Rules order of council 2016, SSI 2016-693. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Could I invite any comments from members of the committee? Nope. Okay. Are the committee agreed that we make no recommendations? Agreed. That's agreed. Thank you very much. Agenda item 2 is on GPs and GP hubs. We have two evidence sessions today. I would like to welcome to the committee Dr Sean Tucker, clinical director of the Lodian Unscheduled Care Service and a representative of the Royal College of GPs. Aileen Bryson, head of policy Scotland at the Royal Pharmaceutical Society. Gabrielle Stewart, policy officer for the Scotland College of Occupational Therapists and the representative of the Allied Health Professionals Federation and Theresa Fife, director of the Royal College of Nursing. We're not expecting any opening statements, so I'll move directly to questions, but before that, I suppose I should declare an interest in that my daughter is a trainee occupational therapist. First question. Would any members like to open up or maybe I could open up and ask you to maybe give us your understanding of how the GP hub model is going to operate or is operating? I think I would address that back. There's three types of hubs that I'm aware of and I wasn't sure which one the committee was interested in, so I don't know if you want me to expand. So there's the Urgent Care Resource Hub, which was postulated by Lewis Ritchie in his report from last year, and for that, that's talking initially about out-of-hours and bringing together all services in a hub out-of-hours, including the GP out-of-hours, but plus community nursing, third sector, mental health services, social care. So that's one type of hub. Since Lewis's report was published, there's been money made available from the Primary Care Transformation Fund to each board to look at developing new models of care, including the Urgent Care Resource Hub, and although initially it was postulated for out-of-hours, it could be used 24-7. The other two types of hub, the Scottish Government and NES, are doing a pilot with what they're calling community hubs in Fife and Forth Valley. I don't know if you know about these ones, but these have their heart GPs, and they take GPs who've just qualified post-CCST. They do a fellowship for a year, working with hospital colleagues, learning some new skills, and then for two years they're in health board-funded positions as community physicians. They're running slightly differently. The Fife model is a day hospital type model, where they're working with integrated teams. The Forth Valley one has some inpatient beds as well, and the third type is there's an integrated hubs, which have been developed across the country, locality hubs, by the integration joint boards, bringing together services, usually in-hours, and providing a single point of access for GPs and for patients to access these services. The hub is quite widely used at the moment, and they're the three ones that I'm aware of, and I wasn't sure which ones you were interested in. That's helpful, very helpful. I'd like to come in at this point. What do you see as the opportunities that we've got to try and change the way in which care is provided through this model? I think that there lies a problem that's just been described very well there, as we're using the word hub in many different ways, and perhaps that's something we need to unpick, because sometimes a hub is seen as a structure, as a building, as a co-location of service, and that might be helpful, but it's not necessarily if it means the patient or the public or more junior staff have to have long distances to access that structure. Other times it's about a network, and a network which in fact describes better than one which is for trainee GPs, but the network could be wider in terms of the network, because if you are talking about integration, you're not just talking about healthcare professions, you're talking about social services, you're talking about third sector and other sectors, so I think that the network model is one that we would support, because actually in order to deliver what we're doing, we need to work together. For us, and I hope that you've had a chance to see the set of principles that were put together by all the primary care professionals that came together, and we believe that it is really important that we actually focus on primary care and really be clear about what we mean and where those services are, and what support people need, but that sometimes is not always easy when some of the funding models you're going to hear about, which are the pilots, tend to focus on one professional group like GPs rather than really focusing on the multi-disciplinary team, which is what we're hoping to get across today, and that can be from across all of the team, and really support that in a way that drives that type of working, and that might be multi-disciplinary, but it could be multi-agency as well, because if we're at the heart in primary care within community, it's important that we actually drive things that way. Alison Johnstone Yes, just picking up on the point that was just made, the allied health professionals in your submission, you highlight that issue that we're speaking about, multi-disciplinary collaboration and moving towards that, but there still seems to be a uniprofessional nature of workforce increases. You point out the GP increases and I'm not suggesting for a second that they're not needed because they're very much needed, but what support do you think we need to genuinely facilitate this move to a more collaborative model? Alison Johnstone Scotland pointed it out that there hasn't actually been a real shift in funding in a workforce planning way for a multi-disciplinary team. It's been very uniprofessional, and the other thing that hasn't really happened is to really look at who's coming to the door of GPs and how many of those people could actually be seen by an AHP rather than a GP. We appreciate that we do like more workforce, but it's which workforce do we actually intelligently use. I think we suffer from a real lack of statistics around allied health professionals to actually build a body of evidence because we're often not recognised within the ISD and within other statistics as well, so having a representation or having some kind of analysis of who's coming in the door, and the other thing that we suffer from is that often the perception of what people think we actually do isn't actually right, so we've got a good example in Breakin where looking at physiotherapy and atriaging to physiotherapy, it was seeing it backs and knees and not thinking about the broader role of physiotherapy around public health and occupational therapy, and the other AHPs suffer from the same misconceptions of what it is that we actually can do. Alison Johnstone Can I comment? I would agree with the three sentiments that have been expressed already, and the lack of clarity around what a hub is has come up in all kinds of ways. When health and social care integration was first talked about, then we've seen lots of emerging virtual hubs, so I would agree with what Theresa said about not concentrating too much on the building but actually looking at how we actually service the local population, so we originally thought that was where the hubs were coming from. I noticed that in the committee papers that you talked about GP hubs, our response has talked about community hubs because we think you have to be thinking in the round. From a pharmacy perspective, what we are seeing and we are very pleased is an increase in recognition that pharmaceutical care is an essential part of that patient care, and with that a willingness to have a pharmacist as part of the multidisciplinary team. We are seeing that in all the different models that are emerging in lots of different ways, which is very heartening for us. We are pleased that, in the circular that came round about the new funding for the 140 pharmacists, there is a commitment from the Government to evaluate the new models. Going forward, we have to evaluate everything that is being done so that, longer term, we have something robust in place that resonates with the comments about pilots. Generally, we hear that lots of good work going on, lots of pilots, sustainability can be a problem. The committee, on a previous occasion, was made aware of the Nuka model in Alaska, which, if I am wrong, I am wrong, comprises a GP, a pharmacist, a mental health practitioner and admin support. I may not be entirely right as to who the team is, but it has led to significant advances in reduced waiting times. They do not have waiting times, they just get seen on the day that you want an appointment. I just wonder if the panel could reflect on, in the community hubs that exist right now, if there are spokes, as it were, to that wheel, which should be there, which are not at the moment, in terms of professionals who you would like to see more of in that team? I think from the urgent care resource hub, which actually is being developed with a multi-professional funding model, so it is not a GP funding model, it is a multi-professional one. I think one of the areas that we have realised as physiotherapy has a big part to play and we are looking at adding those in as well to the hub. The other bit that was highlighted in Lewis's report, which is often forgotten, is the third sector, particularly for mental health. The number of mental health calls in Lothian to the out-of-hours service has increased 41% in the last four years. It is an area that we really need to address. At the moment, all of those are dealt with by a GP, which is not necessarily the best use of resources. I think by increasing, particularly, mental health. Although we have been given money to set up an urgent care resource hub, this is not recurring funding. We cannot employ lots of new staff. We have to rearrange what we have got. That is one of the challenges, particularly with mental health. Using the third sector, which is out there and is brilliant at some of the mental health care, may be a way that we can get over that. Some of those are 24-7 as well. I think we need to be open to new ideas about who we can use and how we use people. Certainly, the third sector would feed into that. I would also like to add that occupational therapists are working in Wales around a project with GPs on mental health alongside their art therapies. GPs also support people with mental health issues into work. The whole employability aspect is also something that we need to think about as well. The model that we are talking about really fits very well for Scotland. You will hear later evidence from very remote areas in Scotland, because it is that geographical model that we always have to consider. Too often, sometimes, the city models drive what goes on. In that, though, if you are in Glasgow or somewhere, you have as much of a travelling distance to get from one side of Glasgow to the other, but it is the access—I will come back to that again—about how patients access the service and how staff who provide the service access. If there is limited public transport, they are not going to do that. Coming to the point that we are making about Sir Lewis's report, we were part of that work, along with others here at the table. We all said at the time that it is so obvious that, when we did out-of-hours, the link is obviously with daytime, but we tend to treat them differently. We have done an amazing piece of work on out-of-hours, as a group together, and came out with a new model that was going to drive that forward. However, we were so frustrated so often, because what needed to happen was that we should have looked at the whole picture together. In fact, it does not really matter who finishes at five—it is about that continuity. It is about how you ensure that, in fact, there is that change of practice that happens, as many of my GP calls me to tell me that four o'clock call on a Friday afternoon before they face thinking that they are going to face the weekend. So, there is something for us to learn about that. I do wish we had had the courage to say we would have made that whole one model for the 24 hours, rather than saying, this is what's