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HS/S5/19/23/A
HEALTH AND SPORT COMMITTEE
AGENDA
23rd Meeting, 2019 (Session 5)
Tuesday 8 October 2019 The Committee will meet at 9.30 am in the James Clerk Maxwell Room (CR4). 1. Primary Care Inquiry - Phase Two: The Committee will take evidence from—
Ainsley Dryburgh, Local Area Co-ordinator, Fife Forum, Fife Health and Social Care Partnership; Caroline Cherry, Service Manager, Adult Assessment & Partnership, Communities and People, Clackmannanshire and Stirling Health and Social Care Partnership; Gerry Power, Director of Integration, the ALLIANCE; Dr John Anderson, Organisational Lead for Primary Care, NHS Health Scotland; Anne Crandles, Social Prescribing/Community Link Worker Network Manager, NHS Lothian;
and then from—
Claire Stevens, Chief Executive, Voluntary Health Scotland; Susan Paxton, Head of Programmes, Scottish Community Development Centre; Gail Anderson, Chief Executive, Voluntary Action Orkney; Suzanne Martin, Senior Public Affairs Officer, SAMH (Scottish Association for Mental Health); Jane Cumming, Director of Services and Innovation, Penumbra.
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2. European Union (Withdrawal) Act 2018: The Committee will consider whether the following instrument has been laid under the appropriate procedure:
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 (SSI 2019/285).
3. Subordinate legislation: The Committee will consider the following negative instruments—
The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019 (SSI 2019/284); and The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 (SSI 2019/285).
4. European Union (Withdrawal) Act 2018: The Committee will consider a proposal by the Scottish Government to consent to the UK Government legislating using the powers under the Act in relation to the following UK statutory instrument proposals—
The Recognition of Professional Qualifications (EFTA States) (Amendment etc) (EU Exit) Regulations 2019; and The Recognition of Professional Qualifications (Miscellaneous Provisions) (Amendment etc ) (EU Exit) Regulations 2019.
5. Primary Care Inquiry - Phase Two (in private): The Committee will consider the evidence heard earlier in the meeting.
David Cullum Clerk to the Health and Sport Committee
Room T3.40 The Scottish Parliament
Edinburgh Tel: 0131 348 5210
Email: [email protected]
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The papers for this meeting are as follows— Agenda item 1
PRIVATE PAPER
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Witness written submissions
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Agenda item 2
Note by the clerk
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PRIVATE PAPER
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Agenda item 3
Note by the clerk
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Agenda item 4
Late paper (public) (to follow)
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM NHS Fife
1. Considering the Health and Sport Committee's report on the public panels,what changes are needed to ensure that the primary care is delivered in a waythat focuses on the health and public health priorities of local communities?
The 2018 ‘Public Health Priorities for Scotland’ report indicates only 23% of adults inScotland agree they can influence decisions affecting their local area. Those livingin more deprived communities are less likely to feel they can influence localdecisions.
Current situationThe Health and Social Care Partnership communicates, consult and engages withthe public in a variety of ways to empower communities to make decisions thatdirectly affect them, predominately supported by Locality Working National andregional SPIRE data, local intelligence and Scotland-wide learning underpin PrimaryCare Transformation planning and service delivery in Fife.
In Fife we have commissioned local area co-ordinators who are embedded inprimary care to help to redress health inequalities and improve access in moredeprived communities. The LACs are employed by a local voluntary sectororganisation – Fife Forum and work collaboratively not just with the GPs surgery butacross Primary Care.
What does a Local Area Coordinator (LAC) do? The LAC is a means for GPs,
Nurses and other primary care professionals to refer people to a range of non-clinical
services. It aims to support people take control of their own health and recognises
peoples’ health is determined by a range of social, environmental and economic
factors. LACs seek to address people’s needs in a holistic way.LACs work alongside
our communities to help identify services and groups which might support individual
needs and wants. LACs will never direct people or force services on people but
instead will offer information and signposting as to how individuals might fulfill their
needs and wants where this is possible.Who might benefit from LAC? It is
designed to support people with a wide range of social and emotional or practical
needs. People who might benefit from the support of a LAC include people with mild
to moderate mental health problems, vulnerable groups, people who are socially
isolated and people who frequently make GP appointments.
What changes are needed?
• Joined-up and better use of data between NHS boards, Local Authorities andHealth and Social Care Partnerships is essential to understanding the placeswe live, demand and the identification of vulnerable people.
• Improved planning across health & social care
Health and Sport Committee 23rd Meeting, 2019 (Session 5) Tuesday 8 October 2019
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• Increased partnership working with the third sector
• Shared IT systems
2. What are the barriers to delivering a sustainable primary care system in both
urban and rural areas?
• Phased funding of Primary Care Transformation over a 4 year period presents
challenges around achieving equitable and sustainable delivery of primary
care services in Fife
• The qualified medical and clinical workforce required to support delivery of a
sustainable primary care system is not readily available, lead time is required
to support workforce pipeline and training
• There is insufficient capital funds to support extended GP Practice
multidisciplinary team accommodation and IT
• Centralisation of specialist services eg. community hub/cluster based MDT
working increases barriers to access for people living rural areas
• Data, information sharing and consent between GP Practices, GP Clusters
and wider Health and Social Care services
3. How can the effectiveness of multi-disciplinary teams and GP cluster working be monitored and evaluated in terms of outcomes, prevention and health inequalities?
The National Monitoring and Evaluation Strategy for Primary Care sets out the overarching
approach and principles for how the Scottish Government will use evidence and analysis to
track, document and understand the reform of primary care, including out of hours services,
between now and 2028.
Current Situation
HSCPs were asked to outline in their 2019/20 Primary Care Improvement Plans how they
will measuring the impact of their service redesign. Scottish Government are considering
ways in which reporting could be made more consistent and effective for partnerships,
health boards and national stakeholders across the MoU actions.
The effectiveness of multi-disciplinary teams and GP cluster working is monitored at a local
level through tests of change, summative and formative service evaluations and public
health academic research and reported through the programme governance structure.
Further work is being developed as the programme matures around implementation audits
and surveys.
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM CLACKMANNANSHIRE AND STIRLING HEALTH AND SOCIAL
CARE PARTNERSHIP
Modern Primary Care needs to be celebrated and assured of the highest visibility and profile at national and organisational level. This should recognise and appreciate the capability of primary care services in delivering the very significant majority of holistic care for a population that is ageing and has increasingly complex needs and expectations. The development and sustainability of primary care requires significant refocus with enhanced prioritisation and investment. Current resourcing to effect sustainable change in community services is grossly inadequate.
Committee are keen to hear responses to the following questions: 1. Considering the Health and Sport Committee's report on the public panels, what changes are needed to ensure that the primary care is delivered in a way that focuses on the health and public health priorities of local communities? The public panels gave views on Technology - Panel were largely in favour of improving / increased use of technology for single record shared across professionals accessing primary care services (making appointments, contacting professionals, alternatives for face to face appointments) Using technology to monitor health and share data with professionals Our View We would fully support all of the above views, we need to do more to improve digital access to health and care records, and to primary care services. GP systems are not fit for current purpose, access to services via telephone remains the norm and likely the biggest source of dissatisfaction from people trying to access appointments and information. People should have more access to their own information, the GP as the “information owner” is outdated. Current systems are also a barrier to primary care modernisation – A single shared record rather than practice based records would enable practices to work better together and enable multidisciplinary health and care supports to design person centred models of care rather than practice based models of care. The use of technology for monitoring in the community is currently growing positively from a telecare perspective but home and health monitoring is very limited, blood pressure monitoring is starting to be used but we have a long way to go, individuals are more likely to identify and use their own applications. Local communities have discussed ideas on better use of telecare. We have been carrying out presentations within communities on how technology can be utilised to support adult’s
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health and well- being at home and these have been positively received, we need to do more of the same. Increasing broadband coverage will also assist. Community Wide Approach to Wellbeing The priorities from the panel are; • Social prescribing – support for physical activity & addressing loneliness e.g. promoting walking groups, active social groups, activities making better use of greenspace • Don’t assume loneliness only affects older people. Use of neighbour networks. • Co-location of facilities – multi-use community facilities. Making use of community locations eg places of worship & social clubs, community hubs providing nutrition & cooking classes. • Teaching basic • life skills in schools, & how to access/use health services. • School nurses integrated into community services • Keeping people at home – using voluntary support for home care – or collective care in homely settings (so that staff can care for more people) Survey responses while not looking at the above areas exactly expressed a desire for services in primary care to be expanded, especially testing and diagnostics as well as pain and weight management clinics. Our View Future care will be dependent on educating the public on personal responsibility, co-production and the need to access services appropriately. Improved system navigation is important. Co-location and collaborative working between practices and with other health and care services will be important to maximise the benefit of multidisciplinary working. Current GP Cluster structures and arrangements should be supported and allowed to evolve to enable quality improvement and shape service delivery. This needs to be stronger links with Locality Planning structures in order for professionals to be able to influence funding decisions. We have been working to support the importance of informal supports rather than formal service provision being the only support. This has worked well in terms of community cafes; dementia initiatives including walks, activity based supports; using community venues and care homes for singing groups, befriending schemes and so on. It’s important that we link with wider place based initiatives in local areas. Dementia Friendly approaches have much to offer in terms of inclusive methodologies. Volunteering will become increasingly important but there needs to be limits on expectations for volunteers and more flexible approaches and ideas. Volunteers could support with loneliness and isolation, volunteering within care at home more formally has significant challenge, especially where there are shortages in care at home staff as a workforce. The role of a community link worker is critical in linking between formal and informal supports within a defined geographic area and oversight of what is working well and where the gaps are.
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2. What are the barriers to delivering a sustainable primary care system in both urban and rural areas? Our view..... Public expectations of health and social care services needs open discussion, we need to genuinely work together to create the change. Working extensively with a rural local reference group in Stirling on health and social care suggests this format, ie a local health and care group made up of local people and local services is helpful to discuss the ways in which services operate; levels of demand and realistic expectations of health and social care. Our key message is that we hope communities can work in partnership with services and develop the role of informal supports, most of which will be developed by communities themselves. We need to understand the needs of individual communities and accept the differences. Lack of national resource and co-ordination around self / supported self -care. There is an appetite for better understanding of how care can be delivered more flexibly but adults tell us they find the system complicated. Workforce Supply That there is a need to provide support and resources to build a workforce with the right skills and capacity to deliver services in the community. Professionals must be supported and have adequate capacity to manage clinical care. Current recruitment, retention and sustainability issues make working in the community a difficult and unrewarding experience for many which impacts on future recruitment and retention. Infrastructure /Technology /Lack of access to shared records The Primary Care infrastructure requires to be robust. There needs to be prioritisation, focus and very significant capital investment to maintain and expand our primary care premises to make them fit for purpose and enabled to provide a base for an expanding multi-professional workforce. Agile and interconnected efficient technology is essential to optimise service delivery. There is much to do to arrive at that position. A fit-for- purpose IT infrastructure that enables appropriate and effective information sharing to optimise patient care and safety must be developed and invested in.. Variation in approach, access and outcomes across multiple primary care systems. 3. How can the effectiveness of multi-disciplinary teams and GP cluster working be monitored and evaluated in terms of outcomes, prevention and health inequalities? Reducing health inequalities must be at the heart of this
Primary care outcomes work does identify the key areas which we require to monitor.
• Outcomes for people both individuals and communities
• Outcomes for the workforce (retention, satisfaction etc)
• Outcomes for the system (e.g. are we reducing secondary care need by improving
primary care?
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Our multi -disciplinary neighbourhood care team in rural South West Stirling have carried
out evaluations within local communities.
The outcomes which represent the difference this team are in place to make are as follows:
• Peoples’ needs are met by the right person, first time, every time!
• People have improved health and wellbeing.
• People live at home independently for as long as possible with the right level of
support.
• Staff are valued, motivated and empowered.
A snapshot of lessons learned reports indicate that the community know how we can all
work together to support our health and wellbeing:
• The Community Reference Group consultation demonstrates that members have
increased knowledge about their health and social services as well as informal
support networks.
• “Regular meetings and updates which inform often about services which I wouldn't
have known about”
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM: HEALTH AND SOCIAL CARE ALLIANCE SCOTLAND (the
ALLIANCE)
The Health and Social Care Alliance Scotland (the ALLIANCE) is the national third
sector intermediary for a range of health and social care organisations. It brings
together over 2,700 members, including a large network of national and local third
sector organisations, associates in the statutory and private sectors, and individuals.
Responses to Consultation Questions
1. Considering the Health and Sport Committee's report on the public panels,
what changes are needed to ensure that the primary care is delivered in a
way that focuses on the health and public health priorities of local
communities?
Primary care encompasses the whole range of multi-disciplinary roles which occur in
both primary care buildings (e.g. GP surgeries) and in the local community. The latest
GMS contract envisages that GPs will be general medical specialists supported by a
range of staff operating within a multidisciplinary team1. In our view, this change can
only be achieved if all staff involved are “bought into” a truly multidisciplinary and non-
hierarchical approach to delivery of services across the local community. General
Practitioners comprise just one of these roles, but there are many other staff
members, for instance Allied Health Practitioners such as physiotherapists, podiatrists
and speech and language therapists, who are equally critical in ensuring that a
sustainable model of primary care is delivered. It is vital trust is nurtured across
professional boundaries and that frontline staff are empowered with the autonomy to
do whatever is relevant to meet people’s outcomes.
The investment in Community Link Practitioners/Workers, in various forms
communities across Scotland, is an example of how an ambitious multidisciplinary
approach can work in practice and how the third sector can play a critical role in
developing and embedding new roles and ways of working, supporting the delivery of
a new vision of primary care which aligns with the priorities described by the public in
the Committee’s public panels. Community Link Practitioners support people to build
self-efficacy and self-determination and find things in their community that can help
1 https://www.gov.scot/publications/gms-contract-scotland/
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them to live well. This is focused on creating better health and wellbeing outcomes for
the individual and not simply driving down pressure on primary care.
The ALLIANCE’s Links Worker Programme2
• Originally delivered in seven ‘Deep End’ GP in Glasgow practices since 2014,
soon to expand into at least 27 practices by the end of 2019
• The Community Links Practitioners (CLPs) have worked with around 10,000
people to date
• Most people who see a CLP work with them to address at least 2 or 3 different
issues. More than half of these issues are either related to physical, mental and
social issues.
• Community resources in the localities where the programme is active have
reported an increase in the number of referrals they receive from General Practice
• Importantly, these community resources report that these referrals are now more
relevant to the services that they offer, compared to before the Links Worker
Programme intervention.
ALISS (A Local Information System for Scotland)
The ALLIANCE manages the ALISS programme, which exists to increase the
availability of health and wellbeing information, supporting the wider social
determinants of health. Within the wide scope of the Committee’s inquiry, ALISS
supports the sharing of information on easily accessible and ‘entry-level’ sports and
activities (as opposed to high-performance sports). ALISS is a free to use online
platform which helps people find and share services and activities which support
health and wellbeing. It can be used by people accessing services and social
prescribers alike.
Integration between all forms of primary care and the third sector (and notably the
significant level of innovation from the private sector in this area) is key to achieving a
sustainable primary care system that meets the needs of people who use support and
services. Where it is successfully achieved, such integration has the potential to free
up valuable resource across the multi-disciplinary team and to increase options and
improve access for people and communities.
Other examples of this integration include the relationship between NHS24/NHS
Inform and Breathing Space to provide an alternative and easily accessible ‘first stop’
2 https://www.alliance-scotland.org.uk/in-the-community/national-link-programme/
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confidential service for those experiencing low mood or depression and the NHS24
helpline, operated in partnership with Macmillan, which provides further options for
those dealing with diagnosis and treatment of cancer.
As recognised by the Committee’s public panels, longer term funding for third sector
services is necessary to enable primary care teams to take advantage of the value
that it brings. The funding of third sector services, largely not by the NHS but by
HSCPs or local authorities, is often under threat and removal of these services does
not necessarily consider the wider impact this may have in supporting the primary care
sector through referrals and prevention.
Transformation is also required in the involvement of people with long term conditions
in planning for their care – a key component of the self management approach around
which the ALLIANCE was founded. In keeping with other societal shifts, people expect
to have more say now than ever before on how they will be treated and to be equal
partners is decision making about care and treatment. The House of Care model is an
example of this, underpinned by the principles of person-centred care and rooted in
the assets of local communities. Healthcare professionals together with people who
are living with one or more long-term conditions, work as equal partners, to engage in
a care and support planning conversation addressing the needs of the individual, and
to develop a care plan if appropriate. This conversation draws on the expertise of the
individual living with their condition, taking into account their own health needs,
personal goals and their limitations.
