3. 1. Grow the workforce
90% of all patient contact
with NHS Scotland goes
through general practice.
Scottish GP practice
teams carry out around
24.2 million consultations
each year – an 11% rise
over ten years.
National Records of
Scotland projections
indicate that between
2010 and 2035 those
of pensionable age will
increase by 26%, with the
associated increase in
the number of long term
conditions per patient and
exponential increase in
demand on primary care
services.
Funding for general
practice has consistently
fallen, from 9.8% of NHS
spending in 2005/06 to
what is a new record
low of 7.6% in 2013/14.
Budget freezes in 2015/16
meant an inflationary
loss of 1.2% for General
Medical Services (GMS).
Deloitte analysis
showed that general
practice suffered a real
terms loss of £1.1 billion
by 2012/13 compared
to funding levels
staying at 9.8%.
71% of Scots support a
shift of funding to GMS to
reach 11% of
NHS spend.
NHS Scotland’s
Information Services
Division (ISD) figures
show Scotland received
only 35 extra Whole Time
Equivalent GPs between
2009 and 2013.
Over half of GPs feel
their current workload
is unmanageable or
unsustainable. Patient
safety is at risk.
One in five GPs in
Scotland are aged over 55
and could feasibly retire
over the life of the coming
parliament. Indeed, the
BMA recently found that
one in three Scottish GPs
was hoping to retire in the
next five years.
1 Commit to a clear
objective of recruiting
an extra 740 GPs
by 2020 and put an
incentivised strategy
in place to do so with
measurable targets
along the way.
2 Ensure medical
students and trainees
are regularly exposed to
general practice each
year throughout their
learning, broadening
their awareness of the
great career available to
them.
3 Expand the wider
primary care workforce
to support people’s
needs. Numbers
of Practice and
Community Nurses
particularly, should
be increased, as
should greater
collaborative working
with communities. All
practice teams should
include a Clinical
Pharmacist.
4 Longer consultation
times should be
included in future
workforce projections,
especially when
considering mental
health, multimorbidity,
and high deprivation.
5 Commit to ongoing,
sustained increases in
investment in general
practice until it receives
the necessary 11% of
NHS Scotland spending.
Publish regular statistics
showing how this is
being achieved.
6 Incentivise universities
for each medical
student they deliver
to general practice
training.
7 Support those
considering retirement
to remain in the
profession. Approach
those nearing retirement
to understand how to
delay it and look to
‘return’ those already
lost to early retirement.
8 Enhance retention by
actively supporting
Continuing Professional
Development.
9 Promote developments
which ease workload
intensity.
‘Three practices
in our small area are
without partners and
we are feeling the strain
of trying to avoid ill
health as we could end
up leaving the practice
unmanned’
‘His day begins at
7.30am and he leaves work
at 7–7.30 at night. He also
covers out-of-hour services
at the weekends.’
‘Average
working
day is now
12-14 hours
long’
‘The man
seems to be
there all day
every day’
SupportingStatements
Manifesto 2016 Royal College of General Practitioners (Scotland) page iii
Calls for action
For two years, RCGP has been
warning that rising workloads,
a shortage of GPs and declining
resources are putting intolerable
pressure on local practices and
posing a threat to patient care. Now,
with vacancies in many practices,
imminent large scale retirement,
qualified GPs leaving to practice
abroad, recruitment to general
practice a major concern, and with
universities not delivering sufficient
numbers of doctors to GP specialty
training, the profession is close to its
tipping point.
patientandGPexperiences
‘The biggest issue is a
workload crisis colliding
with a workforce shortage
giving a sense the wheels
are falling off general
practice fast.’
‘Patient safety is now
being jeopardised by GPs
working in a chronically under
resourced and under
funded service.’
‘We are approaching a tipping
point… and without the appropriate
funding being available, the service
will be unmanned very soon.’
‘For patient safety we
need more GPs. For that to
happen we need better work
life balance. More time and
monetary investment in
general practice.’
4. The guidance for QOF gives
some indication of the
administrative burden. The
Scottish Quality and Outcomes
Framework guidance for
GMS contract 2013/14 ran to
224 pages. After reduction, in
2014/15, it runs to 186 pages.