there. So, most disciplinary is well recognised within the out-of-hours, well established in the way of going forward, but it isn't necessarily in the actual day service yet. It is there, in principle, but it isn't what's being carried out. An example of that is IT and eHealth. At the moment of funding a GP model, which I don't—this is not meant to say GP shouldn't have what they need. This is not what that's about. But, actually, that GP-funded eHealth model may not talk to other professionals, may not talk to pharmacists. So, yet again, we're doing something that's actually stratified for one group, when the whole idea we should be going forward is to say that the patient should expect all of us as healthcare professionals and of agents to be able to talk to each other and ensure that we are sharing information. Thanks, convener. Thanks very much for coming along this morning. There were two things I wanted to just raise. One was round about, if you look at the GP resource, it's an expensive resource, it's a constrained resource, and clearly the objective of a lot of what we're talking about is how much of that work can you move away to other professionals. So, I suppose I just wanted to get your view on how far down that road have we gone and, in a perfect world, how much further can we go down that road if you had a blank bit of paper to just have free reign to go and design the thing? How much of what GPs are doing today do you believe could be done by other professionals? And the second question was, thanks very much, Dr Tucker, if you're running through the three types of hubs and I was struggling to take notes of it. So, if you could maybe just go back through that, but with a specific emphasis on the funding model that lie behind those, because I think you kind of hinted that they're funded in different ways, which might be part of the difference. And very finally, community hospitals, how are they different in your view from what we're talking about in terms of community hubs, as such? Okay. So, the three different types of hubs, as far as funding is concerned so far, the community hub pilot in Fife and Forth Valley came out of the seven day sustainability task force and are funded through that and are in conjunction with MERS. I have to say I'm not sure if that is a three year fixed funding or what the plans are for that. There's an evaluation plan to see how that looks. The urgent care resource hubs, the 10 million from the primary care transformation fund is in the process of being handed out to boards so that they can use it as they wish. So they might not all use it to develop urgent care resource hubs, but they may use it to develop something like that. And that is a one year fixed funding, there's no recurring funding for that. The integration joint board locality hubs are being funded by the integration joint boards, again by reorganising what they already have because there's no new money for that. So that would be the funding streams. And just to address that none of the community hubs that I'm aware of, certainly not the urgent care resource hub, would be for patients to travel to that. The urgent care resource hub would either be a virtual or a geographical location with staff sitting in it who would sort of, so we may have our out of hours have actually our own hubs which take the course from NHS 24 and they would pass on the work to the GPs who would be on the ground in the GP emergency centres out of hours. So it wouldn't be that patients that would have to travel to this new location, it's just this new location would organise the work and send it out to the community nursing teams or may be able to deal with it by phone. As far as the GP resources concerned, I think there's two things. I'm not sure we should be focusing on improving other work as nurses, physios, pharmacy to replace GPs. I think it's work that should have been done a long time ago to recognise the need of a multidisciplinary team and it's come to the fore now because of the GP crisis. But actually I think we should recognise them for the unique skills they have and what they can bring to patients as opposed to saying because we haven't got enough GPs we're going to parachute in these other people to cover the work. So I would sort of turn it round and say that primary care and community care is a whole multidisciplinary team and we need to recognise what jobs people can do. And I think there is some work going into that, the new GP contract will probably move that further forward as GPs concentrate more on what they only they can do, the complex care, things like that. But I think it's important to value the multidisciplinary team for what they bring, not just gaps they can fill, if that makes sense. Yes and no, I don't disagree that what GPs do is very very valuable, but that is not the same thing as saying that GPs could also be doing things that they don't need to be doing. Oh yeah, no I agree absolutely. I agree GPs are doing things that could be done by other people. And I suppose what I'm trying to dig into was can you kind of give an estimation of that? I know it's hard, is it half of it, is it 10% of it, is it and how far down that road it would come, because at the end of the day that's where the solution lies, isn't it? Just adding to that, it's very difficult to quantify that and I agree with what Sean says about looking in the bigger picture and longer term, but having small pieces of work which can give you an indication of things, there's some work which says some figures around 6% of who turn up at A&E could be dealt with by minor ailments service and community pharmacy, and around 10% of who turns up at GP practices could be dealt with in community pharmacy through the minor ailments service. So there is a bit of also about going back to what was said about the third sector, about educating the public on going to the right person at the right place, at the right time, if that service is available for them, so there's that. There's been some work done with the new funding looking at how much time a GP spends on medicine related queries and acute prescriptions in their surgery every day, and that varies on the practice, obviously that's the thing, every practice is completely different. Maybe between one and a half and three hours a day, maybe 40 to 50 acute requests which can be dealt with by the pharmacist, so that's where the evaluation is going to be very, very important because we don't actually know those figures yet, we just have the principles to guide us on actually making sure that everybody contributes what they can contribute, and that the Welsh are using a phrase at the moment, only do what only you can do, which I think is kind of an interesting little nutshell to put it in, and although there's a crossover in that everybody does a little bit of everything when you have one person in front of you, then there is something around that, and it is about us all contributing what we've got uniquely, but linking it together, and as Theresa said, the IT is part of the enabler for that, which we don't have at the moment. For that transition, so we don't really have the data that would demonstrate what you're asking for, but we should get it, and I think without understanding that, because I would agree with Shan that it's not about not wanting GPs or recognising their expertise or not wanting nurses or physios, it's about valuing the expertise, a good multitude of team, builds on relationships, and actually bringing the best of each other to a team, and that's what we should be after. But the public need to understand that, and unfortunately, at the moment we use a message all the time, which just talks about a GP practice, and then we say to the public, actually if you come here, you should be seen by a physio or a nurse or whatever, we should get that better, because actually if we don't, they tend to think there is actually a crisis within the service, there is actually a shortage of GPs, but there's also a shortage of other professionals, and that's not ever debated very often. Great much community hospitals, I think they're a vital part to play within this, but not everywhere in Scotland's got community hospitals, and again that's what I meant by not getting focused on buildings, because some people have designed a model that's based around a building they have, but if you didn't have the building, then you haven't got anything to focus it on, so that's why we're saying be more virtual, and I would agree with Shan without question the way the urgent hours was working within and out of hours was not around a building, it was around actually again a focus of actually how a team, but community hospitals have a very good part to play in this, and actually how they are seen as part of that community process of enabling people to be more local than actually always actually being where they need to be. You said how far can we go? We've gone very far in fact, but what we haven't got clear yet is the referral processes to allow those professionals to act independently, we haven't got the means of them being able to access the patient record in the same way across all those teams, so it's not much use when you're saying to the patient or the public, I will treat you and see you, but I can't actually do what I need to do, or you might make the wrong recommendations, you don't have all the information, so we're going to have to really be brave enough, and it is hard because we tend to think of the record as being one group's record, we're going to have to find a way of actually working with that across all the disciplines, or otherwise we're not going to do that, so it's more about some of the processes we could do to improve it in order to make that happen. I fully support that, and I think access is hugely important, and what we don't want is GPs acting as gatekeepers or referers to other services that they could directly access, so I think there's a lot about educating as well, where you can directly access to an AHP, but the public won't necessarily know that, so I think there's a lot of work to do around forming an intelligent network that really understands what the resource is and how you access that, and that would apply to the third sector as well. Donald, it's a really good question about pharmacists. Actually, yesterday I visited a community pharmacy in the Highlands, and it was a high street pharmacist, they were saying, I'm sure this will be familiar to you, but they were saying with more infrastructure and more investment and improved IT around things like accessing patient records, they could do a lot more. Here, we're talking about putting pharmacists into general practice, and this may be an unfair question, but which of those models is better? It's no better model, we have to look right across the piece. Two thirds of the profession work in community. If we're to have the capacity to actually work as a multidisciplinary team in and out of hours, we have to use every resource that we already have, and it's about working smarter. Theresa referred to the out of hours response, which we did collectively across the professions. There were lots of ideas in there, and I think there are lots of ideas to develop community pharmacy where it works in tandem with the pharmacists working in GP's practices. It's ideal for a community pharmacist to be liaising with a pharmacist working in the GP practice. They can talk pharmacist language to each other, and they can deal with the medicines related queries really, really quickly. That pharmacist should be a conduit. There are models where people work part-time in community pharmacy and part-time in the practice, and that actually has advantages as well. Again, it goes back to we need to look at all the different models and think what would work best in that locality. In some places, it's only the community pharmacy that's there. Geographically, there's not many other health professionals around, so you have to have a different model in that respect. The IT is an enabler. There has to be a culture of sharing information between the professions, first of all, and then the IT obviously helps with that. At the moment, I'd say that there is no one ideal model, but we have