House of Care
House of Care involves redesigning systems to deliver person-centred care, as
opposed to system-driven care based on single disease clinics and services. As well
as attending to patient activation3 and health literacy4 the process involves:5
• A preparatory meeting with a healthcare assistant to collate required information
and discuss how a person-centre ‘care and support planning appointment’ works.
• Materials including test results to be sent with short explanation to the person in
advance of their appointment.
• Significantly extended appointments that use a collaborative conversation to
develop a shared agenda that reflects both patient and professional concerns.
3 www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf 4 www.healthliteracyplace.org.uk 5 www.yearofcare.co.uk/process
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• Proactive linking of patients to sources of help and support that they value.
The House of Care approach helps people be more involved in decisions about their
care and to identify what matters most to them. It also helps people to identify the
resources within their communities which can support them in achieving their goals.
This approach, now been adopted by 10% of GP Practices in Scotland having been
developed in partnership with the ALLIANCE and the Scottish Government6.
This approach, now included in the RCGP curriculum for trainee GP’s, should be
widely adopted across the country and learning from its implementation could be
shared with other similar service redesign processes.
Implementing primary care digital transformation that is person centred
Digital technology is often seen as a helpful solution for some people to access
services. The public panels recommended the use of “email, text and social media for
appointments and prescriptions… (and) Skype or FaceTime appointments with GPs in
particular for those in rural/remote areas and with disabilities.”7
The Scottish Government’s eHealth Strategy suggested a series of measures that
sought to utilize digital technology and whilst progress is being made in some areas,
for example the increasing use of video consultations, in others there has been less
action. For example, the strategy aimed for at least 90 per cent of GP practices to offer
online booking of appointments and repeat prescription ordering by 2017 – however,
with no detailed action plan to accompany this, we understand this target has still not
been met. Further consideration of why these measures have failed to be
implemented to date is required.
Furthermore, we note that Scotland’s ambitious Digital Health and Care Strategy -
launched well over a year ago - doesn’t contain any timescales for delivering digital
services to the public, including those linked to primary care. We believe there is a
clear need for commitments and an associated delivery plan for citizen-facing digital
health and care in Scotland, to spur delivery as well as accountability. This includes
clarifying whether and when Scots will get online access to their health records, as
well as various other digital tools that could potentially support shared decision
making, care and support planning as well as self-management.
6 www.alliance-scotland.org.uk/what-we-do/our-work/primary-care/scotlands-house-of-care 7 https://sp-bpr-en-prod-cdnep.azureedge.net/published/HS/2019/7/3/What-should-primary-care-look-like-for-the-next-generation-/HSS052019R9.pdf
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Electronic patient records
The public panels noted that electronic patient record, shared with all relevant
professionals were a priority for them. The technology exists for there to be live
systems that, in real time, links, collates and analyses data collected by front line
health professionals in a secure manner. Scotland should seek to be a world leader in
developing this and levering the potential of contemporary computer science.
We believe that if they are to attain near universal population coverage they must
incorporate information on the social determinents of health and be designed in a way
that can lead to greater analysis of the relationships between social and biological
indicators and outcomes. This could assist in combating challenge of recruitment of
people from disadvantaged communities into clinical trials/public health studies and
other limitations of the traditional evidence based approach when it comes to tackling
health inequalities.
Out of Hours
The public panels noted the future importance of out of hours (OOH) services and how
they could be improved in the future. We believe that changes are necessary that
enable better shared access to Key Information Summary between professionals,
customer service training for OOH staff and improved signposting to services which
open outside of GP hours.
Health and Social Care Integration
Primary care is a key function of integrated health and social care activity across
Scotland following the Public Bodies (Joint Working) (Scotland) Act 2014.
Governance, planning and resourcing are overseen by Scotland’s integrated joint
boards, which bring together representatives of both the NHS and the local authority.
Some public panel members recommended that the NHS should take over
responsibility for social care from the local authority. We don’t agree with this
recommendation. The vast majority of social care, and support for good
health/wellbeing, is delivered not by statutory services but by individuals themselves,
families, unpaid carers, peer and community-based support and the third sector.
Integration itself should be offering important opportunity to improve connections
between these types of support and statutory services, including primary care.
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2. What are the barriers to delivering a sustainable primary care system in both
urban and rural areas?
Additionally, whilst, in our experience, community engagement tends to be better in
rural areas, often the level of community assets, peer support and choice over
services are limited. Additionally, primary care services are often not well appraised of
the community assets in their local area. This restricts primary care’s ability to refer or
signpost to relevant and helpful local services.
Travel distances, travel costs and work commitments work against people’s ability, or
willingness, to access the range of services offered within primary care. These issues
are often exacerbated for people who live with long term conditions and disabled
people who often experience additional inequalities in each of these areas. For
example, participants in the ALLIANCE’s recent work on the Grampian System wide
Mental Health and Learning Disability Services Review8 “…transport to appointments
or support groups (is difficult) and if you live in a rural area and public transport is poor
- you can’t drive if you are medicated.”
In urban settings, such as those within which we deliver the Links Worker Programme,
some of the key challenges are around the volume and diversity of social determinants
of health and people living with multiple conditions encountered. This presents
challenges for health professionals across roles in that it is seldom one role that can
address all of an individual’s requirements.
Building capacity within workforce development schemes for ensuring
interconnectedness of services and reducing prevalence of complex
exclusion/inclusion criteria is absolutely critical to addressing these issues. Services
must be empowered to work together in a more open, coherent manner, if we are to
meet complex needs of the population. To achieve this, as aforementioned, it is
imperative that a less hierarchical culture, and more autonomous, trusted, frontline
workforce must be fostered. Superfluous, risk averse, bureaucratic processes must
become a thing of the past.
8 https://www.alliance-scotland.org.uk/wp-content/uploads/2019/06/ALLIANCE-Grampian-Final-Report.pdf
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3. How can the effectiveness of multi-disciplinary teams and GP cluster
working be monitored and evaluated in terms of outcomes, prevention and
health inequalities?
As noted in Sir Harry Burns’ Review of Targets and Indicators in Health and Social
Care in Scotland, “The lack of robust primary care data has been a significant
challenge in the drive towards intelligence-led primary healthcare.” Recent
developments such as the Scottish Primary Care Information Resource (SPIRE)
enables GP practices to use data for approved purposes but this is limited in terms of
the scope of effective monitoring and evaluation of new approaches to work.
Developing a variety of qualitative and quantitative means of identifying these impacts
should be a key priority for the implementation of any proposed changes.
The effectiveness of any intervention can only be suitably identified if it adequately
assesses the impact on the individual and their experience. Often data is collected on
service change that reflects too much on information that can be too easily collected
by the existing system (often quantitative) and does not prioritise people’s
experiences. One example of this in the health and social care system has been the
roll out of self-directed support in Scotland, where data is currently collected on the
number of people who use social care who have been given a choice but not on their
experiences9. This is why the ALLIANCE and Self Directed Support Scotland are
running the My Support My Choice research project focussed on service users’
experiences of self-directed support10.
At the same time ISD Scotland should be encouraged to consider operational
measures which can appropriately evaluate the value of multi disciplinary, both to the
health and social care system and the wider community. Often this misses out key
local data from the third sector – this should be addressed.
For more information
Contact: Andrew Strong, Assistant Director (Policy and Communications)
Email: [email protected]
Gerry Power, Director of Integration
Email: [email protected]
9 https://www.gov.scot/binaries/content/documents/govscot/publications/statistics/2018/08/self-directed-support-scotland-2016-17/documents/00539169-pdf/00539169-pdf/govscot%3Adocument/00539169.pdf 10 https://www.alliance-scotland.org.uk/blog/news/my-support-my-choice-sds-research-project/
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Telephone: 0141 404 0231
Website: http://www.alliance-scotland.org.uk/
About the ALLIANCE
The ALLIANCE’s vision is for a Scotland where people of all ages who are disabled or
living with long term conditions, and unpaid carers, have a strong voice and enjoy their
right to live well, as equal and active citizens, free from discrimination, with support
and services that put them at the centre.
The ALLIANCE has three core aims; we seek to:
• Ensure people are at the centre, that their voices, expertise and rights drive policy
and sit at the heart of design, delivery and improvement of support and services.
• Support transformational change, towards approaches that work with individual
and community assets, helping people to stay well, supporting human rights, self
management, co-production and independent living.
• Champion and support the third sector as a vital strategic and delivery partner and
foster better cross-sector understanding and partnership.
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM: NHS HEALTH SCOTLAND, INFORMATION SERVICES
DIVISION AND HEALTH PROTECTION SCOTLAND
This submission is co-authored by the following NHSScotland organisations:
• NHS Health Scotland1, which works to improve health and reduce health
inequalities.
• Information Services Division2 (part of NHS National Services Scotland), which
provides health information, health intelligence, statistical services and advice.
• Health Protection Scotland3, (part of NHS National Services Scotland), which
focuses on protecting the people of Scotland from infectious and environmental
hazards.
We are submitting a single response because the three organisations above will
become part of the new national public health agency in Scotland – Public Health
Scotland – on 1 April 2020. Public Health Scotland’s remit will involve providing
national leadership around realising Scotland’s new Public Health Priorities,4
including supporting primary care’s contribution to public health.
Contact details
If you have any questions or require further clarification on any point, please contact:
Elspeth Molony
Organisational Lead for Policy and Outcomes
NHS Health Scotland
Response
Question 1: Considering the Health and Sport Committee's report on the public
panels, what changes are needed to ensure that the primary care is delivered
in a way that focuses on the health and public health priorities of local
communities?
Reducing health inequalities
1. There is evidence that making services universally available and accessible to all
people in proportion to their need (proportionate universalism) helps to reduce health
inequalities and improve the health of the whole population.5 This applies across
1 https://www.healthscotland.scot/
2 https://www.isdscotland.org/ 3 https://www.hps.scot.nhs.uk/ 4 Scottish Government and COSLA. Public Health Priorities for Scotland. June 2018. 5 The Institute of Health Equity. Fair Society, Healthy Lives: The Marmot Review. 2010
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public services, including primary care, and is advocated for by the Deep End GPs.6
The idea is that:
“For those in the best circumstances, they and their communities need least support
and intervention from public services. For those in the poorest circumstances,
experience of poor health and its determinants is pervasive and leads to low-quality
and reduced length of life. People in these circumstances, and in varying degrees,
on the inequalities gradient, need support according to their need – an approach
termed proportionate universalism.”7
2. This approach would help tackle the Inverse Care Law, which states that “the
availability of good medical care tends to vary inversely with the need for it in the
population served.”8 The practical consequences of the Inverse Care Law limit the
capacity and capability of practices operating in disadvantaged areas to address
health inequalities and respond to public health challenges.9,10 ,11
3. Health inequalities are the unfair differences in people’s health across social
groups and between different population groups.12 There is a significant body of
evidence that the fundamental causes of health inequalities are rooted in the political
and social decisions and priorities that result in an unequal distribution of income,
power and wealth across the population and between groups.13
These fundamental causes influence the distribution of wider environmental
influences on health, such as the availability of good quality housing, work, education
and learning opportunities, as well as access to services, including GP services.
Variations in access to primary care services experienced by different population
groups can perpetuate and worsen inequalities.14
4. To be effective at mitigating health inequalities, the way in which primary care
services are delivered should be proportionate to need and also adaptable to the
needs of people for whom standard pathways are not accessible. This may be due
to, for example, socioeconomic constraints, low health literacy, language issues, or
sensory impairment.15
5. Together we lead the Scottish Public Health Observatory (ScotPHO), which
published two reports16, 1717 earlier this year which show that health inequalities are
worsening in Scotland and that socioeconomic position is increasingly impacting on
6 GPs at the Deep End. Deep End Report 32: Project for 2019-2022. June 2019. 7 NHS Health Scotland. Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities. June
2013. 8 J T Hart. The inverse care law. The Lancet Volume 297, Issue 7696, 27 February 1971: 405-412 9 British Journal of General Practice What can the NHS do to prevent and reduce health inequalities? 2013; 63 (614): 494-495. 10 British Journal of General Practice. General practice funding underpins the persistence of the inverse care law: cross-
sectional study in Scotland. 2015; 65 (641): 799-805. 11 Deep End GPs. Deep End Report 32: Project for 2019-2022. June 2019.
12 NHS Health Scotland. Health inequalities: What are they? How do we reduce them? July 2015. 13 NHS Health Scotland. Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities. June
2013. 14 NHS England. Improving access for all: reducing inequalities in access to general practice services. September 2018. 15 NHS Health Scotland. Maximising the role of NHSScotland in reducing health inequalities. June 2017. 16 Scottish Public Health Observatory. Recent adverse mortality trends in Scotland: comparison with other high-income
countries. February 2019.
17 Scottish Public Health Observatory. Socioeconomic inequality in recent adverse mortality trends in Scotland. February 2019.
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how long we live for, and how long we live in good health. Life expectancy in
Scotland has stalled and in our poorest areas, life expectancy has actually
decreased. This underlines just how important it is that concerted action is taken to
improve and protect health and people’s right to the highest attainable standard of
health, and to reduce health inequalities.
6. The Royal College of General Practitioners (RCGP) recommends18 the following
action to enhance the ability of general practice to respond to health inequalities and
other public health challenges:
a. Increase the overall size of the GP workforce and use incentives to attract more
GPs to under-doctored areas, particularly in areas where patient need is highest.
b. Rebalance resources towards general practice and wider primary care services,
especially in those areas where health inequalities are worst.
c. Ensure new models of care tackle, rather than exacerbate, health inequalities.
d. Create a supportive environment for GPs and their teams to take a more proactive
population based approach to preventing ill health.
e. Focus on continuity of care particularly in areas where a high number of patients
are living with multiple morbidities.
f. Fund outreach programmes to help excluded groups such as those with mental
health problems, learning disabilities and the homeless to access general practice.
7. Further, conducting Health Inequalities Impact Assessments (HIIAs) can help
ensure that actions taken by general practice reduce, rather than exacerbate, health
inequalities.19
Integrating public health and primary care
8. A well-integrated health and social care system underpinned by a strong primary
care infrastructure should be a sound basis for ensuring a focus on the health and
public health priorities of local communities in Scotland. Further, there is evidence
that such a system, incorporating a strong public health approach is necessary in
order to achieve the optimum health of the population and individual patients.20, 21
9. The World Health Organization (WHO) conducted a review of different
approaches to integrating public health and primary care in particular and identified
“five primary care strategies and operational changes needed to integrate public
health actions into primary care”.ibid These are:
- Targeting health improvement actions and resources to the most disadvantaged
areas.
18 Royal College of General Practitioners. Treating Access: a toolkit for GP practices to improve their patients' access to primary
care. 2014. 19 http://www.healthscotland.scot/tools-and-resources/health-inequalities-impact-assessment-hiia/what-is-an-hiia
20 Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. 2012. 21 World Health Organization. Primary health care: closing the gap between public health and primary care through integration.
2018.
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- Building capacity in primary care to deliver proactive promotion and preventive
care.
- Working beyond basic, essential and limited packages of care to a full range of
services needed for first contact with the health system.
- Providing early interventions to prevent escalation of health care needs.
- Taking a broader perspective so that care for individuals is framed in the context of
population outcomes (e.g. equity and social cohesion).
10. Further to these strategies, the WHOibid identified several possible models
through which to achieve the integration, four of which are relevant for consideration
and comment within the Scottish context:
a. Public health professionals integrated into primary care: in Scotland this could
include alignment of local public health staff to GP clusters and support from the
Local Intelligence Support Team (LIST) (see paras. 20 - 21 below).
b. Public health services and primary care providers working together: exploration of
this is being taken forward by a group brought together by the Scottish Public Health
Network (ScotPHN). A key recommendation emerging from the discussions is the
creation of a national Primary Care Public Health Network. In addition to local and
national public health leaders, this would include GPs, dieticians, district nurses,
practice nurses, pharmacists, physiotherapists, and podiatrists. The idea is to create
an environment within which general practice and wider primary care teams are
supported and encouraged through data, skills and evidence provision to better
address local and regional population health challenges through more effective
planning.
c. Multidisciplinary training of primary care staff in public health: there is UK level
evidence that many GPs lack the skills and knowledge to deliver effective public
health interventions.22 In the future, Public Health Scotland will be well-placed to
explore mechanisms for development of such skills and knowledge with NHS
Education for Scotland.
d. Building public health incentives into primary care: consideration could be given to
including actions relating to the Public Health Priorities in Phase 2 of the General
Medical Services (GMS) contract negotiations and/or the next iteration of GP cluster
guidance.
