice nurse teams. To give further impetus to implementation of guidelines the RCGP has set up a pilot project - Scottish Practice-based Accreditation in Clinical Effectiveness - to encourage practice teams to work together to improve the quality of care they provide.
Developing primary care
Out- of- hours review
In 1998 a review of the GP out-of-hours services which were introduced in 1995 concluded that out-of-hours co-operatives have been well received by patients and have led to significant improvements in the quality of GPs' lives and in the range of services available to patients. In general, the new services are monitored more fully and openly than those they replaced, but a number of areas were identified for further research or review, including the variability in rates of home visiting between different organisations, the provision of patient transport and the use of protocols and clinical guidelines. Consideration is being given to finding ways of supporting practitioners in remote and rural areas where co-operatives are not an option.
Primary Care Act pilots
The NHS (Primary Care) Act 1997 allows different types of contractual arrangements for the delivery of general medical services to be tested and evaluated. Seven Primary Care Act pilot studies went live on 1 April 1998: four are for practice-based contracts to test new ways of delivering personal medical services and three concern employment of salaried general practitioners by trusts. The pilots allow general practitioner services to be provided under a local contract, which adapts the national contract to local needs.
Leadership Development Programme
This programme encourages a partnership approach to working and is open to all disciplines including general practitioners, nurses, professions allied to medicine, pharmacists and managers involved in the delivery of primary care. Its aim is to equip staff with the skills and knowledge needed to lead the current changes in the NHS and to support the introduction of primary care trusts and local health care co-operatives.
Primary Care Development Fund
The centrally commissioned projects supported through this fund during 1998 included work exploring models of training which bring together health and social care staff. Such joint approaches will be at the forefront of future work in primary and community care to secure better integrated services for the people of Scotland. Other projects included an initiative that encourages health boards to identify key stakeholders with an interest in, or responsibility for, providing services to adolescents with emphasis on inclusion of young people in debate and decision making. This work will contribute to the tackling of inequalities.
General Medical Services
The number of unrestricted general practice principals in post in Scotland has continued to rise: latest figures show an increase from 3,456 in 1993 to 3,660 in 1998. Of these, 2,367 are male unrestricted principals (2,424 in 1993) and 1,293 female (1,032 in 1993). The numbers working part-time, or job-sharing, are also increasing with latest figures showing 48 male and 224 female unrestricted principals working three-quarters time, 20 male and 126 female working half-time, and 17 male and 53 female job-sharers.
Average practice list sizes decreased from 1,593 in 1993 to 1,554 in 1998 and the number of single-handed practitioners fell to 198. The number of practice staff rose over a 10-year period from 3,598 to 6,506; the steady rise in numbers of practice nurses reflects the considerable extension in their role. Numbers of associate general practitioners have increased from 33 in 1993 to 52 in 1998 and numbers of assistants have increased from 22 to 27 over the same period. The number of general practice registrars rose from 234 in 1996 to 274 in 1998.
Salaried doctors' scheme
March 1998 saw the introduction of this scheme which enables general practices to employ a salaried doctor and allows health boards to use general medical service cash-limited funds to reimburse practices for some, or all, of the consequent employment costs. The scheme aims to assist principals to improve the quality of service provision, to improve career opportunities for general practitioners who prefer not to work as principals, and to help solve any difficulties experienced in provision of out-of-hours services in remote areas.
GP retainer scheme
This scheme is designed to encourage doctors who cannot commit to a substantive appointment in the NHS to continue working and training in general practice. The intention is to maintain and develop skills and thus enable eventual return to a permanent post; the scheme now has greater educational input and direction than was possible under previous arrangements.
General practice premises
During 1998, 67 new purpose-built medical centres (including extensions and refurbishment of existing premises) were completed and 193 smaller scale improvements were made to existing premises through the improvement grant scheme. In December 1998, bids were invited for modernisation of health centres, and for other innovative projects involving primary care premises, to improve provision of services to patients.
Primary care information management and technology
The Strategic Programme for Modernising Information Management and Technology in the NHS in Scotland, launched in December 1998, has particular significance for primary care, given general practitioners' pivotal role in holding and managing clinical information throughout a patient's life. By summer 1998, all general practices in Scotland had been connected to the NHSnet, a secure communications network. In the next stage of the programme health boards
and trusts will also be connected, enabling sharing of patient information between primary care and hospitals in a fast, secure way. A number of pilot projects
are underway, including electronic transmission of referral and discharge
letters, electronic access to laboratory results, and on-line booking of hospital appointments from the GP's surgery. In addition the roll-out of a modern, integrated general practice administration software system (new GPASS) will help ensure that GPs have the highest quality information support for patient care.
Community and practice nursing
Nurse prescribing
There are now 850 qualified nurse prescribers in Scotland and the scheme continues to enjoy the support of general practitioners, nurses and, most importantly, patients.
Opportunities for nurses in the establishment of local health care co-operatives
The new arrangements described in the White Paper Designed to Care afford opportunities for nurses to work with other health care and non health care staff to secure better integrated services for patients. The role of LHCCs in adopting a population-wide focus, and the move to a health gain model, rather than treatment focused care, bring with them the chance for nurses to develop their public health role. The continued development of self-managed, or integrated, community nursing teams is important in achieving the most effective deployment of the experience and skills of all members of such teams. In many areas the model has expanded to include practice nurses, while in some there are plans to include community psychiatric nurses and non health care professionals in the self-directed team.
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