to make sure that we bring all sectors of the profession together with this and actually be very smart about how we develop the services. Remember that, out of hours to a GP practice, it's not out of hours to a community pharmacy because they're open much, much longer hours. There have been pilots where a pharmacist in the borders was given access to records because he was the only health professional around on a Saturday afternoon. Lots of different ways of working and lots of good stuff going out there. We just need to actually have a look at it in the round and bring it together. It's not an unfair question, but it's a difficult one to answer. I agree, and there's a tension, but we don't want to replicate resources. At the same time, I'm very interested in them working together in community and in practice. It can be done. There are some pilots out there trying those different models, which is very, very good. As we go forward, we've all talked about workforce planning in various ways, but workforce planning will be important because we need to make sure that we support all the different sections. We know that pharmacists are really keen to come and work in GP practices and they're moving from other sectors, and we don't want to disadvantage one part that needs to be developed as well. I agree with what Gabrielle said about the referrals. There are a lot of instances where you have to go through the GP to do it, and you could actually be much, much smarter and make it more person-centred and make the patient journey much, much smoother and get it right for that person first time if we were enabled. That would take some, there's some legislative changes that need to be done, there's some contractual changes. There is, the phrase transformational change is not overly dramatic because that is what's required. In the hours period, we already work very closely with community pharmacies, so most boards have what's called a professional professional line where if a patient presents at a community pharmacy, they can contact a GP and get a call back within 15 minutes so the patient doesn't have to go through 24, so we find community pharmacy incredibly useful and I agree that the more skills that they have to manage patients within the community pharmacy would be very helpful for us because as Aileen said, they're often open out of hours and we do have a very close working relationship with them. Hi there, I have to declare an interest because I'm a pharmacist and I'm registered with the general pharmaceutical council. I worked for 20 years as a clinical pharmacist in a psychiatric hospital specialising in mental health and I suspect, I mean we talk about our profession as being hidden in full view so I suspect my colleagues around the table might benefit from hearing a little bit about the different roles that pharmacists do in terms of hospital pharmacy, hospital clinical pharmacy, primary care pharmacy, what that's traditionally been and what it's going to be going forward and the community pharmacy as well and also I'm interested in you know having been a pharmacist for all those years I know that there have been long been a recognition that the level of education that we have and the level of knowledge that we have is possibly underutilised in the health service. I see that way back in 2002 the government recognised that pharmacists were an underutilised resource in the health service. What have been the barriers to you know bringing the profession on and enabling them to participate more fully in healthcare so if you know if it was recognised back in 2002 why hasn't it happened by now in 2016? Well these things do take time. I think somebody who I think was shan mentioned earlier there is the driver at the moment is the shortage of GPs which has driven things forward much faster and that is fantastic but it's about you looking in the longer term the bigger picture. I think as a profession we have been very not very good at shining our light and the focus has always been on supply we've not been very good at actually emphasising that intrinsic to that supply came patient safety and you were never supplied a medicine until the pharmacist was happy that it was safe for you to have and we've not been very good at getting that message over to the public and then there's lots of other layers in there in that we're changing from what I call the Harry Potter world of lotions and potions in the last century to somewhere where we now have complex much more complex care. If you think back 20 years people who are in a care home now would have been in a geriatric hospital in 20 years ago and primary care has been asked to do much more than it was you know that shift between primary and secondary. We're moving to an era which we all know about the demographic changes where we have people living longer there are many many more medicines when I started practicing somebody with diabetes would maybe have two or three medicines now it's not unusual for them to have 15 so we don't make up medicines anymore we actually produce the the pharmaceutical care to make sure that complex array of medicines is safe and to try and minimise how many medicines somebody is on so we're not good at letting people know that we've had that five-year master's degree and it's all about specialising in all aspects of medicines. There's a group through prescription for excellence at the moment talking about valuing medicines which we're involved in and that's about getting the public and patients involved so that we get a bit more idea. People know what a doctor does they know what a nurse does I think the allied health professionals probably suffer from the same as we do that not everybody knows what a pharmacist does and we have to get much better at getting that message out there so that when we have this hub not a GP hub but this team people understand where to come to to get that advice and I'm happy we've done some visits we've met with some of the committee but obviously we're happy outside this meeting to discuss bits and pieces of that further thank you very much. Well don't look a gift horse in the mouth. Gabrielle then Marie we'll go back to you if you want Marie. I think there's just one more point around leadership as well and who is commissioning and making decisions and I think that we've struggled to get representation sometimes at the top tables so that we can share what our expertise is I believe they're going to be forming GP clusters which aren't necessarily going to be coterminous with the integrated joint boards and there's going to be a quality cluster lead for each of these clusters and I suppose what I'm sort of wanting to say is that we want to make sure that that is truly multidisciplinary and reflects the people that could potentially make a difference to the people's health of Scotland. A chance of defining cluster. Marie do you want to come back in? Just I'm interested in some of the barriers to community pharmacy to getting more involved with the multidisciplinary team so you mentioned about how straightforward it is when there's one pharmacy and one GP practice but it's much more challenging for the usual high street setup where anybody from any GP practice can walk into a community pharmacy looking for pharmaceutical care and I know I mean I've done my prescribing course I know that one of the challenges is that it's very difficult for a community pharmacist who has the prescribing qualification to prescribe for people coming through the door because the prescription pad is linked to a GP practice so they can't prescribe for anyone coming through the door. I wonder if again from my colleagues around the table who aren't pharmacists you could explain some of these barriers to community pharmacists getting involved in the more rounded clinical practice. The funding in the past was set up so that a community pharmacist would go to the GP surgery and have a backfill local pharmacist to work in the pharmacy. I think community pharmacy suffers from being in a retail environment which differentiates it from being in a practice and a surgery so the people and patients don't immediately have the same attitude going into what they see as a shop whereas as I say the the background work that's been done before they actually get the end point of a package is what they don't see and it's about the package of care not the package so there has been funding and legislative and there are contractual difficulties there which are barriers. The kind of things we hear anecdotally are concerns about confidentiality if somebody is speaking over a pharmacy counter which is why consulting rooms were funded way back as part of the right medicine and so there's something around that understanding that the confidentiality in a pharmacy is exactly the same as in a GP surgery with the reception staff and I think they do suffer structurally from that and not having the IT links and the funding for the prescribing but there have been there's if the IT links were put in and if we joined up the services there the community pharmacist could be doing very many of the same things that the pharmacist in the GP surgery is doing that that is not a difficult wouldn't be a difficult thing to do and I think the more the public saw that joined joined upness and referrals between the different professionals and referrals from the practice because we know that people turn up at GP practices who should be at minor ailments we really want to get them to be sent to the minor ailments so that they understand that that's where to go rather than have that treatment in the practice taking up time in the in the practice and so those barriers are there they're not insurmountable and I think with slightly nuanced view from policy makers and funding then there could be a lot of improvements in that and developments and the out-of-hours developments there were short-term medium-term and long-term things which could quite quickly you know be put into place and to actually create take down a lot of those barriers and so the public would understand that the community pharmacy can be a go-to place and there's two levels where you have to think there's the accessibility of having a high a health professional on the high street where they can ask for that information and then there's also the pharmacy staff there who can help with public health and and actually have that as a healthy living area so that there's there are two different things going on there which have to be recognised more. Come back to you for the time at the end Marie. Colin, and then Treasor. Thanks very much second leader. As we mentioned a couple of times that the driver for the I suppose the current emphasis on the hub model is that it is a current GP crisis fantastic or otherwise but but I think it was actually Treasor made the point that that there are other workforce difficulties and other parts of the primary care workforce at the moment so to what extent do you think that the other primary care professionals involved are prepared for that the proposed changes that are likely to come forward and from a capacity point of view how readily can the other health professionals actually pick up the work from GPs I'm just thinking one example is the proposal to recruit 140 pharmacists for example where are these pharmacists going to come from? I think workforce planning across the teams is not good enough at the moment we wouldn't have a clue about a projected number of either pharmacists or physios or outees or nurses within the primary care team because we do tend to still focus on at the moment the real data they've got is actually wherever how many GPs they have and that's what we tend to refer to when we talk about primary care so we do need to get a better baseline of what we have and then understand what the growth is and I think my colleagues referred to that earlier on how workforce planning has to look at those disciplines we've had funding put out for 500 advanced nurse practitioners there isn't 500 advanced nurse practitioners out there they'll be growing them but unfortunately what's happening as soon as one area develops a set of them another area rops them because they're short and so it is actually at the moment I'm