Prevention activity
11. There is evidence that appropriately targeted prevention activity, including ‘brief
interventions’ by GPs, are effective at improving health and are economically cost
effective.23, 24,25 It is also acknowledged that the childhood and adult immunisation
22 The King’s Fund. Health Promotion and Ill-health prevention. 2011. 23 Saha S. et al. Are Lifestyle Interventions in Primary Care Cost-Effective? – An Analysis Based on a Markov Model,
Differences-In-Differences Approach and the Swedish Björknäs Study. 2013. 24 The King’s Fund. Transforming our health care system. 2015.
25 Ngalesoni, F. N. et al. Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular
disease in Tanzania: a Markov modelling study. 2016.
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programmes, currently being revisited through the Vaccine Transformation
Programme,26 continue to make significant contribution to vaccine preventable
disease.
12. In addition to a lack of skills and knowledge, GPs identify lack of time, competing
priorities, workforce shortages, lack of support systems, and remuneration issues as
barriers to undertaking public and population health-focused activities, including the
prevention and early detection of disease.27
13. Longer appointment times delivered through GMS contract changes should allow
greater scope for such activity relating to smoking, weight, diet, exercise, alcohol and
drugs. Primary and secondary prevention of cardiovascular, stroke and respiratory
disease, diabetes, cancer and osteoporosis would be enhanced by such efforts.28
14. If GMS phase 1 changes are successful in delivering reduced workload for GPs
and their teams, increased capacity may be available for population health
approaches in key public health priority areas.
15. Ensuring equitable access to primary care is also central to delivering preventive
medical interventions and providing a gateway to a health-care system that delivers
effective interventions for the major causes of mortality, including cancer and
cardiovascular disease.29
Enabling wider use of information and intelligence in primary care
16. To improve health and reduce inequalities it is necessary to understand the
health of a local community and the factors that shape it. Access to good quality
information and robust data is crucial to this. While there is a wide range of relevant
data sources available already, more needs to be done to assist GP Clusters and
others working in primary care to access and use the information and intelligence
they offer.30
17. ScotPHO brings together a wide variety of high quality data, profiles and reports
on the health of Scotland’s population. This includes online profiles which provide a
wide variety of data for local areas.31 Greater use of this sort of information would
help primary care to be delivered in a way that focuses on the health needs of local
communities. A key part of our mission as we move towards Public Health Scotland
is to continue to improve all the information tools and products we provide to make
information more accessible and relevant.
18. An important asset available locally are ISD’s Local Intelligence Support Team
analysts (LIST). This dispersed team offer analytical capacity and capability to
Health and Social Care Partnerships and to GP clusters in particular. They offer
access support in the use of a wide range of data, drawing on national and local
sources as appropriate. Examples might be profiling local populations, projecting
26 http://www.healthscotland.scot/health-topics/immunisation/vaccination-transformation-programme 27 The King’s Fund. Health Promotion and Ill-health prevention. 2011. 28 The King’s Fund. Transforming our health care system. 2015. 29 Gulliford, M. Access to primary care and public health. 2017. 30 ISD Scotland. A Guide to Primary Care Data Sources. April 2018. 31 https://www.scotpho.org.uk/comparative-health/profiles/online-profiles-tool
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future demand and looking at alternative models of service delivery and care –
information that can help find potential answers to complex problems.32
19. LIST works with GP Clusters across Scotland to support Cluster Quality working,
in particular intelligence-led influence and decision making. For example, GP Cluster
intelligence profiles using ISD data are being piloted by senior public health staff in
NHS Greater Glasgow and Clyde to act as a catalyst for data quality discussions and
agreed approaches to improving local population health.
20. There already exists a range of different insights drawn from national data that
are potentially important locally. Examples include the Burden of disease data33 and
infectious disease burden data which can also be used to model current and future
demand related to public health priority areas. Using standardised disease
prevalence rates could help partnerships and clusters to understand local population
health priorities, gaps in service provision and priorities for service development.
21. Among other relevant initiatives that are underway, we are developing public
health intelligence systems for measuring inequalities in access to health and social
care services, quality of care and treatment received, and health and social care
service outcomes by area-based deprivation classification. These could be used by
Health and Social Care Partnerships and GP clusters to aid the mitigation of health
inequalities using locally targeted service developments and interventions.
Question 2. What are the barriers to delivering a sustainable primary care
system in both urban and rural areas?
22. The barriers to delivering a sustainable primary care system in both urban and
rural areas are acknowledged to be complex and multifactorial. The barriers cross
over into issues for other sectors, including third sector sustainability generally and
also specific issues facing the sector in remote and rural areas.34
23. There is significant overlap between the changes needed to ensure that primary
care is delivered in a way that focuses on the health and public health priorities of
local communities highlighted in our answer to question one above, and the barriers
to delivering a sustainable primary care system. For example the Inverse Care Law
(see para. 4 above) and the barriers to undertaking public and population health-
focused activities identified by GPs (see para. 14 above) are significant barriers.
24. A greater focus on prevention activities across the wider public health system
could help with sustainability of the primary care system in both urban and rural
areas. Through public health reform, the Scottish Government has stressed the need
to tackle the social and economic determinants of health “and the need to
increasingly move towards the prevention of illness.”35 The ambition is to create “a
genuine ‘culture for health’ where citizens achieve the highest attainable standard of
health by both taking - and being empowered to take - responsibility for their own
32 https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Local-Intelligence-Support-Team/GP-
Clusters/ 33 http://www.healthscotland.scot/health-inequalities/impact-of-ill-health/burden-of-disease-overview 34 Scottish Council for Voluntary Organisations. Third Sector Forecast. January 2019. 35 Scottish Government. New national public health body 'Public Health Scotland': consultation. May 2019.
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health and care, within an enabling environment that makes it possible for them to do
so.” Public health Scotland will have a crucial role in supporting the public health
system, of which GPs are a vital part, to work collaboratively to realise this shift to
prevention.
25. A number of briefings and reports from the Royal College of General Physicians
and the British Medical Association outline the issues from the perspective of the
profession and made recommendations. This includes the policy paper from the
Royal College of General Physicians Being Rural: exploring sustainable solutions for
remote and rural healthcare36 and the British Medical Association’s “urgent
prescription for general practice.”37
26. The Scottish Government established a short-life working group in 2016 in
recognition of the sustainability challenges facing practices across Scotland. The
Improving Practice Sustainability Group made recommendations in November
201638 and provided an update on progress towards implementation of the
recommendations in November 2019.39
27. With the majority of patient contact with the NHS occurring in primary care,
general practice is central to the delivery of effective public health interventions.
Issues of capacity and resource giving rise to current concerns regarding the
sustainability of general practice services are likely to have a direct bearing on the
ability of primary care to engage in the delivery of effective population health
improvements over time.40
Lack of reliable data
28. There has been a lack of reliable data on workforce and workload capacity at a
primary care level, which is a potential barrier to delivering a sustainable primary
care system in both urban and rural areas. This may be remedied, at least partially,
by means of a new initiative (involving ISD) that is currently underway to gather data
from general practices.
29. There is also a lack of geographical analyses of data on the need for and supply
of primary care services. Such data could be used to reveal variation, desirable or
not, across similar or diverse environments and specifically contrast needs and
supply of primary care in urban and rural areas.
30. Geospacial analyses could help ensure appropriate access to services wherever
they are based; identify variation in need and capacity by geography; and support
joint planning of community functions and delivery of integrated services in both
urban and rural settings.
36 The Royal College of General Physicians. Being Rural: exploring sustainable solutions for remote and rural healthcare.
August 2014. 37 British Medical Association. Responsive, safe and sustainable: our urgent prescription for general practice. April 2016. 38 Scottish Government. Improving Practice Sustainability Recommendations of the Short Life Working Group Report.
November 2016. 39 Scottish Government. Progress report based on the workings of the Sustainability Working group and the recommendations
of the 2017 Sustainability Report. January 2019. 40 The Kings Fund. Innovative Models of General Practice. June 2018.
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31. Much of the health and social care data about people held nationally carries
postcodes of residence and Community Health Index (CHI) numbers. In some cases
(such as hospital admission) the data explicitly identifies the general practice of the
patient. These data can then be appropriately analysed at different geographical and
administrative levels for a variety of purposes. Equally importantly is that a much
broader account of the patient experience and the whole system can be described
through data linkage (where summary records on health and social care events for
individuals are linked across multiple sources and over time). This well established
process, with its appropriate safeguards in place, enhances understanding of the
health and care system and local populations.
32. The on-going development of the Scottish Primary Care Information Resource
(SPIRE)41 should, over time, contribute more and more to the intelligence available
to primary care. SPIRE provides a tool for GPs to build their own reports from the
patient information collected within the practices. In the future it will also allow
extracts of summary information for use at cluster and national level for a variety of
statistical and research purposes including geospacial analyses as required. SPIRE
data will enable greater geospacial analyses thus adding to our understanding of
variation geographically.
33. The creation of Public Health Scotland in April 2020 will also help to tackle this
barrier by bringing together the skills and expertise of Information Services Division,
Health Protection Scotland and NHS Health Scotland. Through evaluation of primary
care health service data and its relationship to the patient journey in secondary care,
PHS will demonstrate the public health impact of treatment and prevention allowing
refinement of patient management at local and national level.
Question 3. How can the effectiveness of multi-disciplinary teams and GP
cluster working be monitored and evaluated in terms of outcomes, prevention
and health inequalities?
34. NHS Health Scotland worked closely with the Scotland Government in the
development of the ten year monitoring and evaluation strategy42 for primary care.
The strategy spans a decade so as to allow sufficient time for the full effect of
changes instigated through primary care reform to be seen throughout the system.
However, while it may take at least ten years to fully achieve the primary care vision
and outcomes,43 the strategy recognises the importance of monitoring the progress
of implementation and evaluating the impact on outcomes in the short and medium
term. We are currently developing a report on the ‘State of Primary Care in Scotland’
which will pull together existing primary care data sources as a baseline for the
strategy, and identify data gaps.
35. The Primary Care Evidence Collaborative supports this work by exploring ways
to generate, coordinate and share primary care evidence on a ‘once for Scotland
41 https://spire.scot/ 42 Scottish Government. Primary care: national monitoring and evaluation strategy. 2019. 43 Scottish Government. Primary Care Outcomes Diagram. 2017.
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basis’ and develop the primary care data landscape. The collaborative co-produced
a detailed outcomes framework44 which maps out the changes that need to happen
to realise the Scottish Government’s vision for primary care over the next ten years.
The framework sets out intermediate outcomes for people, the workforce and the
system.
36. In order to develop an effective monitoring strategy the desired outcomes of any
primary care reforms need to be articulated first. For instance in order to understand
if primary care is better addressing health inequalities in the long-term we would
need to collect data on the impact of the new models of care on different population
groups, such as those experiencing deprivation, people living in urban and rural
settings, and those with protected characteristics.
37. Change in one area will affect other areas and therefore we would caution
against monitoring and evaluating specific areas of primary care reform, such as the
effectiveness of multi-disciplinary teams and GP cluster working, in isolation. Our
recommendation is an approach that looks at individual areas of change in addition
to, and embedded in, a ‘whole system’ approach to the evaluation of primary care
reform.
38. The monitoring and evaluation strategy for primary care is in the process of being
operationalised into a practical evaluation plan. Our recommendation is that this is
done over the next twelve months and that the focus is on evaluating outcomes
based on the GMS Contract and accompanying Memorandum of Understanding
(MoU) 45 in the first instance.
45 Scottish Government. Memorandum of Understanding between Scottish
Government, British Medical Association, Integration Authorities and NHS Boards.
November 2017.
39. The MoU sets out six priority areas for development of services: the Vaccination
Transformation Programme, pharmacotherapy services, community treatment and
care services, urgent care, additional professional roles and Community Links
Workers. Core evaluation questions could be identified that apply to all six of the
priority areas also in addition to questions that are unique to specific professions or
interventions. The evaluation plan should clearly articulate the desired outcomes for
each of the priority areas (including multi-disciplinary teams and cluster working), the
monitoring data required and the resources that would be needed to conduct this
work.
40. Based on our extensive experience in both the fields of primary care and
evaluation, we have found that working together with those who are responsible for
developing and implementing the policy is essential. Therefore we recommend that
evaluation plans are drawn up in conjunction with the relevant primary care
workforce, patient groups, service planners and policy makers. An example of how
this might be achieved is provided in Appendix A.
44 Primary Care Evidence Collaborative. Outcomes Framework for Primary Care. 2018.
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Appendix A: An example of how the effectiveness of multi-disciplinary teams
could be evaluated
Purpose: To identify the most appropriate methods to help us understand how multi-
disciplinary teams (MDTs) are being implemented and what difference they are
making in primary care settings across Scotland.
Suggested approach: Work with stakeholders and subject experts to:
• Establish appropriate short and medium term outcomes which contribute to the
existing long term outcomes for primary care reform articulated by the strategy.
• Explore existing evidence – what do we already know about how MDTs are working
in primary care in Scotland?
• Identify evaluation questions – what do we need to know and how would we
measure achievement of goals?
• Identify and prioritise evidence gaps
• Scope and review data sources for validity, reliability and acceptability
• Develop, test and evaluate proof of concepts to fill evidence gaps with appropriate
methods and data sources
Areas to explore could include:
• What data sources/methods could help to answer questions based on the primary
care outcomes framework about what impact the MDT had on outcomes for:
- people/patients, e.g. health and wellbeing, patient experience, patient satisfaction?
- the workforce, e.g. health and wellbeing, staff experience, staff satisfaction,
recruitment and retention?
- the system, e.g. equality of access, demand, sustainability, efficiency, (cost)
effectiveness, safety and quality?
• The potential of SPIRE, data linkage, experimental studies, statistical modelling,
health economics to inform learning and service development
• How NHS Health Scotland and Public Health and Intelligence (and from 1 April
2020, Public Health Scotland) can work with the wider Primary Care Evidence
Collaborative to complete the knowledge into action cycle and support primary care
improvement plans.
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Potential evaluation questions
Approach/ measures Data sources
What do Primary Care
MDTs look like across Scotland?
How are recruitment and retention rates changing over time?
Secondary analysis of
specified data sources to better understand the shape and size of MDTs by practice characteristics over time
Description of size (headcount and whole time equivalents), shape (profession type, skill mix), governance arrangements, where are they based etc.
Primary Care Workforce
Survey (2009-2017)46
Workforce data extract (2019 onwards)
Primary Care Improvement Plans
What do we know about
the roles undertaken by different professions within MDTs?
Is everyone working to the top of their licence?
Documentary analysis Primary qualitative
research
Scottish School of
Primary Care –National Evaluation of New Models of Primary Care in Scotland 47
University of Strathclyde Evaluation of Pharmacy Teams in GP Practice 48
Local evaluations In-depth case studies
What is the impact of the
MDT on GP workload?
Data linkage
SPIRE Manual data collection,
e.g. week of care audit Appointment book
What impact does the
MDT have on patient outcomes?
Are patients seeing the right person at the right time?
Analysis of the following
by demographic: Consultation rates Waiting times Activity data
Source SPIRE
Morbidity and mortality rates
Prescribing rates Referral rates Unscheduled care use
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How are population
health needs assessments and burden of disease data currently used in workforce planning and what is the potential to expand this?
Documentary analysis Primary qualitative
research
Primary Care
Improvement Plans Interviews/ focus
groups with LIST analysts, GP Clusters and Health and Social Care Partnership Chief Officers
Does the GP footprint
change over time?
Prescribing rates Referrals to secondary
care Emergency admissions
SPIRE Source
What is the public’s
understanding and acceptability of the changes happening and planned in primary care?
Secondary analysis –
do the responses differ by demographics?
Our Voice – Third
Citizen’s Panel Survey on access to healthcare professionals other than doctors49
Health and Care Experience Survey responses to questions around new models of care50
46 http://www.isdscotland.org/Health-Topics/General-Practice/Workforce-and-Practice-Populations/Workforce/national_primary_care_workforce_survey.asp 47 Scottish School of Primary Care. National Evaluation of New Models of Primary Care in Scotland. January 2019. 48 University of Strathclyde. Evaluation of Pharmacy Teams in GP Practice. November 2018. 49 Our Voice. Citizen Panel Survey on access to healthcare professionals other than doctors. January 2018. 50 https://www2.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM Edinburgh Health & Social Care Partnership
1. Considering the Health and Sport Committee's report on the public panels, what changes are needed to ensure that the primary care is delivered in a way that focuses on the health and public health priorities of local communities.
