National Health Service in Scotland: Annual Report 1998-99

	developing primary care Local Health Care Co-operatives are promoting joint working and service developments in local areas, bringing together all the professionals responsible for the delivery of health care services

DEVELOPING PRIMARY CARE

Developing Primary Care

One of the key proposals in the White Paper "Designed to Care" was the creation of new Primary Care Trusts, which were designed to bring together the planning and development of primary and community services through a network of Local Health Care Co-operatives. During 1998/99, as planning for the new Primary Care Trusts' configuration and structure proceeded, service integration and co-operation at the front line continued to develop, fuelled by the commitment of staff to provide accessible services to patients.

Key themes during the year included further investment in infrastructure to support the delivery of care, and a focus on cross-professional team development at every level. Cross-sectoral co-operation, involving joint action between primary care, social work and other agencies, continued to grow, and took particularly concrete form in some of the innovative shared premises developments which received central investment. None of these developments represent an end in themselves. They are simply means to the key goal of primary care; providing increasingly effective and patient focused services where and when people want them.

Resources in Primary Care

The range and scope of services being delivered in primary care is being extended and developed, and this is reflected in the funding of primary care, which has increased by some 15% this year, compared with last year. This additional money means that more and more people can be looked after in their own homes and in the community, and primary care clinicians are able to offer enhanced services. Some £1.2 billion was spent supporting clinicians (GPs, dentists, optometrists and others) and their teams and in funding treatments, drugs and appliances which they provide under the NHS. Of this total, around £630 million was spent on drugs and appliances. In addition to this, an estimated £684 million was spent on the community aspect of hospital and community services, which includes the costs of running district nursing, health visiting and Professions Allied to Medicine programmes.

PEOPLE AND ACTIVITIES

Staffing in Primary Care

The numbers of staff in primary care also continues to increase. As at October 1998, there were nearly 16,000 whole time equivalent staff working within primary care (including community nurses), representing just over 30 per 10,000 of the population.

Working Together

One of the key themes of the White Paper "Designed to Care" is that of teams working together, using their unique professional skills in collaboration to benefit patients. The goal of Local Health Care Co-operatives (LHCCs) is to promote joint working and service development in local areas, bringing together all the professionals responsible for the delivery of front line services. During 1998/99 a good deal of effort was invested in multi-disciplinary team development, particularly in relation to the formation of LHCCs. Other developments in relation to teamwork included a pilot programme of sites developing models of self-managed nursing teams. Interest in this model is widespread, and over 300 people attended workshops sharing the lessons learned by the pilot self managed teams.

Some key issues - particularly in relation to community development and public health - can only be progressed jointly. With regard to the former, two projects are being centrally funded to develop models of team-based community development, addressing inequalities by empowering local people. One has generated a training pack for primary care teams entitled "Community Development in Primary Care", which was scheduled to be launched nationally in October 1999

General Practitioners

The number of GPs continues to increase; there were 3,608 in 1997 and there are now 3,696. However, consultation rates have remained quite steady with only a 0.1% increase in consultation rates between 1997 and 1998, as shown in the table below. The average list size of practices is falling, from over 1,600 per GP in 1997/98 to under 1,500 in 1998/99. This is partly associated with the increase in part-time working by doctors. The ways in which GPs are organised is also changing - fewer work as single-handed practitioners with the numbers of partners within practices increasing. Over 30% of GPs work in practices with 6 or more partner, compared with only 21% ten years ago. Arrangements for dealing with patient needs outwith normal hours is also changing, with the vast majority of GPs now working in out of hours co-operatives.

Source: CMR data for 39 practices who collected complete data for year ending December 1997 and data for 40 practices who collected completed data for year ending December 1998.

Many practices offer an extended range of services to their patients. All Scottish practices offer contraceptive and maternity services to their patients, while 94% offer child health surveillance and basic health promotion. 92% of practices have minor surgery clinics while 89% offer chronic disease management programmes for patients with diabetes and asthma. These figures vary around Scotland; in some Health Board areas all practices offer all extended services, and of course many practices offer a much wider range of services to their patients. It is good team and interdisciplinary working that makes it possible for practices to offer such types of extended services

Nurses in the Community

The number of practice nurses continues to increase, with 968 whole time equivalent staff in post in October 1998, compared with 900 in October 1997. Community nurses bring care directly into the patient's own home - provisional figures show that approximately 4.8 million home visits were made to nearly 255,000 patients during 1998/99. Health visitors offer good health advice and practical support to parents of young children and to older people alike. Provisional figures for 1998/99 show that around 400,000 patients were visited by health visitors, of which nearly half were patients under 5 years of age. This does not include the valuable work done within GP practices, undertaken by health visitors, in clinics for babies and young children.

Professionals Allied to Medicine

Many specialist staff whom patients may meet in hospital also work in the community. For example over 1.5 million treatments were offered last year by the community chiropody service. The number of staff working in the professionals allied to medicine continues to grow overall, as shown in the table below.

Dentists

The White Paper "Towards a Healthier Scotland" highlights Scotland's poor dental health. Primary care dental services can make a significant contribution to improving dental health by addressing inequalities in access to NHS dental care, increasing registrations, targeting resources to particular groups in need, and focusing on clinical effectiveness and quality.

Some areas have initiated health promotion programmes which include registration from birth and have more than doubled the number of 0-2year olds registered with a dentist. The main preventive elements of these programmes include early introduction of the child to a fluoride toothpaste, and health education on diet and reducing sugar consumption.

In April 1998, an 'early years enhanced capitation' scheme was introduced. Dentists registering 0-2year olds on the NHS and providing preventive oral health advice to them and their parents, receive enhanced monthly payments on a sliding scale, according to the deprivation category of the practice, to recognise the additional challenges faced by dentists in deprived areas. There is also an enhanced monthly payment in respect of 3-5year olds registered with dentists in the most deprived localities.

At March 1999, there were 1,854 principal dentists on Health Board lists in Scotland. These dentists completed 3.5million courses of treatment during the year. At 31March, 63% of children and 48% of adults were registered with a general dental practitioner.

The Scottish Dental Access Initiative, which offers funding to general dental practitioners to establish or expand NHS practices in areas where access to NHS general dental services is poor, was extended in October 1997 to make grants available to NHS practices in areas of poor oral health in order to increase patient registrations. Applicants must undertake to provide NHS dentistry to 1,500new patients for at least 5years. During 1998/99, 8grant applications were approved.

In late 1998, the General Dental Council introduced new guidelines for general anaesthesia in dental services to improve patient safety and raise standards. This has resulted in a significant reduction in general anaesthetics in general dental practice and an increased use of safer alternatives such as local anaesthetics and sedation.

Optometrists

During 1998/99, optometrists and ophthalmic medical practitioners undertook over 664,000 NHS sight tests, an increase of 1.3% over 1997/98. In many areas, optometrists have continued to participate in the development of shared care schemes with specialist services, for example eye screening for people with diabetes and glaucoma.

Pharmacists

There has been continued development of joint working between GPs and pharmacists on prescribing, medicines management and direct patient care services. A number of the emerging Local Health Care Co-operatives have been keen to develop this on a locality-wide basis.

To help combat fraud, point of dispensing checks for exemption from payment of NHS prescription charges have been introduced along with improved prescription stationery. Forms are now on coloured paper with serial numbers, UV sensitive markings and microwriting.

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