afraid the notion that there is actually always other professionals the thing that I want to just come back to and really was into comments that Marley was making is that the way of working multidisciplinary is actually about a way of working with respect for each other and so it's not just about whether there is actually barriers for pharmacy it's actually barriers for the team to work those barriers are there I've mentioned a few of them already IT means a referral means of accessing how you get respect and integrity for each other so it's not about one against the other it's about actually how you do that and I would say this has been someone's been around a long time now within our professions perhaps we've moved out of very silo professional thinking into a better multidisciplinary thinking I would say that would have been the time we wouldn't have actually had money shared opinions on these things a few years ago it would be about our own profession but coming back to the final point is transition and funding if you look at the pilots of the and the testing we're really into that's the big thing at the moment to be pilot and test everything I'm very worried now that none of it seems to go actually into a change because if you are really short of money and I've been in that place in a board where you're in development and someone says there's money you'll take it because you want to try something but actually shifting the resource from what you currently provide to actually neighboring the resource to be there to employ permanently the people you need in those teams is really hard to do so people might have ideas of having a wider team but they won't have the long term funding because actually the pilot ends or the test ends if I was a manager right now out there I think I would be I would just be a lot at a loss as to which of these pots of funding would be best and what would actually give me in the longer term the transition that we need actually so that's going to be an issue so we can't always grow people and then employ them and get them into place so you can get the better team working so that would be a perennial problem and some parts of Scotland more so than others because they do have problems of recruitment just on that point is the temporary nature of these you know the more pilots than Heathrow take a scenario is the temporary nature of that a barrier to people going into it because they think well I'm only going to be in for a year or two then it's all over and how are we going to end up if this is the model where we're heading for yes how is it going to become sustainable well our workforce planning is actually predicated on how many posts you have so if you're piloting and testing you actually don't have a post you have a temporary nature so when you're forecasting your workforce plan you'd say well I need 15 amps or advanced nurse practice whatever people won't say that if they know they can't employ 15 amps because actually it comes down to that's the funding you have and if you train people and then you can't put them into a post because you don't have the funding so we're in a we're really in a difficult place I like pilots too I like testing we're just doing too many now we think that's actually transformational change and with my colleague transformation change is doing something much more radical than piloting and testing it is about saying this is the team that we need this is how we need to do it I'm being prepared to do workforce planning actually in a way but people won't go into a job that they know that in fact it's going to be ended within a year or in fact the training for advanced first practice is really really hard and it's actually got to do a huge commitment quite rightly it is it's actually very important it is but why would you do that if you don't think you're going to get a job at the end of the day you know so we have to find a way of actually looking at more the permanent changes we needed rather than reliant on funding that's going to run out and been two to three years and Sean we did you want it yeah it was partly to say looking because the funding is short term what we are all having to look at is using what we have in a different way and I think as Ivan pointed out we don't know what percentage of GP workload can be transferred over so we're not absolutely sure how many of everything we will need yet so I think trying to reorganize what we have and having some funding for that and some time and space to do that is essential and then we can look at by measuring and getting some figures and some evaluation about what we need going forward and that's going to be where we need the money because we are going to need money going forward and as far as developing multidisciplinary teams I think that's absolutely brilliant but as has been mentioned repeatedly that the GP workforce crisis is one of the main issues I don't think however many multidisciplinary teams we develop we will be able to replace GP's nor do I think we should want to replace GP's so we are going to have to grow our GP workforce as well even to to stand still because as well as the GP workforce crisis being a driver for development of multidisciplinary teams it's a changing demographic and the amount of care you know the 2020 vision people want to be cared for at home or in a homely setting and to do this we have to change our view which at the moment and in the press and everybody talks about his hospital it's a cute view there isn't a big view about primary care and for the NHS to sustain it's going to have to be primary care Clare Thank you very much for the briefing papers that you provided they were really helpful in terms of setting out a vision of what the multidisciplinary team could potentially do but what I'm hearing in a series of answers to questions is that there's a real lack of statistics of evidence of how GP's time could be spent better or things that they're doing that other professions could pick up and so how are we going to demonstrate in the long term that actually to expand the multidisciplinary team is a benefit to everyone so can you tell me what what you're doing is professional groups to actually look at statistics look at trying to build up some sort of evidence base or some sort of baseline. Gabriol? A lot of pilots as AHPs that have been really successful and will have the statistics and the evidence but there's no forward funding so it's been funded on a temporary basis so we've had some fantastic examples that then stopped because the money hasn't gone with it. One of the concerns I have as well is incentive what incentive is there to work in a multidisciplinary way and it's about being collegiate it's about trust it's about lots of things but it's also what is the incentive so yes there's a GP crisis we have other aging workforces as well so it's if we can see it as a whole workforce and the whole offer and understand that true offer I mean I sometimes think what is the dream team we don't know that yet and it might be different in different places so yes we do need to test but we also need to make really brave steps because at the moment I think we're just tinkering with with pilots and I would really agree with Theresa in that regard I think we need to be much braver I think all the professional bodies have their own evidence base I think from you know we've all got our own stories that we can share it's about pulling it together in a sort of systems-based network-based approach and understanding the full offer of all of the workforce. A question in two parts really I think we heard earlier that as of now right now 10% of people presenting at GP surgeries could be dealt with by the minor ailments service at the local pharmacy I wonder if whilst we can't quantify this exactly at all but I wonder if there was a way that with the resolving IT issues so that pharmacists could have better access to notes they could see what people were already taking and public awareness how much more of that GP workload could be taken on by community pharmacists if we got everything right and then secondly we're all aware in this committee that one of the biggest areas in growth in terms of demand on the health budget is in GP prescribing and that's about the demographic it's about the aging population people living longer and needing support to do that I wondered if if there was more of that coming through pharmacists is there an opportunity to rationalise that or reduce that just through the added expertise that pharmacists have in what they're prescribing not to belittle the prescribing powers of GPs of course said earlier it's not all about taking the workload off of GPs it's about filling the gaps in patient care so that each of us around the table and all the other professions aren't here are actually contributing in their unique way so that the patient actually gets the most benefit from the whole primary care team and the prescribing and pharmacists have always had a role in the governance and the decisions of prescribing so that happens in the GP practice and in the managed service more than it does in community back to the referral systems and there are times when there's changes need to be done to prescribing which could quite easily with an independent prescribing community be done without actually having to go back to the GP and that's a very simple way of saving time because we both know what the end of the conversation is going to be but you actually legislatively have to go through that process so there are lots of small things that can be done to save time if you think about where the minor ailment services is then at the moment we have a minor ailment service which is suitable for certain parts of our population to go to as the first put as using pharmacy and community as the first port of call so if that's okay for some of the population why is it not okay for everybody so I understand that government is committed to having a look at reviewing it which we would wholeheartedly support because it could be widened out there are other things which could be done within the minor ailment service and there was project a few years ago where we actually use had some pharmacists who did some of the minor illness training which they could do quite quickly which meant that in hours they actually used this for out of hours but had they used that in hours in a normal day-to-day business that could actually have helped the appointments at the GP surgery as well so expanding that minor ailment service reviewing it and how it works and then thinking about better direct referrals to all the other professionals without having to go through unnecessarily to the GP and then it means that when you do have to contact the GP it's because it's when the GP is actually needed and there's always been the system of red flags where the pharmacist will refer and that happens all the way through it's a domino effect so lots that could be done and the we would really welcome a review of the minor ailment service to think how do we better triage people and use that opening which is accessible long hours as the first port of call and make it there are some pharmacy first pilots going on again we'd like to see that opened out more we've we're running short of time so we need to be really quick with answers on questions gabriel can yes i just wanted to highlight that some hhp's are prescribers as well and also a little bit around the associate physicians and link worker roles that are often mentioned at the moment and we think that you're bringing in new professions or new roles when you've actually got an existing workforce that could fill some of those posts or and more successfully and actually be able to to support people through their professions rather than these unregisterated um workers so it's really just to think about the workforce as a whole but also be very very careful about announcing about new workforces that could come forward when you haven't actually really understood what the offer is from the current one what's concerning is that it is often about what i meant about not about relationships and structures it's about who wants to employ people and like to have that line management responsibility