- What would be useful is consideration of ‘what is a community?’ The citizens of Edinburgh see themselves in c150 ‘natural communities’ ie one per 3000/4000 people. Only primary care provides a recognisable local service at that level. In contrast, we refer to ‘locality’ communities – populations of over 100,000 not recognised by the public – although helpfully now by all public services and the Third Sector (in Edinburgh).
- There is also need for clarity about the question posed; is Primary Care shorthand for GMS, for GMS + the attached and aligned healthcare teams, or non hospital delivered healthcare.
- There may be merit in establishing sub cluster areas with interlocking practice boundaries as a meaningful way to engage the public about primary care, and in turn to start a long term dialogue about how to support better health and an adjusted relationship with services across the community. Local flexibility remains key in view of the long experience of initiatives to establish the required relationships; none of which have endured.
- Primary care is not established to focus on the priorities of local communities – its priority is the (ill) health needs of individuals, and before clusters no consistent capacity or encouragement was given for this.
- It is difficult for Primary Care to ‘engage’ with its local community – partly lack of capacity but also lack of an acknowledged and representative mechanism for doing so. GPs in particular, are more likely to trust the feedback they receive directly from c30 individual members of the public every working day.
- Early days! - The major public health challenges facing local communities; poverty, alcohol, drugs,
violence, antisocial behaviour, parenting, housing and social isolation, all require a much broader approach than primary care. This has been rehearsed for decades, but we don’t organise public services in a way which is coherent or effective for disadvantaged communities. ‘Failure demand’ remains a popular observation, rather than a stimulus for sustained change. Collaboration and integration are well recognised prerequisites, seldom supported by aligned resources, reporting and accountability frameworks.
- Any sustainable local partnership to address medium and long term priorities needs to be locally accountable and again, all parts of public service are resistant to the potential professional implications of this. Impasse.
- The report is useful in confirming the understanding that people are not resistant to seeing a broad range of healthcare professionals and making better use of technology.
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- Many of the responses however, reflect the views of those who are able to make use of Primary Care as it is currently organised. There is challenge in how we capture the views of people who do not use Primary Care effectively and the reasons why.
- The development of a suite of potential quality markers which would allow us to assess long term changes in the health of economically deprived populations at a level relevant to primary schools (see below) and GP practices would be welcome. The potential sensitivity of some of this eg drug related deaths/domestic abuse/children under care system, being reported at a local level is understood. Nevertheless, unless we can make public health priorities and tackling inequalities a clear expectation at the service delivery level, we will not move beyond thoughtful observation to purposeful intervention.
- Quality markers seen as directly relevant to a broad section of public services/local communities would be welcome.
2. What are the barriers to delivering a sustainable primary care system in both urban and rural areas?
- Short and medium term shortages with particular staff groups are well rehearsed elsewhere and widely understood, particularly in the context of the implementation of the new GMS contract
- Rural and urban areas have inherently different challenges in the development of their workforces; opportunity of specialisation/segmentation and requirement for generalised skills for smaller populations.
- One of the significant barriers is the lack of investment in primary care premises and the physical condition of a sizeable proportion of current inner city premises
- NHS processes make securing available land on a commercial timescale very difficult, even when funding is available
- The separation of responsibility for sustained and large scale house-building from the provision of primary care premises is long overdue as a statutory amendment to Section 75 provision. Primary education, transportation and primary care are the front line of public service provision for expanding and new communities, yet Primary Care has no statutory provision.
- Several attempts have been made to establish this principle in Edinburgh, as part of the ‘Supplementary Guidance’ supported by Edinburgh Council Planners. To date Scottish Government has not permitted the adoption of this guidance.
- The balance between ‘local’ as understood by the public in urban areas ie one mile from where they live, and local as defined by public services can be very different (see previous comments)
- The issue of ‘access vs. continuity’ would benefit from sustained focus. Our local insight suggests that c30% of the population don’t use primary care in any given year, 60% make incidental use where access is paramount and 10% rely on sustained relationships (continuity) for effective care. The trick is how the balance between the two reconciles demand with need.
- The application of technology in primary care has progressed slowly, despite 20 years of ‘prioritisation’. This needs to move beyond exhortation and the focus on large scale systems, to the ongoing development of useful technology keeping pace with the prevalence of social media.
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3. How can the effectiveness of multi-disciplinary teams and GP cluster working be monitored and evaluated in terms of outcomes, prevention and health inequalities?
- In Edinburgh we have defined our currency of augmentation to be in medical sessions eg a full time Primary Care Mental Health Nurse embedded in Primary Care team with prescribing qualifications will augment capacity by the equivalent of 4-5 medical sessions.
- This approach had allowed us to define/estimate the City wide capacity gap (c600 weekly sessions) and how our implementation of the New Contract resources relates to this (c200 sessions to date).
- GP Clusters continue to develop at different paces, mainly related to the experience of those who have been selected to participate by their practices. We are not sure whether the attempt to define outcomes for the clusters would add anything at this stage. Nevertheless, the thoughtful provision of practice and cluster information stimulates the debate, as does access to national data sets. Practices within the same cluster often serve populations with quite different populations and may not value the relevance of local averages. The unit of accountability in Primary Care firmly remains the individual practice.
- Although not directly related to evaluation of outcomes – the success of the new roles is highly reliant on effective evaluation and support. Any framework for this will naturally include assessment of both individual and collective MDT impact. This starts with the current focus on workload impact, but will develop into a broader assessment of what primary care can contribute including and beyond its established role in the treatment of ill health.
- The lack of any national benchmarks for primary care beyond comparative prescribing remains puzzling. This would be readily achieved and allow a stimulating dialogue to develop across and between systems. Placing this expectation vaguely with Clusters is almost guaranteed to frustrate all parties.
- In Edinburgh we have formed 5 ‘demand groupings’ based on age profile and deprivation. This allows our 70 practices to recognise other City practices which serve similar population types, facilitating more meaningful comparison and linkage across the City. This approach does not need to be confined to Edinburgh and would benefit from the addition of practices from other areas serving similar populations.
- Critical outcomes which are sought in Edinburgh are the continued absorption of new population despite ‘restricted’ lists, and the stability of the practice teams themselves.
- Admissions to hospital are already low per 1000 population, but we believe that steady progress is being made in understanding how further reductions might be made through the segmentation of the (admitted/at risk of admission) population. Asthma and falls prevention are obvious areas which lend themselves to a programme approach – already begun by our Long Term Conditions team.
- Health inequalities cannot be effectively tackled directly and solely by primary care – the insights of primary care are however vital to the multi- agency and multi sector approach which is required for long term change in the health status of a population.
- Primary Care does a great deal to mitigate the effects of health inequality and has insight into the effective behavioural strategies which constitute effective preventative strategies
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- Making use of naturally occurring communities for health interventions may be a useful way forward. Using Place Making tools to explore the community assets within defined geographical areas - this would include access to transport, to shops; to greens spaces – factors we know that influence health behaviours,
- Primary Care together with Primary Schools (and to a lesser extent libraries), are perhaps the obvious public services with both the reach and local credibility, to lead (or better - to provide the public sector support to community leadership) the coherent and sustained change to public health outcomes which is required.
- It is instructive to compare the public sector focus on delayed discharges, with the focus on rising mortality in some sections of our population.
David White
Primary Care Strategic Lead
Edinburgh Health & Social Care Partnership
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SUBMISSION FROM: Voluntary Health Scotland
12th September 2019
Introduction
Voluntary Health Scotland (VHS) is the national intermediary and network for health
charities and other third sector organisations with an active involvement in health. We work
with our members and other partners to address health inequalities and to help people and
communities live healthier and fairer lives. We are Secretariat to the Cross Party Group on
Health Inequalities. Our vision for the future of primary care is for an effective, person
centred and compassionate system that understands its role in addressing health
inequalities, and that is confident and able to work with third sector partners.
Our response has been informed by our members’ work, our involvement in the public
health reform programme, and by three recent VHS reports:
Living in the Gap, our 2015 study into the voluntary health sector’s approach to
health inequalities, with case studies that focused in particular on our sector’s role in
mitigating health inequalities.
Gold Start Exemplars1, our 2017 study commissioned by the Scottish Government to
map the wide range of third sector initiatives across Scotland that deploy community
link working approaches. Community link workers aim to tackle health
inequalities and improve health and well-being, as well as reducing pressure
on general practice, particularly in areas of deprivation.
The Zubairi Report2, our 2018 study into the lived experience of loneliness and social
isolation. This was primary research that involved speaking to 57 individuals through
5 focus groups and 6 in-depth interviews. One of the major themes to emerge was
the need for compassionate health and care services and the role of primary care in
addressing loneliness and social isolation at a community level.
VHS is playing an active role in the public health reform programme, our role being to ensure
the effective engagement of the third sector: for example, through the development and
implementation of the six national public health priorities. By influencing the wider social and
economic determinants of health, public health can play a role in supporting primary care to
be as effective as possible.
Question 1: Considering the Health and Sport Committee’s report on Public Panels,
what changes are needed to ensure that primary care is delivered in a way that
focusses on the health and public health priorities of local communities?
Operationalising Realistic Medicine
The Chief Medical Officer for Scotland, Catherine Calderwood, introduced the concept of
Realistic Medicine3 in her 2016 Annual Report. The aim of realistic medicine is to put the
1 Gold Star Exemplars: Third Sector Approaches to Community Link Working Across Scotland 2 The Zubairi Report: the lived experience of loneliness and social isolation in Scotland 3 Realising Realistic Medicine: Chief Medical Officer for Scotland annual report 2015-2016
HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
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person receiving health and care at the centre of decision-making and create a personalised
approach to their care. It does this by ensuring health professionals deliver healthcare that
focuses on true value to the patient and where the patient is an equal partner in their own
healthcare through shared-decision making.
It is clear that that moving away from a purely medical model to a more holistic approach to
people’s health and wellbeing would help to ensure a person centred approach and align
with principles of realistic medicine. Maximising the roles of the current primary care
workforce, including community link workers, and working in partnership with the third sector
to engage effectively with people in local communities and support them to achieve positive
health outcomes, can help to operationalise realistic medicine. This also resonates with
many of the Inquiry’s public panels’ priorities: for example, sustained relationships with
health staff who know individuals, greater engagement and consultation with patients about
services, more effective triage and accessible information about referrals and signposting to
services.
Compassionate Health and Care
VHS research into the lived experience of loneliness and social isolation, The Zubairi Report,
found that, whilst NHS values are embedded in compassion, this is in practice not
everyone’s experience of primary care. What people want is to be listened to, understood
and supported.
Participants in our study highlighted the time pressures that GPs were under, and
understood that this was an underlying cause of what they experienced as a lack of
compassion in the care they received. One participant commented that, “GPs are far too
busy, they have 10 minutes to deal with you and they are looking for a physical health
issue”. Another participant with both physical and mental health issues felt constrained about
discussing all of the issues affecting them with their GP: “the GP has a 10 minute slot and a
lot to fit in. So it becomes a case of we don’t have time to discuss all of this today so we will
make you another appointment in 4 weeks. Sometimes you are given a number for self-
referral – and it feels like the doctor has taken it out of their own hands and made it your own
responsibility. If you are depressed and lonely how can you go and phone that number or
use a service – you will end up going back to that empty house and the same
circumstances”.
Others spoke of their experiences of compassionate health staff elsewhere in the system. A
recently bereaved carer recounted that it was her gynaecologist who picked up on her
situation. She said, “the gynaecologist was the only one to ask me about myself and how I
was doing – she looked at me as a person and actively listened and recognised the issue.”
Our research found that it is important for primary care to do more to understand the nature
and importance of compassion, in order to improve people’s experiences of its services. The
Chief Medical Officer for Scotland has also recognised the importance of compassionate
health and care services, and the Royal College of Physicians of Edinburgh dedicated a
conference to discussing, ‘How compassionate is our NHS?”4.
Multidisciplinary teams and holistic support
Deployment of multidisciplinary teams should help to alleviate the time pressures that the
primary care work force faces, maximise best use of available resources, and help to provide
4 Royal College of Physicians of Edinburgh conference A Patient’s Tale
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more holistic and joined up support to patients. It should help shift the focus of primary care
towards prevention and early intervention by ensuring patients can get the right support at
the right time. Some participants in The Zubairi Report research said they wanted to see
more prevention, “NHS has to shift from being about fixing people to being about preventing
people from becoming broken”.
Currently a barrier to voluntary organisations being an effective community resource and
partner with primary care, i.e. to assist in providing joined up support to people in the
community, is the complexity of local geographic infrastructures as they are not aligned.
Health and social care localities. GP clusters and community planning partnership localities
all comprise different geographic areas. This can cause difficulties for voluntary
organisations receiving funding to provide a service in a particular locality, community and/or
postcode area but not others.
Community Link Workers
The Scottish Government is committed to creating an additional 250 community link workers
(CLW) during the current Parliamentary session. The stated aim is to provide additional
support to primary care in Scotland’s most deprived areas (SNP Manifesto 2016). The
University of Glasgow’s evaluation of the Deep End Link Worker Programme in 2017
(commissioned by the Scottish Government) showed that patients referred to a CLW
experienced a range of positive ‘soft’ outcomes such as improved mental wellbeing and
increased confidence. While the number of GP appointments with patients using CLW
services did not necessarily reduce, the quality of conversations with the GP did improve.
The new CLW roles are designed, planned and commissioned by Health and Social Care
Partnerships (HSCP), based on assessment of local need, and through discussion with local
GP’s, patients and local community based organisations. An unknown number of these
posts have been provided within the third sector. CLWs need to have strong local knowledge
and relationships with local services and resources if people are to be successfully linked
into them.
A new briefing5 by the Scottish Public Health Network (ScotPHN) draws attention to a
number of challenges. Whilst the manifesto commitment focussed on additional CLW
support being provided to ‘Scotland’s most deprived communities’, the funding allocation for
CLW has been distributed via the NHS Scotland Resource Allocation Committee (NRAC)
formula which is adjusted for, rather than based on deprivation. Given the pressures facing
HSCPs, ScotPHN say that it is unclear whether or not they will all prioritise the CLW
resource to working with GP practices in their most deprived communities. This is a question
the Inquiry might usefully seek an answer to. There is anecdotal evidence that austerity and
ongoing cuts to funding third sector and community based organisations are constraining
their ability to provide support and services to people ‘linked’ to them. The capacity of CLW
to respond to new referrals is in turn being constrained, as they need to provide ongoing
support to people until appropriate community based support and services become
available. Like ScotPHN, VHS would call for robust monitoring and reporting of how CLW
resources are being used, so that their impact on reducing health inequalities can be
assessed.
5 https://vhscotland.org.uk/kates-blog-rights-of-way-what-affects-older-adults-walking-to-stay-healthy-and-happy/
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Recognising socio-economic circumstances
Primary care, with its local knowledge of patients and communities, has a role to play in
helping to identify and highlight the wider socio-economic determinants of health in their own
area. That intelligence should be informing how primary care works in partnership with
others across the community to plan services, and in how they engage and support patients.
The impact of deprivation on people’s agency is well known, so primary care should look
beyond bio-medical issues and try to better understand how the wider determinants of health
impact on people’s ability to make decisions about their own health and wellbeing. Professor
Sir Michael Marmot has described the 30-70 split whereby 30% of health issues are caused
by disease, genetic factors or medicalised issues and the remaining 70% are due to social,
environmental and economic circumstances.
There also needs to be a more sophisticated approach to deprivation so that investment is
directed accordingly. Local Authorities with low SIMD levels overall nonetheless all contain
multiple pockets of deprivation. Whilst we are not in a position to comment on how this
affects investment in primary care, we do know that voluntary health organisations operating
in what may be deemed more affluent areas typically have less funding options, which
impacts on the services they are able to provide and reduces community capacity.
Working with the third sector
The strength of third sector organisations is their ability to engage and develop the trust of
vulnerable people in a way that statutory services sometimes find hard to do. There is
significant scope for our sector to be a much stronger partner for primary care in the future.
VHS’s report, Living in the Gap: A voluntary sector perspective on health inequalities in
Scotland, drew attention to this. One charity commented, “often the individuals who are most
in need are not accessing statutory services, and therefore remain in the shadows of service
provision”. Another charity commented, “The relationship that (the) voluntary sector develops
with individuals in the community is the start of a health behaviour change.” Third sector
organisations can act as a lynchpin or conduit between public services and services users.
