The new Scottish GP contract, what next for people with long term conditions?

• Written by: Dr Graham Kramer — Annat Bank Practice, Tayside — GP
• Published: 18th January 2018

Graham reflects on the contents of Scotland's newly agreed GP contract.

GPs in Scotland have voted overwhelmingly to accept a new contract which will come into force in April 2018. It signals a departure from the boxed-in approach of the QOF (Quality and Outcomes Framework) to one that sets a foundation for the expansion and remodelling of primary care with GPs being seen as expert medical generalists, working collaboratively in clusters, sharing traditional workload with a wider base of skilled-up health and care professionals. It signals less micromanagement of GPs to a more mature relationship of trust, and peer-led, values-based professionalism. It hopes to improve the “mood music” in order to recruit and retain GPs; a bold ambition given the current famine. Also wider teams will pose challenges for joined up working and continuity.

What are the implications and opportunities for the care of people with long term conditions? Some may worry that the end of QOF will see a loss of focus given to the case management of people with chronic health conditions. Hopefully, it will be an opportunity to take a more “Realistic” personalised approach with a primary focus on people, and not simply their specific individual conditions. It should strive to identify and prioritise those with multimorbidity and frailty customising more time for those who need the most care and support and therefore addressing health inequalities. Hopefully, it will move us on from a model that turned our patients into passive recipients of surveillance to one that helps them to be more involved in decisions about their care and supports them to self manage.

The contract suggests that practice nurses will move from traditional “chronic disease management” approaches to one of proactive “care planning”. This implies they will be less interrupted with the tasks of biometric measurement and recording, so they can spend more time helping their patients, identifying what matters most for them and planning care and support to help people achieve their personal outcomes. Care Planning approaches have been shown to be more wholesome and satisfying for patients and professionals alike and linked to better health outcomes and system performance. It is most effective when it is more nuanced by careful preparation of patients, with sharing of personalised information, ahead of a care planning conversation.

However, this will require new challenges, training and facilitation for practice teams. It will require different processes of care with health care assistants trained up to help in more of the measurement and recording tasks such as spirometry and foot screening. They will also be well placed to help prompt people to think of what they would wish to discuss at their Care Planning review. Admin teams will need to look differently at how they identify and plan appointments. Practice Nurses will need training to build on their communication and health coaching skills. Finally, when people do feel more more involved in their care, wider support needs often become apparent. To this end it will be crucial to see how community links workers are deployed as a resource for patients and practices, building connections with the valuable assets in the community that provide more than medicine. It will require recognising and resourcing the contribution of the voluntary and “third” sector.

These approaches are not new in Scotland but are yet to become widespread. Much can be learned about embedding care and support planning in practice from Scotland’s House of Care Programme and building self management support through the Links Worker Programme. However, it will need to be seen as a priority for GP clusters, supported by Health & Social Care Partnerships and Chief Officers. There will need to be a commitment of resource for IT, training and facilitation within local primary care improvement plans backed up with primary care transformation funding. It will also require us to think differently about quality from not simply managing diseases according to medical targets. It will ask us to see how we are engaging and involving people in their care, responding to their health literacy needs and supporting them to address what matters most to them in life (and death) despite their conditions.

Dr Graham Kramer is a GP at Annat Bank Practice in Tayside. He is also Chair of Scotland’s House of Care Executive and an Executive Officer with RCGP (Scotland)’s Patient Partnership Group.

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