and we have got a bit focused on something we'll find a new role yet we have a team there we could work differently with and i would say that is absolutely can i just make a point about clearing data absolutely key isd have got to change what they record and what they start to do a data primary care workforce sorry comes out very shortly which you'll see it it is only about the gp practice and those who are employed within the gp practice and doesn't capture all the others we've just been talking about here today so we do need to get better data males my question relates more to the real new gatekeeper potentially in the gp hub would be reception staff and how do you think they can also see professional development to make sure they're directing people to the right professional you know for example 30 percent presenting in a gp caseload should be going directly to a pharmacist i think 15 percent are actually phoning up to get advice on medication and repeat prescriptions where can that conversation be had at the initial stage of someone phoning up to make sure that they're not phoning up to say i want to see my gp and then you find out where to actually send them i would say in the urgent care resource hub which we're talking about most patients will still go through nhs 24 so will have had it you know triage but we're also the highland hub has a gp or clinical presence within it some of the time so that there is immediate support there so you're not putting receptionist under pressure to make clinical decisions also in out of hours some of the money that we've bid for from the Scottish Government in Lothian is to put receptionist through customer training and increased training for them as well so i think it's concentrating on the wider team and not just medical or nursing within it so to try and get training i think that the gp practices there's no plans that the gp practices would change the way that they work at the moment that they wouldn't suddenly all change into gp hubs so i think reception will be important to sign post and there's a lot of that that's done already and there's a lot of posters and advertising in gp practices about where you can get help and i think we need to be smarter about that what had been mentioned in the richie report and i think we do need to think about is maybe more national patient education as well not just about where they can go to get help but about self-care because i think there's a lot of of self-care stuff that maybe particularly younger patients now contact healthcare professionals certainly is a gp working out of hours idea with a lot of things that my granny would have told me about when i was little so i wonder if we need to look at that as well we have been discussing sort of focusing on ensuring people see the right professional at the right time but i just wondered if you had a view on how these primary care reforms will help tackle health inequality i mean some of this has been driven by the fact that people are living longer but there are a lot of people who are not living longer and these are people who are very hard to reach so i just you know i know we're short of time cuvina but just you know your opinion on whether or not this will actually help those people point that's why i kept referring to access and absolutely some of what we're doing is virtual models but if we become focused on the building and we know already that those who actually have not got you know their their lifestyle isn't actually the way it is where they would turn up as an appointment in a practice in a centre there is an issue already what we mustn't do with these new reforms is actually risk the chance of people getting to the service they require and making it more difficult for them to get to i believe in fact if we open it up the way we want to go we've other disciplines there is actually more of a chance to actually ensure that people have accessible services because there's more people they could go to if they feel they have a barrier with one particular professional because that can happen that they proceed that professional has not actually paying attention to their needs so it is the most important all through the out of ours report with Lewis i kept saying do not do anything that actually maximises inequalities be careful because professionals can be very good at fixing it up for themselves that makes it better for them and doesn't necessarily make it better for people who need the service yeah i would just say that i think what we are aiming to do here is offer new routes and not shut down any so if patients turn up and still want to see their GP then that will still be available we're not talking about shutting anything down we're talking about giving more choice and hopefully providing increased access for people who find it daunting or intimidating to access through the normal routes and there's a couple of things that when patient education them i've always felt that we should patients every day should get something like you know the yellow pages or whatever it is that comes every year and you keep it and it actually guides you through what you should be doing and has any of that been i'm sure that you say piloted yeah there was a know who to turn to campaign which would highlight who to go to for what in different areas i know there's just being an app developed as well because about patients can look on the app and find out what's open and what's accessible in their area as well i don't know of any phone books or yellow pages i'm talking about a similar thing yeah you keep in the house that's a yeah you know something that you can go and reference anytime that tells you basically the pathway that you should be going if you've got ailment a or ailment b i mean if you're telling me that i bet you most of the committee here didn't know there was an app or a no the app is is um just in development it's not out there yet but the know who to turn to campaign i think started in grampian and they had leaflets and everything that went out about where only grampian no certainly but it has come out a wee bit further and finally see un name the how will we know if this has been worth it how will we know if it's you know producing the goods and value for money and how is it how will we assess that there it is difficult with healthcare to make targets and quantify things because you can you can if you focus on one thing you can inadvertently topple things around otherwise but there are some qualitative ways you can look at things we're encouraging pharmacists to do audits in their practice to benchmark you can look at patient surveys in what's the quality of life for the patient in in care homes you can have things like you know your better appetite less swallowing difficulties it's there's less time for the the staff to actually do the medicine rounds you can look at unplanned hospital admissions and referrals there are lots of markers i think shan mentioned though we do have to have the time to actually do that and it comes back to what's been mentioned already about the thoroughly and robustly evaluating what's there and looking at the different ways of looking at it but there are different measures you can take comes and with indicators because it goes back to my point the data we currently collect wouldn't tell us we're going to get there it would tell us some things i think we have to recognise that the data that's been done for some time has fitted the service as it is we have to step back now think what that new service is what that new model and find the outcomes and indicators and actually change the data collection that we do um and actually start to get somewhere with that okay yep shan you want the final as well as um i think we need to ask patients as we said i think we need to see if patients prefer it but also i think we need to ask staff um an incentive for working in a multidisciplinary team is it's fun we need people to work in the health service we need gps and we need all these other professionals so we need to make it an attractive career as well so i think we need to look at the final point gavriel i think this ties in also with health inequalities so we need to make sure that the people that we're communicating with actually understand us and i think i can feel my um royal college of speech and language therapists behind me um screaming that we need to be a communication nation as well we need to make sure that uh people who you know experiencing health inequalities do actually have access to all the information and services thanks very much there is um i'm really surprised and i don't want you to come back in this because we've no time is that no one has mentioned social care in the whole ever which really surprises me but thank you very much or maybe you did in a mistake if i did i apologize no here we go here we go but i think it's a big issue that um we didn't get into the offer we didn't get into and we should we maybe should at a future time thank you very much and we'll just suspend briefly could i welcome to the committee uh our witnesses floor this morning dr elaine mcnotton who is a gp and deputy chair of policy for the royal college of general practitioner scotland elaine tomson locality team leader uh in the pharmacy uh dundee health and social care partnership and a representative of the royal pharmaceutical society christopher rice who's a senior char's nurse nhs shetland and linda harper associate nurse director nhs grampion we're not expecting any opening statements so we'll move to questions we have um got a very limited time available to us so short questions short answers would be helpful and not everyone needs to answer every question so would anyone like to begin richard good morning and welcome um me to listen to the i'm sure the first panel one of the questions which we didn't really get into too much was the fact that over the years doctors mainly had their own premises um were leaders managers employers basically an accountant managing everything within their their own practice now that the gp contract is currently being being negotiated and hopefully will be settled by 2017 what way do you think the contract should go uh do you agree that um within i know we have one doctor and other professionals uh within the situation do you think that we should have the doctor concentrated with the other um professionals rather than owning the practice um that i mean obviously what you're referring to is really the independent contractor status that gps currently hold um it is it is the the new contract is not going to bring any fundamental change to that model um there's sufficient evidence out there that that is in fact um undoubtedly the most cost effective way to deliver primary care at the moment and we could have huge widened debate around whether that model facilitates or creates barriers for the sorts of really constructive things that have been discussed earlier within that model however um we still have a very strong underpinning philosophy of team working and in fact i would suggest that in fact that model supports team working gps take on a responsibility for employment um and for managing the unit if you like and in fact um but within that and and do you continue as leaders in that um you know within that model but working very very much in a mutually valued team now my experience and it's very interesting because i mean i will be 30 years in my practice in november and i'm hearing all this discussion around teams and in fact one of the things that when i moved into practice 30 years ago that really i valued most about being a gp was being a member of a really comprehensive team and within my building i had a full team of not just um our district nurses we had our practice nurses we had um community um psychiatric nurses i had a midwife um working with me um we had visiting consultants all working within my practice now so we're not talking about a new model we're talking about overcoming barriers that seem to be making it more challenging to maintain that underpinning philosophy um so so i think that i don't i mean i don't think the contract will um change the model substantially i'm not sure that that's necessarily going to overcome you know