The charity CIRCLE6 talked about providing “information and support to help people engage
with health services…including support for families to register with the local
GP…encouraging someone to engage with mental health services…or building confidence
so that an individual is more likely to participate in medical interventions”.
An example of successful cross-sectoral collaboration is the Jigsaw Project7 which involves
a local charity Cope Scotland8 and the Drumchapel and Yoker GP cluster, comprising seven
GP practices. The project developed a whole system learning programme, led by the third
sector and GP cluster, in order to better understand and help to find solutions for people who
experience long term or recurring mental health difficulties and who also face barriers to
accessing and using existing services. The project has identified and sought to correct the
barriers and disruptions at the interfaces between statutory services, third sector,
communities and GP practices.
6 http://circle.scot/ 7 https://vhscotland.org.uk/hildas-blog/ 8 https://www.cope-scotland.org/
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The outcomes of the project include:
(1) The GP cluster has prioritised wellbeing and prevention of burnout as a quality
improvement topic.
(2) Steps have been taken to improve communication between GP practices and NHS
mental health services.
(3) The availability of community-based resources has been strengthened through seed
funding.
(4) Awareness by GPs of community based resources and alternative sources of support for
patients has been improved.
(5) The problems and possible solutions have been more clearly defined from a variety of
perspectives, reflecting a ‘whole system’ ethos.
(6) The Jigsaw steering group has become a useful forum for bringing together the GP
cluster leadership with NHS managers, third sector leaders and community planning
processes.
Question 2: Barriers to sustainable primary care system in both urban and rural areas
We support the use of technology for self-management of conditions and understand that it
has particular efficacy in rural areas. However, we point out that this must not become a ‘one
size fits all’ approach, as technology is not always either accessible or welcomed by
everyone. Greater awareness of and involvement of the third sector in supporting patient’s
self-management is also important. We need a shift in primary care to become a community
hub for social health that develops capacity and connects people with the support they need.
One example of this is the Edinburgh voluntary organisation Wester Hailes Health Agency9.
They play a key role in tackling health inequalities in their local area, using community
development approaches that aim to empower people, individually and collectively, to
identify and address the issues that confront their lives. They work collaboratively with other
voluntary and statutory services and are based in NHS Lothian premises alongside
community health, social care and family support services. They take a holistic approach to
supporting people, with a wide range of services including counselling, complementary
therapies, carers groups, social groups and physical health classes. They are also
connected with the Wester Hailes Health Practice community link worker.
9 https://sites.google.com/a/whhealthagency.org.uk/home/
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3. How can the effectiveness of multidisciplinary teams and GP Cluster working be
monitored and evaluated in terms of outcomes, prevention and health inequalities?
The third sector is a rich source of data for communities throughout Scotland, particularly
qualitative data about people’s needs and lived experience and data on innovative and
effective interventions. It already contributes valuable data to health and social care
partnerships and there is considerable scope for greater recognition of and use of third
sector data. Our sector has the trust of vulnerable and seldom-heard groups, supports and
empowers people to voice their own stories and be heard, and has local intelligence that can
help to create a detailed and nuanced representation of Scotland’s health, alongside clinical
and statistical data.
For further information, please contact: Kiren Zubairi, Policy Engagment Officer:
Mansfield Traquair Centre 15 Mansfield Place Edinburgh EH3 6BB 0131 474 6189 [email protected] www.vhscotland.org.uk @VHSComms Registered Scottish Charity SC035482 Company limited by guarantee SC267315
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM Scottish Community Development Centre (SCDC)
Introduction
Formed in 1994, SCDC is the lead body for community development in Scotland. We work
to our vision of an active, inclusive and just Scotland where our communities are strong,
equitable and sustainable. SCDC works with community groups, community development
practitioners, government and other policy makers, and local partnerships and agencies
across Scotland who want to involve communities in their work. SCDC is strongly
concerned with tackling poverty and inequality, concerns that are at the heart of community
development.
The Community Health Exchange (CHEX) has been part of SCDC since 1999 and works to
support and promote community development approaches to improve health and wellbeing.
We provide support to a network of community-led health initiatives and their public sector
partners who are tackling health inequalities in communities across Scotland. We work
strategically to support community-led health initiatives to engage with policy makers, and
operationally to help link community-led health initiatives, voluntary organisations and public
sector agencies together to tackle health inequalities and achieve health and wellbeing
outcomes with and within their communities.
Our response is based on our knowledge and experience of working with community-led
health initiatives and their partners, and our involvement in the structures and processes of
public health reform in Scotland. Our role within the reform process is to advocate for
community development approaches as an important part of the health system and to
promote greater recognition of the community and voluntary sectors’ role in prevention,
participation and partnership working within public health and health and social care
services.
Question 1. Considering the Health and Sport Committee’s report on Public Panels,
what changes are needed to ensure that primary care is delivered in a way that
focusses on the health and public health priorities of local communities?
Community-led health
We believe that in order to be more preventative, primary care needs to invest in and
harness the potential of community-led health. Community-led health is a way of improving
health and wellbeing that starts with what people say is important to them. It follows the
social model of health which recognises that our health and wellbeing results from factors
including work, education, housing, leisure and the way we organise ourselves as a society.
Community-led health organisations are focused on tackling inequality in all its forms. They
involve people experiencing poverty as well as disabled, BME, LGBTQ people and other
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marginalised groups at all levels of their work. In order to improve health and wellbeing and
the factors which impact on this, it is important to involve the people who are most affected.
That way services will be more relevant to the people who use them, and decisions will be
more appropriate to those they impact on. Community-led health builds people’s capacity to
influence service delivery and people get direct benefits from being involved in decisions
that make services better. They feel they have more of a stake in their communities and
services and develop increased skills and confidence. This is essentially what is meant by
‘empowerment’ and it has knock on effects for health and wellbeing. So, the very process of
community-led health in increasing participation and control has direct health benefits –
prevention in action.
An example of this approach is the Health Issues in the Community (HIIC) Course, which
aims to develop community members’ understanding of the range of factors that affect their
health and the health of their communities. The course introduces concepts around the
social model of health. It draws on people’s experiential learning and explores how issues
around poverty, inequality and social justice can be addressed collectively using community
development approaches. A group of women in Douglas, Dundee who have completed part
1 of the course has turned their lived experience into action. They developed a play based
on how their families had experienced and dealt with issues around mental-ill health, self-
harm and addiction. The play helps ‘shine a light’ on their experience of mental health
services and has been delivered numerous times, including to the former Health Minister
Shona Robison and at a meeting of the Mental Health Strategic Planning Group meeting in
Dundee.
The women themselves have gone on to gone on to speak publicly about the course and its
benefits – demonstrating the increased skills and confidence they have gained. They are
engaged in processes to improve delivery of mental health services and some have gone
on to volunteer with Healthy Minds, a drop-in service being developed locally, offering
mentoring to people who are going through mental trauma. They have also formed a self-
reliant craft group to generate some income and help their own mental wellbeing. This
demonstrates how community development can enable and empower independent,
collective action by community members on health issues, and how they can contribute to
the improvement of health services, including primary care.
CHEX has put together a range of reports, case studies and other resources showing the
value and impact of community-led health approaches, available on our website, and
including: our last CHEX policy briefing on social prescribing which summarises a mass of
evidence on the benefits that community-led organisations bring to working with people
experiencing mental health issues, loneliness and isolation and other health issues; our
Communities at the Centre case studies from 2013 and 2015 which show a range of ways
community organisations around Scotland work with local people to improve health and
wellbeing; our case studies highlight how community organisations with a health focus have
made use of the Community Empowerment (Scotland) Act, and how one CHEX network
organisation has engaged with local health and social care structures; and our role in
highlighting some of the work Public Health England has been doing promoting and
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evidencing “community-centred approaches for health and wellbeing”. In addition to a guide
to community-centred approaches which CHEX has highlighted previously, Public Health
England have pointed to evidence building the case for investing in community-centred
approaches that increase social capital and, in turn, health and wellbeing.
Social prescribing
We support a continued focus on prevention, participation and partnership, all of which we
see being part of a move towards the social model of health. An increased roll out of social
prescribing should be part of this. In order to focus on the health priorities of local
communities, social prescribing should be designed to tap into and, importantly, invest in,
the community sector. Social prescribing therefore needs to:
1. Recognise community-led health organisations can have a key role in social
prescribing, acting as the link, or bridge between statutory services and community
provision.
2. Support individuals throughout the process and work with them to identify suitable
community provision.
3. Be ‘scaled up’ further, with investment in the community sector and a focus on
inequality, engagement and partnership vitally important to ensure it meets the
needs of those who need it.
4. Focus, where possible, on projects that empower people and communities.
Community organisations can link people to suitable non-medical treatment and activities.
They are likely to have a strong knowledge and understanding of their communities as well
as of local community sector provision, enabling them to match up individuals to suitable
services.
A new project is being funded in Scotland and Northern Ireland which will support
community-led health organisations to better link primary medical care to community-based
resources. Social prescribers will work with referred individuals to link them with local
resources ranging from stress management services to community groups offering peer-
support. A cross-border partnership, the SPRING Project is being led by Scottish
Communities for Health and Wellbeing (SCHW) and the Northern Ireland Healthy Living
Centre Alliance (HLCA). The National Lottery Community Fund is providing £3m to fund ten
community-led health organisations in Scotland £40,000 per year for at least three years to
develop the project and to host social prescribers. The SPRING Project describes a
community-based approach to social prescribing as being effective:
• Because community-based organisations are best placed to know the range of
community activities that are available in their areas. Primary care practitioners can
trust them to find something appropriate without having to find it all out for
themselves.
• Because community-based organisations often provide, or can offer access to, a
wide range of activities, allowing people to develop flexible personal pathways,
rather than being referred to just one type of activity at a time by primary care
practitioners.
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• Because ‘patients’ or users often trust a community-based organisation to be ‘on
their side’ or be suitable for ‘people like them’, and so they may be more willing to
engage.
• Because community-based organisations often take a community development
approach, building capacity for the activities that are needed to respond to health
needs.
• Because community-based organisations can offer people chances to feel in control
of what happens to them, through responding to their own and community needs,
involving volunteers etc.
• Because community-based organisations often offer people the chance to meet and
get involved with a wider range of people in their community, combatting social
isolation.
• Because the activities that community-based organisations can offer as social
prescriptions are often also available to a wider range of people for whom they help
to prevent potential ill health and poor well-being.
Question 2: Barriers to sustainable primary care system in both urban and rural
areas
Due to ageing populations particularly in rural areas but also urban, and declining budgets,
primary care is unsustainable as it currently is. We support a shift in focus towards
prevention and community participation as a means of making services more sustainable.
Through our Supporting Communities Programme we have been working with local
community organisations, both in urban and remote, rural areas to develop community led
action plans that identify and respond to local issues affecting their community. Issues
around health and social care services are routinely being identified as important,
particularly where services become or remain inaccessible. Learning from the programme
suggests that communities have an interest in working with primary care service providers
to develop joint solutions to address the availability and accessibility of health and care
services. We understand that this requires active engagement and dialogue between
communities and service providers to develop different models of delivery and that building
community and agency capacity to engage with each other is critical to this. For example,
whilst the use of technology to assist self-management of conditions is welcome, a shared
dialogue at community level would be important to address barriers in using technology,
particularly in rural communities and identify what other measures could be used to
maximise self-help, self-management and peer support.
Question 3. How can the effectiveness of multidisciplinary teams and GP Cluster
working be monitored and evaluated in terms of outcomes, prevention and health
inequalities?
We are aware of emerging programmes to develop more holistic, person-centred models of
care, notably the work being led by Healthcare Improvement Scotland Ihub’s
Neighbourhood Care Programme which will test models such as multi-disciplinary team
working, reflective of local need and context, delivering person-centred care that enables
individuals to live well in the community for longer. Another programme, Community Led
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Support (CLS) seeks to change the culture and practice of health and social work towards a
community focus in achieving outcomes, the empowerment of staff and a true partnership
with local people. More recently, its support for People Led Care to develop community-led
care provision in rural areas and explore alternative ways of commissioning care will
provide valuable insights on how services can be better delivered at a neighbourhood level.
The evaluation of impact and outcomes from these programmes and models will provide
valuable learning on how outcomes and preventative approaches can be monitored and
evaluated.
We would also suggest that communities and the organisations that support them should
participate in evaluation processes so that they can also judge what works and what
doesn’t, ensuring lived experience is ‘taken inside’ of the health system. Further, ‘softer’
outcomes such as increased confidence, participation and wellbeing, particularly for those
who experience the poorest health and social outcomes, should be considered alongside
health statistics and medical data as a measure of improved health and effective service
delivery to tackle health inequalities.
For more information on SCDC and CHEX please contact Susan Paxton, Head of
Programmes: [email protected]
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM VOLUNTARY ACTION ORKNEY (VAO)
Considering the Health and Sport Committee's report on the public panels, what changes are needed to ensure that the primary care is delivered in a way that focuses on the health and public health priorities of local communities?
In general, we welcome the proposals and the positive comments detailed in the report to
change the way primary care is delivered, recognising the potential benefits to individuals
and communities of a place-based, person-centred approach. However, this will require a
significant shift in public and perhaps NHS/Third Sector staff understanding of what the
changes are and what they aim to achieve.
We also feel a shift is needed from regarding the third sector as referrers to or from primary
care to being partners in the creation of a network of support around each individual to
meet their specific needs, with a focus on addressing long term conditions and health
inequalities.
Third sector organisations are rooted in their communities, understand their issues and
develop trusting relationships with vulnerable people that statutory agencies sometimes find
difficult, therefore they can contribute a great deal to the work and outcomes of primary
care teams. It would be a positive step to include third sector skills and experience in
workforce planning so utilising the total workforce available within each area/community.
A clear understanding will be required of local needs based on accurate, up to date data
from which to develop collaborative outcomes. This should include mapping of local
services to identify what is already being delivered e.g. community-led support ‘hubs’, link
workers, third sector projects/services, to ensure a joined-up approach and to avoid
duplication. An example of a recent community-led initiative is the island wellbeing project,
which is led by VAO in collaboration with 5 island development trusts. Several new
collaborative services have been established ie The Hoy and Walls Daily Living-Aids
Centre, established in collaboration with both the island GPs and the mainland resource
centre to:
● provide general information to carers, friends, families or interested parties, on
a two-week basis;
● inform residents as where to purchase some of the smaller, more readily
available items;
● signpost where required to other organisations for example, Occupational
Therapy, Sensory Impairment Services, Telecare, Orkney Care and Repair
and the Orkney Disability Forum
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A wealth of local information can be accessed via Third Sector Interfaces (TSIs) who have
direct and positive relationships with and understanding of their local third sector and
communities. We also keep comprehensive, up to date, online and paper directories of all
local services.
Effective information-sharing within and across sectors and services is essential to enable
multi-disciplinary teams to meet their outcomes. Greater emphasis on the status of an
individual’s permission, with safeguards for the most vulnerable, would reduce a great deal
of unnecessary and time-consuming bureaucracy around GDPR compliance.
Increasing public knowledge and understanding of the different primary care/allied health
professional roles and developing confidence to contact them instead of a GP- staff from all
sectors may also need this information. Allied to that is the use of plain language.
Recognition of the time that needs to be devoted to creating high functioning multi-
disciplinary teams by breaking down professional, process and cultural barriers and
addressing current restrictions placed by regulatory bodies, which may inhibit innovation.
Utilising new technology effectively and appropriately recognising that many people,
including staff and particularly some older people will need time and support to engage with
it; also, to ensure that the current different IT systems can ‘talk to each other’ to make
internal communication more effective and efficient.
Clear commitment to allocating funding to prevention and tackling issues that lead to health
inequalities with an understanding of the long-term nature of the work in achieving positive
outcomes and within that context making a commitment to longer term
funding/commissioning of the third sector.
2. What are the barriers to delivering a sustainable primary care system in both urban and rural areas? Recognition that additional resources are involved in maintaining equable access to
services, where in our location with a main island (mainland) and 13 inhabited non-linked
islands, the use of ferry, plane and sporadic public transport is essential to reach those
populations, or for those populations to reach services. These resources are not just fares
and expenses but the disproportionate staff time per individual appointment, session or
contact. Usually a whole day for workers to reach one island community or for a member of
the community to come to mainland Orkney to receive the service. Our island populations
are the most disadvantaged in terms of access to services as apart from GP or practice
nurses based in or visiting islands, all other services are based on our mainland.
Small staff teams in both third and statutory sectors, means that where a member of staff is
lost, the service cannot be delivered effectively. Along with this is the ongoing challenge in
attracting staff and a current high employment rate. Another barrier is the ability to attract
properly qualified staff when there may not be a significant network of others in their field to
make Orkney an attractive prospect. This includes, in our experience, CAMHS workers,
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Psychiatrist (no proper provision when one visits every 3 months), Health Workers, Social
Workers, Third Sector Managers.
The concept of community hubs needs a properly thought out infrastructure. Elderly,
vulnerable or immobile individuals may have difficulty with a 100-meter trip let alone making
a journey from the parish of eg Evie to Dounby GP Surgery. Regular targeted transport
links or some system of supporting people to attend appointments is also vital.
The transport challenges of delivering or enabling easy access to services for our island
population and the limitations of very small staff teams would make the aspiration to ‘have
multidisciplinary teams in every locality’1 particularly difficult in our island area.
Technology has its place and would be beneficial to the non-linked island communities
given the travel and access issues, but there should be some caution and not a one-size-
fits-all-people approach. People should be able to ask for other types of consultation (face
to face). Even some young people would be extremely uncomfortable with for example a
counselling/psychiatric appointment via VC when suffering extreme anxiety and would
prefer to be in the room with the professional. Progress for some may be extremely off-
putting for others.
The effective use of technology is dependent on up-to-date efficient IT infrastructure which
is not in place in our islands, particularly the most remote. Communities that would benefit
most, are the least likely to be able to take advantage of new technology.
3. How can the effectiveness of multi-disciplinary teams and GP cluster working be monitored and evaluated in terms of outcomes, prevention and health inequalities?
There should be a focus on identifying clear outcomes for and with patients and their
involvement in contributing to the measurement of progress towards achieving those
outcomes. Primary Care outcomes have been clearly articulated and should form the
basis for monitoring and evaluation of the service. In addition, the team could measure
progress towards alleviating the factors that cause health inequalities ie map and measure
their activities against the public health priorities, as the local third sector has begun to do.
More thought should be given to the incorporation of third sector data which is a rich source
of quantitative and qualitative data about local people’s needs and experiences – often of
those who are seldom heard.
1 Paragraph 9, page 2, What Should Primary Care Look Like for the next generation? Health and Sports Committee, 3 July 2019
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HEALTH AND SPORT COMMITTEE
WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION?
SUBMISSION FROM SAMH (Scottish Association for Mental health)
Introduction
SAMH has represented the voice of people most affected by mental health problems in
Scotland for more than 90 years.
Today, in over 60 communities we work with adults and young people providing mental
health social care support, services in primary care, schools and further education, among
others. These services together with our national programme work in See Me, respectme,
suicide prevention and active living, inform our policy and campaign work to influence
positive social change.
SAMH is dedicated to mental health and wellbeing for all: with a vision of a society where
people are able to live their lives fully, regardless of present or past circumstances. SAMH
welcomes the Committee’s approach to this inquiry, which recognises the importance of
listening to people’s lived experiences. Over 20 people who use SAMH services responded
to the Committee’s survey and we hope to continue engaging with the Committee as this
inquiry progresses.
1. Considering the Health and Sport Committee's report on the public panels,
what changes are needed to ensure that the primary care is delivered in a way
that focuses on the health and public health priorities of local communities?
Mental health support as a key aspect of primary care provision was frequently highlighted
by both survey respondents and the public panels. This is not surprising, with research
showing that one in three GP appointments now involve mental health .1 SAMH agrees
that the provision of mental health services, including through the third sector, should be an
integral part of primary care.
Access to services
Ahead of the 2016 elections, SAMH called for an Ask Once, Get Help Fast2 approach to
mental health, to which the Scottish Government has committed in its Mental Strategy. This
approach is based on the knowledge that many people have to ask repeatedly, in different
settings, before receiving any help, and then may have to wait a long time before help is
forthcoming. Asking for help with mental health takes courage and this should be
respected.
1 RCGP, Scotland Policy Paper on Mental Health, 2012 2 SAMH, Ask Once Get Help Fast, 2017
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It is clear from the work of the public panels and from the work of the Scottish Youth
Parliament (SYP) that access to services – in particular for mental health support – remains
an issue for both adults and young people. All three public panels indicated that referral
processes need to be improved; there needs to be better signposting; and people need to
be directed to the most appropriate support.
The findings of the public panels and the SYP in relation to access to services are
supported by other research. The Scottish Government audit into CAMHS rejected
referrals, which was undertaken by SAMH and ISD Scotland, analysed how many children
and young people were being rejected from CAMHS services before receiving support, and
explored what – if any – alternative support children and young people were then
signposted to. The audit found that only 42% of respondents felt they had been signposted
following rejection from CAMHS services, while one in five young people continue to
receive a rejection. 3,4 Similarly, a SAMH survey on NHS clinical governance found that
60% of respondents felt that they were not offered the most appropriate care at the right
time within the last year.5
Since the pilot in 2014, Community Links Worker (CLW) programmes have been helping to
address the issue of access to services by providing non-clinical support for people, linking
them in with support services and resources in local communities. This can be a particularly
helpful service for people experiencing poor mental health linked to personal or
environmental circumstances, who may not benefit solely from clinical support. SAMH is
currently delivering CLW programmes in North Lanarkshire and in Aberdeen.
SAMH welcomed the commitment in the Scottish Government’s National Health and Social
Care Workforce Plan to have ‘at least’ 250 Community Link Workers (CLW) working within
GP practices across Scotland by the end of this parliament. However, given that CLW
programmes are locally-determined and delivered based on local need, SAMH would like to
see an option for recruitment to continue beyond the 250 workers where this is needed in
order to address health inequalities, including in mental health. At the moment delivery of
CLW programmes varies substantially. SAMH would like the Scottish Government to
provide clarity over the CLW role and also over where CLW programmes will be delivered.
SAMH is also calling for the Scottish Government to commission an independent inquiry
into the failure of NHS Boards to meet the 18 week waiting time target for psychological
therapies. While Scotland was the first country to introduce a waiting time target for
psychological therapies, NHS Boards consistently fail to meet the target, with none of
Scotland’s NHS Boards meeting the target last quarter.6 We know that people who receive
therapy faster and who feel like their treatment has lasted long enough are more likely to
feel it has helped.7 As such, increasing access to psychological therapies has to be a
3 Scottish Government, Rejected referrals to child and adolescent mental health services: audit, 2018 4 ISD Scotland, Child and Adolescent Mental Health Services in Scotland: Waiting Times, 2019 5 SAMH, Response to call for evidence on clinical governance, 2017 6 ISD Scotland, Psychological therapies waiting time in NHS Scotland, June 2019 7 SAMH, Talking It Out, 2015
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priority. The Scottish Government should give serious consideration to the Youth
Commission’s recommendation for an eight week waiting time target.8 It is unacceptable
that anyone waits 18 weeks or more for support for their mental health when they need it
most.9
In order to improve access to mental health services for children and young people, SAMH
would like the Scottish Government to outline a timetable for the urgent development and
implementation of the community mental wellbeing services for 5-24 year olds, which was
promised in the 2018/19 and 2019/20 Programmes for Government. We would also like to
see the implementation of a multi-agency assessment system for referrals, to ensure that
every young person is directed to appropriate support; this was one of the
recommendations from the audit of CAMHS rejected referrals, which was accepted by the
Scottish Government.
Prevention, health promotion and early intervention
Through our children and young people’s campaign – Going To Be – SAMH has been
calling for a refocus on and investment in early intervention services, to help children and
young people with their mental health at the earliest opportunity. We know that only a
quarter of young people know where to go for support for their mental health,10 but that the
number of young people experiencing psychological distress11 and contacting Childline
about suicidal thoughts is increasing,12 clearly demonstrating the need for such investment.
Our focus on early intervention aligns with the priorities outlined by the survey respondents
to the Committee’s inquiry and the public panels. Early intervention and prevention was a
key theme running through the feedback received from participants in stage one of the
inquiry, in particular in relation to mental health. The public panels highlighted the
opportunities presented by schools and education, with suggestions like wellbeing spaces
for pupils and having teachers trained in mental health.
These gaps in early intervention and prevention services have also been highlighted by
SAMH. Our research found that 66% of teachers who responded to our survey felt like they
had not been given sufficient training in mental health to carry out their role properly. The
same research also found that only 34% of school staff said their school had an effective
response to pupils experiencing mental health problems.13
To start addressing this gap in service provision, SAMH called for the provision of school
based counselling in all of Scotland’s schools. As such, we welcomed the
Scottish Government’s investment of £60 million in additional school counselling services,
which was announced in its 2018/19 Programme for Government. Part of this investment is
8 Youth Commission on Mental Health Services, May 2019 9 Youth Commission on Mental Health Services, May 2019 10 The Scottish Youth Parliament, Our Generation’s Epidemic, 2016 11 SAMH, Going to Be All Right, 2017 12 NSPCC, The courage to talk: Childline annual review 2017/18, 2018 13 SAMH, Going To Be Well Trained, 2017
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going into the creation of 350 counsellors in schools, ensuring that all of Scotland’s
secondary schools have a counselling service.
SAMH has also been calling for a national training programme in mental health for all
school staff. While the Scottish Government has committed to offer all local authorities
training for teachers in mental health first aid, this does not go far enough. SAMH wants to
see a national approach to mental health training for school staff, that ensures that all staff
working in schools feel equipped to have non-stigmatising and supportive conversations.
This training should not seek to provide staff with skills in counselling, but should seek to
build confidence within the school workforce, so staff can recognise when a pupil is
struggling, appropriately respond to pupils in distress and signpost to support when young
people ask for help.
SAMH has created an e-learning resource for teachers, which is designed to provide
teachers with an introduction to mental health; equip them with the skills and knowledge to
recognise and respond to a pupil who is experiencing a mental health problem; and lead a
conversation about positive mental health. This resource is not an answer to the lack of
training and resources in mental health for school staff, but it does provide a tool that
teachers and school staff can use at the moment to help them develop their knowledge in
mental health and skills in having effective conversations.
In addition to our work on children and young people’s mental health, SAMH also delivers
services in sport and physical activity. Improved social prescribing, including to physical
activity programmes, was recognised by the participants in stage one of the inquiry as a
priority. It was seen by participants as a means of preventing or alleviating certain health
problems, as well as a way of promoting healthy living more generally.
Indeed, being physically active has been proven to protect mental wellbeing, as well as
improve a person’s quality of life when experiencing a mental health problem.14 But in
Scotland, one in three people do not currently meet the World Health Organisation’s
guidelines for physical activity.15 People experiencing mental ill-health are less likely to be
physically active than those experiencing a high level of mental wellbeing.16 Studies
consistently show doing more physical activity reduces the likelihood of experiencing low
mood, depression, tension and worry.17
While both the Scottish Government’s Mental Health Strategy 2017-275 and A More Active
Scotland: Scotland’s Physical Activity Delivery Plan, have actions to increase physical
activity to benefit Scotland’s mental health, SAMH wants to see more done in primary care
to link people who are struggling with their mental health to physical activity opportunities.
Specifically we want the Scottish Government to make exercise referral schemes available
nationwide, with sufficient provision of evidence-based services that are accessible without
14 Bauman, A., Updating the evidence that physical activity is good for health: an epidemiological review 2000–2003, 2004 15 Scottish Government, Health of Scotland’s population – Physical Activity 16 Shor, R & Shalev, A, Barriers to involvement in physical activities of person with mental illness, 2014 17 Royal College of Psychiatrists, Physical Activity and Mental Health
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cost to the participant. Moreover, we want to see continued Scottish Government funding
and support for Action 31 of the Mental Health Strategy 2017-27, with funding for the ALBA
programme due to come to an end late this year.
2. What are the barriers to delivering a sustainable primary care system in both
urban and rural areas?
Funding
We are delighted that the Scottish Government’s mental health strategy commits to the
creation of an Ask Once Get Help Fast approach, which SAMH called for. However, this
approach needs both funding and commitment to be realised. We have concerns about the
resource currently available for the provision of mental health services, including those that
are accessed within and through primary care.
We recognise that the Scottish Government is spending over £1 billion on mental health
services this year; however, it is very difficult to track this funding and know where it is
invested. For example, we do not know what proportion of this funding is being invested in
primary care, or what proportion of the overall primary care budget it being spent on mental
health services beyond Community Mental Health Teams. Similarly, it is unclear how much
funding is going into CAMHS tiers 1 and 2 services, beyond funding announcements for
individual initiatives like school-based counselling. Indeed, Audit Scotland’s report into
children and young people’s mental health found that ‘[m]ental health funding has primarily
been used for specialist services.’.18
Total health expenditure in Scotland in 2018/19 was over £13 billion,19 meaning that
expenditure on mental health – at just over £1 billion – made up only around 8% of the
overall health budget. The World Health Organisation estimates mental ill-health is the third
largest cause of disease burden worldwide.20 This is supported by data from the Scottish
Public Health Observatory, which found that depression causes more years of poor health
than all but two other diseases.21 It would therefore be reasonable to expect substantial
expenditure in this area of health.
Indeed the Lancet Commission on Global Mental Health and Sustainable Development has
urged high-income countries to spend 10% of their healthcare budget on mental health.22 At
a mental health spend of around 8% Scotland should clearly be doing better, in particular
given that NHS England has successfully met the 10% target and sustained it for three
years.23 It is also worth noting that the Lancet Commission recommends that spending on
mental health should be redistributed from hospitals to community-based services, with a
focus on early intervention and integration with established services.
18 Audit Scotland, Children and young people’s mental health, 2018 19 Scottish Government, Government Expenditure and Revenue Scotland 2018-2019, 2019 20 World Health Organisation, The Global Burden of Disease: 2004 update 21 Scottish Public Health Observatory, The Scottish Burden of Disease Study, 2016 22 The Lancet Commissions, The Lancet Commission on Global Mental Health and Sustainable Development, 2018 23 NHS England, The NHS Long Term Plan, 2019
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We hear regularly from people who have waited many weeks for first appointments, who
then wait a further lengthy period for follow-up appointments, and experience enormous
frustration through appointments delayed or cancelled because of sickness absence or staff
moving on. Increased sustainable investment in mental health, that is proportionate to the
population need is required if these issues, many of which are experienced in primary care,
are to be resolved.
Service design
All of SAMH’s services take a person-centred approach, based on an ethos of recovery. We
would like to see all mental health services in Scotland, including those linked to primary
care, take this approach. However, it is clear from the findings of the survey and the public
panels that many primary care services are not always designed with people in mind, with a
person-centred approached highlighted as a priority for primary care development by
participants in stage one of the inquiry. The Youth Commission similarly found that young
people do not feel that mental health services are person-centred.24
This is supported by SAMH’s own research, which shows that more needs to be done to
improve person-centred approaches in mental health services. Our research showed that
almost two fifths of respondents were not as involved in decisions about their care as they
would like to be, and almost 80% had never been asked what mental health services they
would like in their area.25 To be effective and sustainable, primary care services need to
meet the needs of people in local communities; this is not achievable unless patients are
involved in decisions about their own care, as well as in decisions about mental health
service design and delivery.
Indeed, providing services and support that people want to use and that are aligned with
their preferences, is key to achieving the Ask Once Get Help Fast approach. In contrast, at
the moment we know that people who are struggling with their mental health are often
forced to recount their experience multiple times to different healthcare professionals before
getting the support they need, which is also aligned with what they want. Furthermore, we
know that giving people more choice over what their support looks like increases the
likelihood of the patient benefitting from that support.26
Many of the suggestions made by the survey respondents and the public panels are about
increasing patient choice. For example, there was strong support from respondents for
alternative GP opening hours, as well as for appointments by video and telephone
consultation. This was balanced with support for existing opening hours for GP surgeries
and face-to-face contact with clinicians, indicating that people do not necessarily need
services to be completely changed, but that they simply need more choice.
24 Youth Commission on Mental Health Services, May 2019 25 SAMH, Response to call for evidence on clinical governance, 2017 26 Mind, We still need to talk, 2013
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3. How can the effectiveness of multi-disciplinary teams and GP cluster working
be monitored and evaluated in terms of outcomes, prevention and health
inequalities?
We note that in England, expenditure on mental health is one of the metrics in a scorecard
which measures Clinical Commissioning Groups’ performance. We would welcome a
similar approach in Scotland.
We would also like to see patient satisfaction included within the evaluation process for
multidisciplinary teams and GP cluster working. Measuring patient satisfaction with health
services is crucial if primary care wants to see the continual improvement that’s needed to
ensure effectiveness. While measurable clinical objectives are useful in many ways, people
will not always be seeking or require only clinical support.27 As such, it is equally important
to seek to evaluate patient experience separate to clinical outcomes, with a view to
delivering care that is not just effective, but also compassionate and empathic.