even considering that will be overcome the barriers that we've discussed earlier um i do think that um one of the things that we've said repeatedly and we will say from the college is that we need to continue to have sufficient gps in order to continue the model um one of the other barriers and i know you say short questions one of the other challenges we face with the teams is creating a culture where each individual professional feels confident and supported and trusted in making their decisions if we're going to really fully develop these roles as we've just discussed earlier each professional needs to feel safe in that role and i think with you know i think the current climate is perhaps an unsaid barrier to um the professional development of each of the different um professionals in fully embracing the model that has been discussed in the earlier session so we've gone about safe in that role pharmacists at the end of the day could possibly dispense prescriptions could as far as i'm concerned could actually sign prescriptions every time i spoke to a doctor in in any role i've had in this committee they continually not complain but they continually tell me that they're an hour a couple of hours sitting signing prescriptions now we've got presigned nowadays we've got computers we've got a printer you know why can't the prescription and i know the reason why but i want you to tell me why the prescription can come off the printer straight away and you know most prescriptions are repeat repeat repeat um you know so why can't we take that time away from doctor signing can you know spending all that time spend checking why can't we shift it to someone else to give it the end of responsibility we would absolutely support that in fact we can with the right um with the right structures in place to support that i mean we've presented the joint paper that um the royal college of dps and the royal pharmaceutical society have um which describes exactly that role for pharmacists working within practices there are some um there are some administrative and legislative processes need to be sorted in order to allow pharmacists to sign their own prescriptions but provided a pharmacist feels that they are working within their competence and are suitably supported by the systems and safe systems that allow that process to happen then we would absolutely support that and and i think the key thing is around having um helpful and supportive systems for any of us working in practice because that same that applies to gps as much as it does to pharmacists with regards to safety of prescribing can i just come in on that one there um we do now have different systems in place that allows us to um to take some of that workload away from gps we have the chronic medication service which allows us to assess suitable patients and if they're stable they're well controlled they're managing the medication there are no issues we can put them on a serial prescription which basically is for up to a year so these are people who have been assessed that the prescribing is safe and that can either be a gp who does it or the pharmacists who work within practices can do it equally the community pharmacists who are working with these people on a day-to-day basis can assess how well controlled and how you know how motivated how stable these people are and we can then give them that option to have a one-year prescription which reduces you know if somebody's getting a prescription every two months that's reducing your contacts with the gp from seven to one if they're on monthly prescriptions for whatever reason that's reducing it from 13 to one and that service has a whole load of safeguards in there to make sure that the people who are on that service are supported with their medication they're reviewed for any issues they have taking it any safety issues any side effects so there's a whole new service that supports that and will take some of that workload away but a lot of pharmacists themselves can actually set all these things up they can assess and review patients so it's definitely there and of course it's back to the multidisciplinary team isn't it you know there are other disciplines who prescribe nurses, AHPs and many nurses will will run their own chronic disease management clinics and they will sign you know they will see the patient sign the repeat prescription if that's within their area of competence so it is back to team working and working together to support everybody within their workload I think there's a there's a systems issue I work as an advanced nurse practitioner and I've got legal rights to prescribe and I prescribe on a daily basis and working with my colleagues from pharmacy on my GPs and coming off from a shetland point of view we did quite a lot of anticipating to be cared so we can anticipate in the community what we're going to prescribe and put mechanisms and frameworks in place to support people in the community so rather than going to a GP the drugs will necessarily be available to the patient in their own home which prevents a GP admission and also frees up GPs time as well I also think that it goes back to the point that Linda was saying about competency we need to stick with our competencies without prescribing and I think from working within the GP practice I see numerous prescriptions, hundreds of prescriptions in the GP just simply just checking through them to me I would need to sit down and go through each one of them so I think it's a time issue and also think it's a process issue as well thank you I'd just like to pick up on an issue that I raised with the previous panel and I guess I'm hearing here that there's lots of work being done by other professionals prescribing which would take time away from GP prescribing and save time there so how are you quantifying that, how are you recording that, how much GP time have you saved through employing advanced nurse practitioners or having a pharmacist in GP practices? I work in the main in the out-of-hours arena so we have a multi-disciplinary team there where we have doctors, nurses, social workers, mental health nurses although we've sort of lost them and that is a big loss to the team so we will continually assess our prescribing and we continually assess we have an annual patient experience. Sorry to interrupt you but you're not actually answering my question what I'm asking is how much time has been saved or how much money has been saved and how have you quantified that? Time is very difficult to identify how much time we have saved but if you look at the team the team is probably now from being a full GP team to a mix of probably 65 GP, 35 nurse practitioner, so therefore that's a lot of time taken away from the GP actually writing the prescriptions for the patients because we are seeing the patients ourselves but we've actually never audited the time that it actually takes to and I suppose it takes different times it depends how complex that patient is because you're assessing and so it could take you. Sorry Tintor, I'm just really aware that we're on it. Christopher, it's talking about your change of practice in Shetland, have you quantified time there in Shetland, I don't mean you personally, but has Shetland health board looked up what was happening before what you've saved? I mean we've just initially gone through the we again we have issues with we've come to sustainability GPs so we've just employed five advanced nurse practitioners so we are producing cystics in relation to ISD for the amount of work that community nurses do and the nurse practitioner is again I think it's a systems issue in a sense of the I give an example I spent six hours doing cystics last Friday for ISD and numerous other things that takes me away from patients care so I think this should be something that integrates with our computer systems and the package to actually record this which is what we don't have at the moment. Okay so the answer that's no essentially. Yeah I mean just one of the things that's very complex I think that I mean and how I quantify my 10-minute appointment is very complex and to be able and there have been many attempts to try and quantify what time is allocated to what element of the work and quite frankly that's not practical and certainly within the constraints of the you know the day-to-day work and pressures of workload at the moment is not possible I think would be fair to say because many of these projects are done in small boxes if you like again that makes it very difficult to actually quantify in bigger terms there have been a number of study I mean there is a fairly recent study on the use of for example pharmacists in doing certain roles in multi in chronic disease management and in fact cost effectively it's not looking terribly optimistic I have to say if we're certainly looking at cost savings in a model that we have described I think there's sufficient evidence out there in its entirety that shows that one of the most cost effective and cheapest ways of getting through the biggest numbers of roles is for GPs to do all in a winner and that's very crude but in fact that is a suggestion however the reality is that we have a shrinking you know we have a very stressed workforce that can't deliver that is struggling to deliver so we have to be creative so you're absolutely right that in order to do that in a meaningful way and to order to ensure the public out there that we're making the best use of resource then we really need to be having some of these answers but it is complex it is very difficult to tease it down to that level of black and white I don't think we'll ever do that and I think what we'll have to do is complement as much pieces of evidence in the context in which we're working because the reality is if we were to do that I would I strongly believe and suspect that we'll have GPs running one man shows and producing a very cost effective service I don't think it'd be the best care for the patient by any means but if that's the sorts of things we're looking at so I think we need to look at the wider picture I think we need to look at the quality of care that patients are getting I think we need to go right back to what we discussed already about the right person providing the right role for each patient for the right you know in the right area to look at this in a wider way whilst we are trying to get our heads through the complexities of what measurements will be useful and helpful in contributing to that development just reflecting on that then are you saying that this is all driven by the lack of GPs rather than the desire to improve patient care I mean I know it's not as stark as that yeah I think but is that is that first point the principal driver I think the other principal driver which was referred to in the earlier is the changing demographics of our population I think we've got many many more patients being needed to be looked after at home or near to home with multiple conditions and increasingly complex needs across their care both social care and I think I think it was mentioned at the end social care and the investment of social care is critical to this as a GP I have to say one of my biggest frustrations on a day to day basis is not being able to manage my patient at home with my community pharmacy sport with my district nursing team support with the other support because I've got insufficient social care support so actually that's critical to it so but I think that you know in answer to your original question not having the clinical expertise of GPs or the holistic comprehensive skill base that GPs have to offer is one driver but also not you know not meeting changing significantly changing needs for patients I think is the other key driver here Marie I'm interested in in the models of practice that are out there so you talked about being a GP and part of a you know running a team and you mentioned several different kinds of nurses I think traditionally probably allied health professionals and pharmacists went into part of that team and I'm interested in how you think they might be incorporated into the GP team and also whether it's happening across the board so I'm well aware that there's big practices near me where I live in the