--
Suzanne Martin, Senior Public Affairs Officer
September 2019
27 The Kings Fund, Outcomes for mental health services: What really matters?, 2019
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HEALTH AND SPORT COMMITTEE WHAT SHOULD PRIMARY CARE LOOK LIKE FOR THE NEXT GENERATION? SUBMISSION FROM PENUMBRA We welcome the opportunity to submit evidence to the Committee’s inquiry. The role of the third sector in primary care. Penumbra is a leading mental health organisation providing a range of recovery focussed support services to around 1800 adults and young people each week and 4500 people each year. We work with partners across seventeen local authority areas to provide innovative mental health support in a community setting. Our compassionate and highly skilled recovery teams work with the people we support to create tailored and person focussed strategies that give practical steps towards recovery. Using our I.ROC and HOPE toolkits, our whole person approach is based on the rights of the people we support through choice, dignity and the expectation of recovery. We believe that the 3rd sector has a significant role to play in delivering key public health priorities. Question 1 Considering the Health and Sport Committee's Report on the public panels, what changes are needed to ensure that the primary care is delivered in a way that focuses on the health and public health priorities of local communities? a) Language. It is interesting to note that many GP practices are called either medical centres or health centres. Given the desire to move to earlier intervention and prevention we would suggest that practices could be called health and wellbeing centres, this reflects the fact that you do not need to be ‘ill’ to attend. There is a clear need to shift public expectation of what a GP practice is and can offer. Increasingly they are places where many different disciplines work together from medical staff to voluntary/3rd sector organisations. b) Digital. We agree with the public panels that use of digital services and sharing of data (where required and appropriate) would modernise the way the public interacts with primary care. In a number of situations, we are told it is not possible to receive emailed/electronic referrals for our services due to confidentiality and security worries. This means that referrals are made by phone or letter which is not always the best or most timely way to pass information. The use of online scheduling of appointments (including after 5pm and weekends) and text reminders would bring the NHS in line with many other services (e.g. dentists and optometrists etc). Self-management using digital technology such as wearables or online accredited websites (e.g. living life to the full) and the use of Attend Anywhere for secure online video appointments would greatly increase the interaction between the public and health professionals.
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ALISS is a community health and wellbeing portal that offers an online directory of local community services. Currently it is difficult to ensure the information it contains is up to date and still valid, due to agencies being responsible for keeping their own information up to date. However, it has the potential to be a trusted aggregator platform of community health and wellbeing resources fulfilling a role that would complement NHS Inform. There needs to be an increased connectedness of GP practices to the wider health and social care strategy and commissioning to ensure an integrated response to the health and wellbeing needs of communities. There also needs to be a greater awareness within primary care of alternative sources of support, for example through 3rd sector services and community resources. c) There should be a greater focus on community wellness, and a promotion of the idea of wellbeing and maintaining good mental health as opposed to individual illness. d) Primary care teams to include quick response to emerging health and mental health needs e.g. having wellbeing practitioners/peer workers that are able to respond quickly to mental health needs as a 1st response. In parts of Angus, Penumbra has Peer Support workers (people who use their own lived experience of mental ill health and recovery) working within practices to offer practical support to develop self-management techniques or to connect to local community resources. In many parts of the North East of Scotland we have developed 1st Response services where people can walk in and see a Penumbra worker. In Elgin for example over 1500 have accessed this service in the last year. Many are looking for information, guidance and some support to overcome emerging challenges to their mental health and wellbeing. This form of early intervention has worked well and people have positively rated this support. We have some concerns about the term ‘social prescribing’ as it still positions the work within a medical model by virtue of the word prescribe. This is because the public connect the term prescribe/prescription with doctors and ill health. Often people require support to ‘connect’ with local community resources and do not have illnesses or symptoms that require medical intervention. We prefer terms like community connectors or wellbeing practitioners etc. Question 2 What are the barriers to delivering a sustainable primary care system in both urban and rural areas? a) Recruitment. We often face challenges to recruit skilled staff for some of the emerging roles for 3rd sector workers in primary care. Particularly if funding is only awarded on an annual basis as we cannot offer medium to long term job security and personal development opportunities.
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b) Procurement and commissioning of the 3rd sector. Often this is carried out via competitive tender and is for a 3-year contract or shorter. If it is a spot purchase or 1-year contract this does not provide the security and sustainability we need to offer good quality services. Often tenders for work are heavily specified which also hampers or restricts innovation and the opportunity to put emerging practices into effect. c) Health priorities. We believe that primary care is vital to assessing the health and public health needs of local communities. Clear links between primary care and local strategic planning groups should be supported and maintained so that data and information can be shared to ensure that locality plans and commissioning strategies meet the Health needs of local populations. d) Access. Opening hours and travel distances can be a deterrent to people to access primary care in a timely manner, particularly in rural areas. People often feel they have to be ‘really unwell’ before ‘seeing the doctor’. We need to think more clearly about how we market primary care as a wellbeing service, not just an illness service. As mentioned earlier alternatives such as video links and more use of online tools could help here. e) We feel that more use can be made of the third sector in providing walk-in services that give support and information along with the ability to connect people to local community resources. Question 3 How can the effectiveness of multi-disciplinary teams and GP cluster working be monitored and evaluated in terms of outcomes, prevention and health inequalities? a) Clearly defined expected outcomes for MDTs/GP clusters. A lot of data is collected for secondary care services which reflects use of hospitals and out-patients. We need to be clear what health and wellbeing outcomes we want for primary care and identify clear measures and datasets for this. We already have the Scottish Public Health Observatory which produces locality profiles, and more use should be made of this data when looking at setting objectives and outcomes for an area. b) Involve people who use the service in identifying clear outcomes for a locality. c) Less focus on clinical outputs and more focus on people outcomes. Traditionally, we have measured and counted systems outputs. We believe more work can be done to identify outcomes for people. Penumbra September 2019
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Health and Sport Committee
23rd Meeting, 2019 (Session 5)
Tuesday, 8 October 2019
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 (SSI 2019/285)
Introduction
1. This paper supports the Committee’s consideration of the following Scottish statutory instrument—
• The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019
2. The Committee is invited to consider the statutory instrument and—
• agree whether it is content that the parliamentary procedure attached to the instrument by the Scottish Government is appropriate; and
• consider the instrument in the usual way.
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019
3. These Regulations make a number of minor technical changes to ensure continuity of law after the UK’s exit from the EU and inserts transitional provisions for food labelling into several existing regulations. That will provide a 21-month transition period to give the food industry time to adjust to new labelling and information requirements for EU businesses and food products following the UK’s exit from the EU.
4. The instrument also amends the Honey (Scotland) Regulations 2015 to make technical changes to the origin labelling information requirements for blended honey. The amendments are to EU focused terminology and provide various new options for providing information on the origin of blended honey.
5. The amendments proposed in this instrument would apply if the EU and the UK were not to agree a partnership arrangement and common approach to food legislation after the UK leaves the EU. The policy note is attached at Annexe A.
6. The SSI was laid on 12 September 2019 and the lead committee must report by 4 November 2019.
7. The Scottish Government has given the SSI the ‘low’ categorisation on the basis that the instruments “makes mainly technical amendments in order to fix deficiencies in domestic law.”.
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8. The DPLRC agreed on 24 September 2019 that the instrument should be considered under the negative procedure and with the ‘low’ categorisation.
Background
9. In anticipation of the UK leaving the EU, changes are required to devolved legislation by way of statutory instruments. Under the European Union (Withdrawal) Act 2018, and where the Scottish Government considered a UK-wide approach to the legislative changes would be appropriate, these have been made by UK statutory instruments (SIs) laid by the UK Government with Scottish Ministers’ consent. The Scottish Parliament has considered these legislative changes – notified to them by the Scottish Government – in advance of the Scottish Government giving consent.
10. Other legislative changes are being made through Scottish statutory instruments (SSIs). SSIs related to EU exit will be considered in the same way that ‘domestic’ SSIs are considered except that the lead committee has the opportunity, in advance of its policy consideration, to recommend to the Scottish Government that the parliamentary procedure allocated to the instrument should be changed. This process is known as the sift.
11. A protocol has been agreed between the Scottish Government and Scottish Parliament on the process for considering SSIs laid under the 2018 Act. The protocol sets out further information about the sifting process.
12. The protocol also sets out an approach which categorises SSIs – high, medium or low – to assist committees’ prioritisation in terms of scrutiny and gives the Delegated Powers and Law Reform Committee (DPLRC) a role in highlighting to a lead committee those SSIs where it disagrees with the Scottish Government about the categorisation.
Consideration of the parliamentary procedure – the sift
13. Scottish Ministers have discretion about whether instruments made under Schedule 2 of the 2018 Act should be subject to the affirmative or negative procedure, unless the instrument makes provision falling within one of the categories which requires the mandatory affirmative procedure to be used.
14. As set out above, the lead committee has the opportunity, in advance of its consideration, to recommend to the Scottish Government that the parliamentary procedure allocated to the instrument should be changed. Thus, the lead committee can recommend that an instrument laid under the negative procedure should be revoked and laid as an affirmative instrument and vice versa. The protocol states this “enables committees to recommend a change where they consider that the matter is of such significance that it requires active Parliamentary approval (or conversely is not so significant that it requires Parliamentary time to be allocated to its approval)”.
15. The DPLRC will also consider the parliamentary procedure allocated to the instrument and make a recommendation to the lead committee where it agrees the procedure should be changed.
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16. SPICe and the Office of the Solicitor of the Scottish Parliament (OSSP) have provided advice to inform the Committee’s consideration of the sift. This is set out in paper HS/S5/19/23/2(P).
No recommendation to change the parliamentary procedure 17. Where a lead committee agrees with the parliamentary procedure, the instrument is thereafter considered and disposed of in the same way as a ‘domestic’ SSI.
Recommendation to change the parliamentary procedure 18. Where a lead committee recommends the parliamentary procedure should be changed, it must report to the Parliament. The Scottish Government is expected to meet that recommendation as soon as possible.
19. A change of procedure does not, however, affect the timetable for Parliamentary consideration and the SSI should be considered under the procedure recommended by the lead committee.
Consideration of the SSI
20. As set out above, the process for the policy consideration of an SSI related to EU exit following the sift is the same as for a ‘domestic’ SSI. The Scottish Government has decided the negative parliamentary procedure is appropriate for this SSI.
21. The negative parliamentary procedure is set out in Chapter 10 of the Parliament’s Standing Orders. Instruments subject to the negative procedure come into force on a specified date and remain in force unless it is annulled by the Parliament; for this reason, negative instruments can be described as instruments subject to annulment. Thus, the Parliament does not need to agree to the instrument in order for it to come into force.
22. The Parliament may, however, and on the recommendation of the lead committee, recommend the instrument be annulled within 40 days of the instrument being laid. Any MSP may by motion propose to the lead committee that the committee recommends “that nothing further is to be done under the instrument”. Any motion for annulment would be debated by the lead committee and a report made to Parliament.
For decision
23. The Committee is invited to:
• Agree whether it is content the parliamentary procedure given to the instrument by the Scottish Government is appropriate (agenda item 1).
• Note the instrument or consider if it has anything to report to the Parliament in relation to either of them (agenda item 2).
Clerks Health and Sport Committee
HS/S5/19/23/3 Annexe A
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POLICY NOTE
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 (SSI 2019/285)
The above instrument was made in exercise of the powers conferred by paragraph 1(1) and (3) of schedule 2 and paragraph 21(b) of schedule 7 of the European Union (Withdrawal) Act 2018. The instrument is subject to negative procedure.
Purpose of the instrument. The amendments proposed in this instrument would apply in the event that the EU and the UK were not to agree a partnership arrangement and common approach to food legislation after the UK leaves the EU. This instrument will ensure the operability of domestic food legislation in Scotland following the UK’s exit from the EU. It includes minor technical fixes and addresses blended honey country of origin labelling and transitional provisions for food labelling.
Policy Objectives Where practical and appropriate, European Union legislation is being retained in relevant domestic law applicable in Scotland on the UK’s exit from the EU. In the fields of food information, labelling and standards, Food Standards Scotland, in line with the Scottish Government and other devolved administrations, plans to retain the current standards set out in EU legislation and EU-derived domestic legislation that ensure, following a “no deal” UK exit from the European Union, continued regulation of food information, labelling and standards within Scotland. This will protect human health and the environment and provide continuity for businesses and consumers. This instrument concerns the relevant fixes to the EU–derived domestic legislation in this policy area. Upon exit day a number of technical and some more substantial corrections are required. The objective of this instrument is to ensure the operability of Scotland’s food information, labelling and standards framework. Explanation of the law being amended by the Regulations The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 inserts transitional provisions into the following domestic legislation to allow businesses to use up stocks of labels whilst working to meet the new labelling requirements:
• The Quick-frozen Foodstuffs Regulations 1990
• Food Hygiene (Scotland) Regulations 2006
• The Food Additives, Flavouring, Enzymes and Extraction Solvents (Scotland) Regulations 2013
• Caseins and Caseinates (Scotland) (No. 2) Regulations 2016 The new requirements are as a result of technical changes to retained EU law which maintain the operability of the relevant legislation in the context of the UK having left
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the EU e.g. new health and identification marks for products of animal origin and changes to the labelling requirements for EU businesses and products intended to be placed on the UK market in future. This instrument also makes changes to the origin labelling information required for blended honey in the Honey (Scotland) Regulations 2015. However these changes are minor, removing EU-focused terminology and replacing it with flexible options for the origin labelling of blended honey. Reasons for and effect of the proposed change or changes on retained EU law The amendments do not make any substantial changes but will ensure continuity in Scots law after the UK exits the European Union.
Statements required by European Union (Withdrawal) Act 2018 Statement that in their opinion Scottish Ministers consider that the Regulations do no more than is appropriate The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view the Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 do no more than is appropriate.”. This is the case because they make only those changes necessary to fix deficiencies in domestic law and insert transitional provisions in order to minimise re labelling costs to Scottish businesses. Statement as to why the Scottish Ministers consider that there are good reasons for the Regulations and that this is a reasonable course of action The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view there are good reasons for the provisions in this instrument, and I have concluded they are a reasonable course of action. This is because, in order to ensure that food information, labelling and standards legislation continues to operate effectively at the point that the UK leaves the EU, they make only those changes necessary to fix deficiencies in domestic law and insert transitional provisions in order to minimise relabelling costs to Scottish businesses.”. Statement as to whether the SSI amends, repeals or revokes any provision of equalities legislation, and, if it does, an explanation of that amendment, repeal or revocation The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view the Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 do not amend, repeal or revoke a provision or provisions in the Equality Act 2006 or the Equality Act 2010 or subordinate legislation made under those Acts.”. Statement that Scottish Ministers have, in preparing the Regulations, had due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010
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The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view the Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 have had due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010.”.
Additional information provided for EU Exit instruments in terms of the protocol agreed between the Scottish Government and the Scottish Parliament Statement that Scottish Ministers have, in preparing the Regulations, had due regard to the guidance principles on the environment and animal welfare The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view the Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 have had due regard to the guiding principles on the environment and animal welfare as derived from the equivalent principles provided for in Articles 13 and 191(2) in Titles II and XX respectively of the Treaty on the Functioning of the European Union.”. Statement explaining the effect (if any) of the Regulations on rights and duties relating to employment and health and safety and matters relating to consumer protection (so far as is within devolved competence) The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the following statement “In my view the Food Composition, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 have no effect on the rights and duties relating to employment, health and safety and matters relating to consumer protection. An indication of how the Regulations should be categorised in relation to the significance of the change proposed Low – this instrument makes mainly technical amendments in order to fix deficiencies in domestic law. Statement setting out the Scottish Ministers’ reasons for their choice of procedure The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick has made the following statement regarding use of legislative powers in the European Withdrawal Act 2018 “In my view the Food Composition, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 are subject to negative procedure”. This is the case because it complies with the requirement for the negative procedure schedule 7 of the European Union (Withdrawal) Act 2018 and, in particular, do not contain provisions of the type listed in paragraph 1(2) of that schedule.
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Further information Consultation In line with the requirements of Article 9 of Regulation (EC) No. 178/2002 of the European Parliament and of the Council, a consultation was launched on 26th July and closed on 9th August 2019. Local authorities, consumer groups, trade associations, food and feed businesses including manufacturers, wholesalers and retailers were contacted. There were 13 responses to the consultation in total however not all respondents answered all the questions. On country of origin labelling of blended honey only 1 additional impact was identified if it were the case that the Scottish market had different requirements to the rest of the UK. The amendments which are being made to Scottish legislation in this area allows for businesses to use the same terms as have been legislated for in the rest of the UK. On transitional provisions, all respondents in this area agree that they are necessary in order to use up stocks of existing labels with the majority agreeing that this should be provided consistently across the UK.
Impact Assessments Full impact assessments have not been prepared for this instrument because the amendments do not alter the Scottish Government’s current environmental policies and priorities and therefore do not have a significant impact on the environment. The impact on business, charities or voluntary bodies is expected to be minimal.
Financial Effects The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, confirms that no BRIA is necessary as the instrument has no financial effects on the Scottish Government, local government or on business. Indeed its intention in part is to mitigate against the effects of UK Government changes to retained EU law. Food Standards Scotland 10 September 2019
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Health and Sport Committee
23rd Meeting, 2019 (Session 5)
Tuesday, 8 October 2019
Subordinate Legislation Briefing
Overview of instruments
1. There are two negative instruments for consideration at today’s meeting:
• The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019
• The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019
The National Health Service (Serious Shortage Protocols) (Miscellaneous Amendments) (Scotland) Regulations 2019 (SSI 2019/284)
Background 2. The policy behind this instrument is to allow pharmacists within a community
pharmacy to supply an alternative quantity, an alternative pharmaceutical form, an alternative strength, a therapeutic equivalent or a generic equivalent as indicated in the protocol – without going back to the prescriber. The Policy Note is available at Annexe A.
3. An electronic copy of the instrument is available at: https://www.legislation.gov.uk/ssi/2019/284/contents/made
4. There has been no motion to annul this instrument.
5. The Committee needs to report by 6 November 2019.
Delegated Powers and Law Reform Committee consideration
6. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 24 September 2019. The Committee determined that it did not need to draw the attention of the Parliament to this instrument on any grounds within its remit.
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment) Regulations 2019 (SSI 2019/285)
Background 7. The policy behind this instrument is to ensure the operability of domestic food
legislation in Scotland following the UK’s exit from the EU. It includes minor technical fixes and addresses blended honey country of origin labelling and transitional provisions for food labelling. The amendments proposed in this instrument would apply in the event that the EU and the UK were not to agree a
HS/S5/19/23/5
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partnership arrangement and common approach to food legislation after the UK leaves the EU. The Policy Note is available at Annexe B.
8. An electronic copy of the instrument is available at:
https://www.legislation.gov.uk/ssi/2019/285/contents/made
9. There has been no motion to annul this instrument.
10. The Committee needs to report by 6 November 2019.
Delegated Powers and Law Reform Committee consideration
11. The Delegated Powers and Law Reform Committee considered the categorisation of the instrument at its meeting on 24 September 2019. The Committee determined that it did not need to draw the attention of the Parliament to this instrument on any grounds within its remit.
12. The Committee further considered the instrument at its meeting on 1 October 2019. The Committee determined the following recommendation:
13. The Committee’s full report on the instrument is available at:
https://digitalpublications.parliament.scot/Committees/Report/DPLR/2019/10/2/Subordinate-Legislation-Considered-by-the-Delegated-Powers-and-Law-Reform-Committee-on-1-October-2019#Introduction
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ANNEXE A
POLICY NOTE
THE NATIONAL HEALTH SERVICE (SERIOUS SHORTAGE PROTOCOLS) (MISCELLANEOUS AMENDMENTS) (SCOTLAND) REGULATIONS 2019 (SSI
2019/284)
The above instrument was made in exercise of the powers conferred by section 17E, 17N, 27, 28(1) and 105(7) of the National Health Service (Scotland) Act 1978(a). The instrument is subject to negative procedure.
This instrument amends the National Health Service (Pharmaceutical
Services) (Scotland) Regulations 2009, The National Health Service (General
Medical Services Contract) (Scotland) Regulations 2018 and The National
Health Service (Primary Medical Services Sections 17C Agreements)
(Scotland) Regulations 2018 in order to extend the scope and operationalise
Serious Shortage Protocols (SSPs). Where there is a serious shortage of a
prescription only medicine or other drug or appliance ordered on an NHS
prescription form, SSPs will allow pharmacists and dispensing doctors to
supply a different product or quantity or strength in accordance with the
SSP, rather than fulfilling the original prescription.
Policy Objectives
Amendments to The Human Medicines Regulations 2012, which entered into force on 9th February 2019, enabled UK Ministers to issue Serious Shortage Protocols (“SSPs”) for prescription on medicines (POMs). This SSI amends The National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 to allow community pharmacists to operate under an SSP issued by UK Ministers.
Amendments also made to the English equivalent Regulations, The National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, made provision for UK Ministers to issue SSPs in England only for all other drugs / appliances which are not POMs. This SSI allows Scottish Ministers to issue a Scottish SSP for all other drugs and appliances classed as in serious shortage.
Previously, if a community pharmacy could not dispense what was on the prescription, the pharmacists needed either to refer the patient back to the prescriber or, if there was an urgent need, contact the prescriber to discuss an alternative and then get the prescription changed by the prescriber.
This instrument allows pharmacists within a community pharmacy to supply in accordance with a SSP issued under the Human Medicines Regulations 2012, which may allow for the supply of an alternative quantity, an alternative pharmaceutical form, an alternative strength, a therapeutic equivalent or a generic equivalent as indicated in the protocol –without going back to the prescriber.
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This instrument also creates another type of SSP where Scotland or any part of Scotland is experiencing or may experience a serious shortage of a drug or appliance, which is not a POM. In these circumstances, the Scottish Ministers can issue a “Scottish Serious Shortage Protocol” (“Scottish SSP”) – community pharmacists will be able to supply a different drug/appliance or quantity or strength of the drug/appliance without the need to go back to the prescriber. Dispensing doctors will also be able to supply a different drug or appliance or quantity or strength of the drug or appliance where a Scottish SSP is in place.
The Scottish Government and NHS Scotland have well established procedures for managing medicines shortages, and Scottish Government work collaboratively with UK Government and the Medicines and Healthcare Products Regulatory Agency in order to manage supply issues when they occur, SSPs will provide an additional tool for the purposes of managing shortages. It will be impractical for patients and a burden on NHS Primary Care services for all patients affected by a serious shortage to return to the prescriber, usually a GP, or for the pharmacist to liaise with the prescriber for each individual prescription. As an example, a delay caused by the need for a new prescription could increase the risk to patients requiring a supply of an auto-injector which would be needed should the patient experience an allergic reaction. In addition, the effective management of shortages of products may prevent products in short supply from running out completely, and so potentially significantly decreasing the risk to those patients who would otherwise be left with none of the product.
Avoiding referrals back to a prescriber, where an alternative supply can be made safely and appropriately, will also enable GPs and other prescribers to focus more time on other patients care needs, including urgent care.
The power to issue a SSP (POM only) is reserved to UK Government and would only be used in exceptional circumstances.
“Scottish SSPs” for all other drugs and appliances than POMs may be issued by Scottish Minsters. Ministers signing off a “Scottish SSP” will be advised by the Medicines Shortage Response Group Scotland (MRSG(Sco)) which is chaired by the Chief Pharmaceutical Officer for Scotland. The MRSG(Sco) will consult with expertise in the relevant area to provide the clinical content for any protocol for a “Scottish SSP”. Each protocol will clearly set out what action can be taken by the pharmacist, under what circumstances, for which patients and during which period.
The instrument does not relate to the UK’s withdrawal from the European Union. However, if withdrawal from the European Union was a contributing factor to a serious shortage of a product normally available on an NHS prescription form, a SSP may be issued by UK Ministers. For all other drugs/appliances that are not POMs, Scottish Ministers may issue a Scottish SSP should they consider a serious shortage is in place in those circumstances.
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Consultation
The Scottish Government consulted with the contractors’ representative body in Scotland, Community Pharmacy Scotland, on both terms of the amendments to the 2009 Regulations and the operational guidance for pharmacists in the event of an SSP. NHS Boards were also consulted.
Impact Assessments
Impact assessments have not been prepared for this instrument as there is no change in accessibility to the pharmaceutical services being delivered by community pharmacies for patients. The amendments made by these Regulations are enabling and the new arrangements will only be used when there is a recognised serious shortage. It is not possible to predict the number of serious shortages that might arise, the duration and the nature of the products that may be affected. This will be driven by intelligence gathering at the time, but expectation is that SSPs will only ever be needed in exceptional circumstances.
SSPs would ensure the timely access to treatments for patients. Serious shortages of treatments in themselves present risks to patients.
Financial Effects
No BRIA is considered to be required. The financial impact of medicine shortages are part of the day to day operations of the NHS in Scotland. In the event of a medicine shortage, drug costs are likely to increase as a result of more demand for less available products. SSPs will not eliminating the potential for increased costs but will endeavour to mitigate by providing alternative available product for dispensing to patients. SSPs will help in reducing the costs to the NHS in Scotland in both time and resource for new prescription forms being completed by prescribers as a result of a serious shortage.
Scottish Government
Directorate for Chief Medical Officer
Pharmacy and Medicines
11 September 2019
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ANNEXE B
POLICY NOTE
The Food Information, Labelling and Standards (EU Exit) (Scotland)
(Amendment) Regulations 2019 (SSI 2019/285)
The above instrument was made in exercise of the powers conferred by paragraph
1(1) and (3) of schedule 2 and paragraph 21(b) of schedule 7 of the European Union
(Withdrawal) Act 2018. The instrument is subject to negative procedure.
Purpose of the instrument.
The amendments proposed in this instrument would apply in the event that the EU
and the UK were not to agree a partnership arrangement and common approach
to food legislation after the UK leaves the EU.
This instrument will ensure the operability of domestic food legislation in Scotland
following the UK’s exit from the EU. It includes minor technical fixes and addresses
blended honey country of origin labelling and transitional provisions for food
labelling.
Policy Objectives
Where practical and appropriate, European Union legislation is being retained in
relevant domestic law applicable in Scotland on the UK’s exit from the EU. In the
fields of food information, labelling and standards, Food Standards Scotland, in line
with the Scottish Government and other devolved administrations, plans to retain the
current standards set out in EU legislation and EU-derived domestic legislation that
ensure, following a “no deal” UK exit from the European Union, continued regulation
of food information, labelling and standards within Scotland. This will protect human
health and the environment and provide continuity for businesses and consumers.
This instrument concerns the relevant fixes to the EU–derived domestic legislation in
this policy area.
Upon exit day a number of technical and some more substantial corrections are
required. The objective of this instrument is to ensure the operability of Scotland’s
food information, labelling and standards framework.
Explanation of the law being amended by the Regulations
The Food Information, Labelling and Standards (EU Exit) (Scotland) (Amendment)
Regulations 2019 inserts transitional provisions into the following domestic
legislation to allow businesses to use up stocks of labels whilst working to meet the
new labelling requirements:
• The Quick-frozen Foodstuffs Regulations 1990
HS/S5/19/23/5
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• Food Hygiene (Scotland) Regulations 2006
• The Food Additives, Flavouring, Enzymes and Extraction Solvents (Scotland) Regulations 2013
• Caseins and Caseinates (Scotland) (No. 2) Regulations 2016
The new requirements are as a result of technical changes to retained EU law which
maintain the operability of the relevant legislation in the context of the UK having left
the EU e.g. new health and identification marks for products of animal origin and
changes to the labelling requirements for EU businesses and products intended to
be placed on the UK market in future.
This instrument also makes changes to the origin labelling information required for
blended honey in the Honey (Scotland) Regulations 2015. However these changes
are minor, removing EU-focused terminology and replacing it with flexible options for
the origin labelling of blended honey.
Reasons for and effect of the proposed change or changes on retained EU law
The amendments do not make any substantial changes but will ensure continuity in
Scots law after the UK exits the European Union.
Statements required by European Union (Withdrawal) Act 2018
Statement that in their opinion Scottish Ministers consider that the
Regulations do no more than is appropriate
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view the Food Information, Labelling and Standards (EU
Exit) (Scotland) (Amendment) Regulations 2019 do no more than is appropriate.”.
This is the case because they make only those changes necessary to fix deficiencies
in domestic law and insert transitional provisions in order to minimise re labelling
costs to Scottish businesses.
Statement as to why the Scottish Ministers consider that there are good
reasons for the Regulations and that this is a reasonable course of action
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view there are good reasons for the provisions in this
instrument, and I have concluded they are a reasonable course of action. This is
because, in order to ensure that food information, labelling and standards legislation
continues to operate effectively at the point that the UK leaves the EU, they make
only those changes necessary to fix deficiencies in domestic law and insert
transitional provisions in order to minimise relabelling costs to Scottish businesses.”.
HS/S5/19/23/5
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Statement as to whether the SSI amends, repeals or revokes any provision of
equalities legislation, and, if it does, an explanation of that amendment, repeal
or revocation
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view the Food Information, Labelling and Standards (EU
Exit) (Scotland) (Amendment) Regulations 2019 do not amend, repeal or revoke a
provision or provisions in the Equality Act 2006 or the Equality Act 2010 or
subordinate legislation made under those Acts.”.
Statement that Scottish Ministers have, in preparing the Regulations, had due
regard to the need to eliminate discrimination, harassment, victimisation and
any other conduct that is prohibited by or under the Equality Act 2010
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view the Food Information, Labelling and Standards (EU
Exit) (Scotland) (Amendment) Regulations 2019 have had due regard to the need to
eliminate discrimination, harassment, victimisation and any other conduct that is
prohibited by or under the Equality Act 2010.”.
Additional information provided for EU Exit instruments in terms of the
protocol agreed between the Scottish Government and the Scottish Parliament
Statement that Scottish Ministers have, in preparing the Regulations, had due
regard to the guidance principles on the environment and animal welfare
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view the Food Information, Labelling and Standards (EU
Exit) (Scotland) (Amendment) Regulations 2019 have had due regard to the guiding
principles on the environment and animal welfare as derived from the equivalent
principles provided for in Articles 13 and 191(2) in Titles II and XX respectively of the
Treaty on the Functioning of the European Union.”.
Statement explaining the effect (if any) of the Regulations on rights and duties
relating to employment and health and safety and matters relating to
consumer protection (so far as is within devolved competence)
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, has made the
following statement “In my view the Food Composition, Labelling and Standards (EU
Exit) (Scotland) (Amendment) Regulations 2019 have no effect on the rights and
duties relating to employment, health and safety and matters relating to consumer
protection.
HS/S5/19/23/5
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An indication of how the Regulations should be categorised in relation to the
significance of the change proposed
Low – this instrument makes mainly technical amendments in order to fix
deficiencies in domestic law.
Statement setting out the Scottish Ministers’ reasons for their choice of
procedure
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick has made the
following statement regarding use of legislative powers in the European Withdrawal
Act 2018 “In my view the Food Composition, Labelling and Standards (EU Exit)
(Scotland) (Amendment) Regulations 2019 are subject to negative procedure”. This
is the case because it complies with the requirement for the negative procedure
schedule 7 of the European Union (Withdrawal) Act 2018 and, in particular, do not
contain provisions of the type listed in paragraph 1(2) of that schedule.
Further information
Consultation
In line with the requirements of Article 9 of Regulation (EC) No. 178/2002 of the
European Parliament and of the Council, a consultation was launched on 26th July
and closed on 9th August 2019. Local authorities, consumer groups, trade
associations, food and feed businesses including manufacturers, wholesalers and
retailers were contacted.
There were 13 responses to the consultation in total however not all respondents
answered all the questions.
On country of origin labelling of blended honey only 1 additional impact was
identified if it were the case that the Scottish market had different requirements to the
rest of the UK. The amendments which are being made to Scottish legislation in this
area allows for businesses to use the same terms as have been legislated for in the
rest of the UK.
On transitional provisions, all respondents in this area agree that they are necessary
in order to use up stocks of existing labels with the majority agreeing that this should
be provided consistently across the UK.
Impact Assessments
Full impact assessments have not been prepared for this instrument because the
amendments do not alter the Scottish Government’s current environmental policies
and priorities and therefore do not have a significant impact on the environment. The
impact on business, charities or voluntary bodies is expected to be minimal.
HS/S5/19/23/5
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Financial Effects
The Minister for Public Health, Sport and Wellbeing, Joe FitzPatrick, confirms that no
BRIA is necessary as the instrument has no financial effects on the Scottish
Government, local government or on business. Indeed its intention in part is to
mitigate against the effects of UK Government changes to retained EU law.
Food Standards Scotland
10 September 2019