highlands which don't have any nurse prescribers which seems astonishing to me nowadays you know I would have thought that the nurse practitioner should be running you know regular health care for chronic illnesses you know like asthma clinics and things like that the other thing I would be very interested in hearing is from you Elaine about the chronic medication scheme what sort of level of uptake is that of that how many of the target population do you think are using that scheme and what are the barriers to using that scheme and the third thing I'd be interested in hearing we touched on it in the last evidence session is about the minor ailments scheme I've heard people talk about expanding that and I would love to hear from the panel here whether you're talking about making that available to more patients or whether you're making it available to cover more illnesses I've heard from my community pharmacy colleagues that there's pilots going on to treat UTIs to treat Empatigo and to possibly treat exacerbations of COPD so how do you see that going to to reduce the workload of GPs and put some more of it into community pharmacists I mean I'll just dance very quickly with regards to the wider team I think you're right I think the pharmacy role in practice is a very much a newer expanding role that is it wasn't something that the community pharmacist has always played a big role but this is new and I think that is quite very exciting I think from a GP point of view and for development of pharmacists um I do think um sorry your your around allied health professionals I mean interesting enough we in the times of fund holding for GPs and I'm talking 1990 plus we used our funding to set up open access physiotherapy in our practice so again that concept is something and the patients really loved it was a really useful resource the pharmacist we worked as a team we worked under some premises so these models have worked and again it's about supporting those but very much I think the other point you made is absolutely right there's a huge variation and I think when you talk to Elaine about the chronic management scheme as well there's huge variation for a whole variety of reasons one thing I think it's important to say at this point in time which has been raised as a potential um as a current potential perceived barriers the whole issue of sharing patient records and I I do think that's a critical um because if we're talking about community pharmacists treating UTIs um exacerbations of COPD we need to have um sharing of that information across the all the health care professionals who are delivering that care otherwise we will not have the holistic care of patients that we really need to hold on to and that the college would support in our vision document around what good primary care should look like for patients as outcomes and one of the legislative challenge there and I think there's a lack of understanding of this is that GPs currently are the data controllers of the the patient information so we carry responsibility legal responsibility for the for the confidentiality of that information and for the systems that support it now I don't know what the solution to that is I suspect everyone in this room will have a different idea of what the solution but it's it's a it's something that needs to be redressed I think it is and legislatively I think if we're going to go over that I think I think if we're going to have true sharing and comprehensive records that the right professionals have access to in in the right way we need to revisit a model that support you know and a legislative process that supports that okay so I think Elaine you possibly want to talk about the chronic medication scheme yeah in the interest of time I'll just pick up on the cms and the minor ailment service the chronic medication service has been going for a few years and you're right the uptake is not as good as it could be there are various reasons for that some of that is again it's to do with it as usual it's always to do with it you know it's quite a back to front system they have to register with the community pharmacy before the gp practice can set the serial prescription then they're going back so you know that that only is refined with any new system there are loads of it issues and what we're doing is we review and revamp it and we change it and we develop it as we go and some of it are as simple things like patient factors you know I've talked to people about getting set up set up on these schemes and they like the independence you know they like going to their gp to get their prescription they like going out to the pharmacy every week you know there are some of these cultural things that potentially need change but you know you're balancing that against workforce pressures within practices so there's a lot of work that we need to do in terms of rolling that out a lot lot further because potentially it does have a massive impact on gp workload but also in terms of the pharmaceutical care that we provide for people it's an ideal service that allows us to improve the pharmaceutical you know the care that we give it takes it away from being purely supply function and actually focuses on the care just to pick up on that the minor ailment service what we are looking to do is the minor ailment service is currently available to people who would not have paid for prescriptions what we would like is as Eileen mentioned earlier we would like that extended to everybody so that anybody who has a minor illness can go to the community pharmacy and then be treated for that we are also looking at how do we develop that beyond the minor ailment service and what's currently prescribable from that to some more complex conditions so we can start moving more people away from gp practices and into community pharmacies and through next we have we now have the common clinical conditions training course which is actually upskilling pharmacists giving them the skills to diagnose and manage more than just what's on the minor ailment service and to do that we need to develop a lot more independent pharmacist prescribers and sort out all the issues that we have around pharmacist genital prescriptions. I would just like to ask Dr McNaughton to expand on a couple of points you made you said that we're not talking about a new model here but we're talking about overcoming barriers to maintaining the model that you've clearly practised with for some time and you also spoke about insufficient insufficient social care support as a barrier do you think that discussion around this inadequate social care support needs to form a greater part of this discussion primary care reform? Absolutely absolutely without question I think I mean you know the health and social care integration was I think underpinned by a recognition that it might be more efficient and collective way of addressing the combined needs of patients but there's absolutely no question that social care is absolutely crucial and the third set we've talked about you know others the third sector voluntary agencies there are that wider team there who can deliver a significant support to what is you know to patient care as a whole so yes the very short answer to your question is absolutely um sorry you want to I was just going to I get totally good with what the comments you were saying I think we have two models we have a rural model and a urban model I live in a world where the shops don't close at five o'clock at night it's half day Wednesday and Sunday is a wash day and and and that needs to to issues in a sense of that we still have issues in a sense of that we have finite access to resources we have 222,000 population on shatland and we have minimal resources that we can access to within health and social care the money is there which is great however we don't have the physical resources to actually put that in place and I think with the health and social care hasn't merged we have a board that works great it works on the ground because people like myself integrate with our health and social care to deliver care packages for our patients but when you look at the middle of the management it doesn't work due to simple facts or of logistics it systems and actually how the the joint board works and I think that needs to be addressed to combine with all the other out of hours reviews just to go to the other question about models I think we need to be creative with models I think what I was saying was the principle underpinning philosophy of having multiple professional teams working together is what we're working from but how that's actually delivered in practice will vary enormously depending on the context within which it's being delivered and the needs of the individual patient population that's being served and the geography of course that that Christopher refers to I think there's no question that all of these things need to be need to evolve and therefore the pilot sites that are testing various different ways of delivering that are certainly going to help feed into that intelligence I don't think there's any doubt as well is that whilst I talk about that that is absolutely not the way it has been for that number of years across across Scotland I think that's very I you know I'm aware that was relatively unique within the practice that I in the community within I watched because the community setting in the geography facilitated that and the systems and the management systems and the structures of the different healthcare professionals and how they were managed and deployed facilitated that so I think you know there absolutely is not going to be one model fits all for it by any means but I think that you know I think and as I said to you said before as well I think the other question around different professionals working being able to feel confident in working autonomously is you know quite a cultural development that is going to where where there needs to be a feeling of confidence and freedom to work within your competence without a fear and I think that that is that is another culture that needs to be overcome within the healthcare system that we're working within at the moment and so I you know I think these all contribute. Thank you. I was very struck in the last presentation with the revelation that 10% of patients who present to GP surgeries could actually be dealt with in the minor ailments communities then in the margins of this meeting I was speaking to the Royal College of Physiotherapists and they point out that actually as much as 30% of patients presenting who have musculoskeletal conditions could be dealt with by physiotherapists we've touched Dr McNaughton you touched on the barriers in terms of data control and that's a legislative issue but I wonder if you could expand on that and identify any other potential barriers to moving some of that workload out of GP's surgeries and into other professions. I think it's been alluded to already I think we have a workforce challenge across each professional group we've already talked about I mean I have two nurse practitioners in my practice but I felt jolly guilty because I pinched them from other places where they were equally needed so I don't think there's any doubt that there is a workforce challenge that's perhaps a key barrier. I think the other thing from a GP perspective which is difficult to measure is that when I see patients in my 10 minute consultation I will deal with their musculoskeletal problem I will sort out their medications but actually what they came to see me about was something different and therefore how we evaluate that and how we make that efficient and effective. Now I think that there will be a great deal if that will have to go to patient choice patients will need to be helped and aided in the information they receive about who the most appropriate person to access for their particular need at that particular time will be but actually it will be a complex evolving process as to how the holistic care of patients and the other issues that we deal with in a consultation not least of which are the associated mental health problems and the stress in society the other things that impact patients present presenting problems and that is complex so I think there is you know I think that will be work in progress in terms of what patients learn they get in terms of the best have their needs best met there is absolutely no doubt that as a professional there are many many things that I'm absolutely the last person that should be dealing with in terms of the skill base within the team and that it's not I'm not you know and I should be seeking the help of my colleagues where you know where I can if the patient presents to me and similarly when patients present to the physios or the pharmacist there will need to it is likely will need to seek help from each other so that will be key to how that works well but you know patients needs are complex they very rarely present to me with one problem and even those going to physios and that's the challenge that we're how we meet that in the most efficient way we can I think there's a lot that we need to do in terms of because we've talked about increasing the awareness of the patients and the public around how they access services but there's equally some work that we need to do with the wider team and how that develops and knowing who you can sign posts to you know I know I can refer to a physio I know I can refer to a dietician but I'm not sure that my community pharmacy colleagues have these same referral pathways you know it goes back to what you're talking about yellow pages we have had books like that for health professionals like refer with confidence that allows health professionals to know where is the appropriate place to sign posts and also as these teams develop the referral pathways will develop so where we may not have been able to refer to another professional in the past there's much more acceptance that I as a pharmacist or a nurse can refer into other people that may may not have been able to before I need to declare an interest here as a registered mental health nurse still registered with the nursing mental referee council because I want to ask a question about mental health it's not something that we've touched on but obviously plays a a huge part in terms of the the volume of presentations to primary care services how do you see the role of mental health supporting gps hps and so on in a primary care setting a very quick response to that I think they will as well need to become an integral part of the team and we'll be part of the sign posting options for for patients I think there we already know there's a huge amount of mental mental illness mental distress emotional distress we've got a spectrum and we need to be wise to how we deliver that service obviously we have all just responded to the the 10-year mental health strategy and how that these these issues will be delivered I think key to all of this will be the interfacing and the network literacy that supports how we integrate with each other I think the interface will be critical and it and absolutely mental health will be a crucial part of the primary care team as well before you answer one that you said earlier that you lost the mental health nurses from your team could you maybe address that while we are answering questions I think the mental health nurses are key certainly out of hours and within general practice and we had mental health nurses within our team but workforce is an issue for mental health nurses too in terms of of having enough and and I suppose it's sorry can I just ask me you see within your team what this is the out of hours team up in and grampian where we have a multi-disciplinary team and within that team we had mental health nurses sitting with us overnight which was really good for the team and really good for for patients but again due to workforce changes the team went down to our to Cornhill hospital and so now the patients are triaged or are seen by a GP or a nurse with us and then we refer on rather than the patient having direct access to that team so it is workforce I think we need more mental health nurses to support the team within the hospital at Cornhill so there wasn't enough mental health nurses they took them out your team put them in here hospital settings essentially Miles upon Claire's question in terms of expanding beyond the health professionals into the third sector how is that relationship being built up so that people are being referred for social prescribing for example before that becomes the next barrier that people aren't then sending people beyond sort of a hub team to other people who might actually be key to to addressing their health concerns I think again that's something that's very variable across across Scotland you know my personal experience is very positive of that we have third and voluntary sector representation within our multidisciplinary weekly team meetings in the in the practice and I absolutely know that's you know not the case and I think again I think it is about a recognition and of I think that the health and social care partnership planning structure should facilitate that process I think that that's something that whatever structure works within the context of the geography that it's being delivered will will direct how that will be done effectively but yeah it's going to be a practical you know finding pragmatic solutions for the way forward several times people have mentioned that there's a shortage of the professions various professions we have a thousand approximate GP practices and funding for additional 140 pharmacists and we're supposed to be rolling out this hub model and well potentially how on earth if we can't staff what we have the now if we're going to roll this out or is this going to develop can you see that realistically happening without a huge injection of cash from somewhere I think it's back to the point that was made earlier we need to be able to sustain these things so it's it's it's not having funding for for one year but looking at how we can sustain these models and offer substantive posts to people but but in saying that I know there is difficulties in some areas in recruiting nurses to the to their universities to actually complete training I don't know what it's like for for pharmacy but but yes we have to encourage people to to think about healthcare services and social care caring to encourage them to come into that profession and make it a profession that they they want to join and be proud of from a GP perspective as you know the I mean obviously the direction of travel is the wrong direction we're actually reducing the number of GPs that are reducing in fact effectively we're about you know we're facing a huge retirements and bulge which we've been you know have been highlighting now for as much as 10 years that that was coming and there are a number of challenges in terms of recruiting into general practice for GPs I mean we've just um we've just I think as Shana alluded to earlier we've just launched our think GP to try and encourage and to promote what an attractive career option is for doctors to come into general practice but there are some fundamental challenges with recruiting through the system and we recognise that there are only approximately slightly well slightly over approximately half of our medical students are Scotland domicile and therefore we have a big challenge with retaining the number of medical students that are being trained in Scotland and we're also and it's really going to be important to increase the amount of general practice exposure within undergraduate training so in order to encourage direction into our specialty and so I think in terms of we have had you know 100 new places for training places that have been created and have now been advertised and are in the process of appointment but unfortunately we are not feeling going to fill these places or anything like it and in fact we've still got a number of unfilled places for GP training that from the previous recruitment round so so we are not attracting potential GP future GPs at this point in time and it's our role in the college to do everything we can to promote that at every stage in our career flow process and but it is a real real challenge and a real real concern and it's very difficult to see how we can sustain models both in and out of hours of the whole team including GPs without a shift of resources into primary care to support that and is the very sort of absolute answer to your initial question. I think you're right 140 pharmacists across a thousand practices in Scotland is not really going to go very far but we're talking a lot about transformation and a lot of this is about doing things differently and it's about utilising the resource that we have to the best of its ability you know so utilising the skills of pharmacists and other professionals as well I think in the earlier session somebody talked about the prescribing demands we know that 50% of medication is not taken as the intended prescribed and I know when I go into people's housing on a day-to-day basis there are bucket loads of medication that's not taken as prescribed so you know we need to start talking to people about what is it they want from their health what outcomes do they want you know because if you think about it in the longer terms if we deliver the care properly then some of that workload will naturally reduce because we're actually giving people the services that they want as we're currently looking at how do we deliver services based on the current demand but actually that doesn't necessarily mean that the current demand is the right demand as time goes on so I think things will change as the years go on so do any of you have evidence of that change happening where you know people are no longer sitting by buckets of medicines and tablets is that one of the things that has facilitated is that is the introduction of pharmacy technicians into practices and pharmacy technicians are going out to people's homes they are doing exactly that looking at the medications they're looking at delivery systems they're working with their pharmacy colleagues and looking at medications and prescribing I mean obviously the whole issue of realistic medicine and the CMO's report is the reminder to all of us that that's actually I mean if it's fundamental to general practice we would you know that's what we do we look at patients needs and prescribing and look at it in the context of the whole patient and we look to be much more realistic in what's being what's being prescribed I think moving away from our quality and outcomes framework will facilitate that process a lot of prescribing was target driven and so that's going to rationalise prescribing so there will be changes very much within how we deliver care and and being more efficient with the support that we need to ensure patients are actually following what's expected you know what what they should be and they're informed appropriately to do that will be really important I mean we do have data from you know like some of the some of the work that we've been doing in care homes and so on where we've looked you know we've gone in and we've done medication reviews as a multidisciplinary approach and we can see through time what happens in terms of the amount of medication that's prescribed for people I have data on the number of high risk medicines that have been stopped the number of untreated conditions that we've started treatment for and the costs as it changes through time so that the data is there and as we as we develop more and more of those models and that data will get more robust okay and of course it's not just medicines there's dressings as well a huge amount of costs around dressings and certainly locally we have done a piece of work around when you write a prescription that dressing belongs to that patient so they could have a box of 40 dressings and they might need two so it belongs to that patient so I know other areas will have done the same looking at and this is just one large practice within our area and we can save a thousand pounds per month by doing things differently so so areas are looking you know at best ways to serve the patient and also cost vector okay anybody any final points to the panel no thank you very much thanks very much for attending this morning and as agreed we agreed we will now move into private session