One Tayside practice, with
a list size of c. 6,000, has
annually audited the amount of
‘paperwork’ managed through
their electronic (Docman) filing
system. They found a yearly
increase, from an average of
1,389 items/month in 2006, to
3,424 items/month in 2013 - a
250% rise over just eight years.
A 2015 Scottish Liberal
Democrat survey found that
91.9% of respondents thought
that QOF should be abolished or
reduced (with 54% for abolition
and 38% for reduction).
A 2007 large-scale study by
Campbell et al could not identify
a difference in improvement
trend between incentivised
and non-incentivised clinical
indicators.
A 2010 study by Howie explored
the complexity of diagnosis in
general practice and concluded
that current incentives veer
healthcare away from what both
patients and clinicians want.
SupportingStatements
Manifesto 2016Royal College of General Practitioners (Scotland)page iv
patientandGPexperiences
2. Promote values based quality and leadership
1 QOF should be replaced
with a system of
professional, peer
led, values driven
governance to better
meet the local needs of
patients and the health
care service, and allow
skills and expertise to be
shared across practice
clusters.
2 Clusters of GPs should
be formed, defined as
groups of GP practices
within a geographic
locality (community),
covering between c. 20-
50,000 patients.
3 Practices should then
be asked to agree to the
shared values that are of
greatest importance in
their locality. Practices
must then have the
time and resources to
undertake audit and
quality improvement
work to show that what
they are delivering is
congruent with those
values.
4 Trials should be
undertaken urgently
whereby practices
pilot this model of
governance through
the clusters approach.
Funding equivalent to
QOF payment should
be guaranteed to
participating practices
while trials are
underway.
‘let us
look after
our patients
and not “the
books”.’
‘The GPs have
changed over the years
for various reasons but the
ethos of the practice has
not changed.’
Calls for action
The Quality and Outcomes Framework
(QOF), implemented in 2004, adds
to administrative burdens on a
GP workforce already at capacity.
RCGP Scotland believes that the
replacement of QOF is necessary and
that a framework should be developed
which will meet quality ambitions and
ensure patient safety while minimising
administrative duties.We can capitalise
on our devolved system, and use
these ideas to inform the way in which
clusters of general practices could work
together to enable a process that is
peer led and values driven.
‘I am saddened to see my
younger partners exhausted and
dispirited due to … the overwhelming
burden of administrative and quasi-
clinical work … We need to aim to reduce
this burden which is NOT the type
of work that GPs entered the
profession to practice.’
‘There is a very
basic lesson taught in
management circles; do not
attempt to incentivise already
incentivised individuals. The
result is you corrupt their core
values; generally caring for
others (not money) was the
reason they became
doctors/GPs in the
first place.’
‘[QOF] takes the heart out of the job we are
trained to do which is about listening to patients and
their needs and helping them to find wellness … it shifts
the way we view ourselves, as professionals who are
highly trained and skilled at treating
people, to number crunchers.’
‘Until this fundamental
change is made you will continue to
lose doctors abroad once trained and
discourage people from a career
in general practice.’
‘As it stands
GPs do a large
proportion of their
administrative work
in their own time.
This results in 13 hour
working days and
working at weekends
and during annual
leave’
5. The Health Foundation
reported in 2011 that
a review mapping out
the medication system
in UK primary care
demonstrated that error
rates are high. Several
stages of the process
had error rates of 50%
or more, interface
prescribing among them.
The same report
concluded that, ‘Key areas
with heightened risk
include … the interface
between primary and
secondary care’.
Existing IT systems are
currently not considered
fit for purpose; they are
unreliable, inflexible,
incompatible and limited
in their functionality. This
significantly impacts on
safety and efficiency of
clinical data sharing.
The United States’
National Center for
Biotechnology Information
reported in 2009 that, in
the UK, 55% of Significant
Event Analysis reports
described the direct or
indirect involvement of
other health and social
care agencies in the
significant event with
secondary care making up
30% of those.
A RCGP Scotland survey
of members found that
an average of 71% of
respondents across 12
of Scotland’s Health
Boards felt they lacked
a recognised system
through which to
feedback issues relevant
to secondary care, with
a profound sense of
disconnect between
primary and
secondary care.
The lack of appropriate
structures significantly
impacts on two-way
feedback processes
relating to concerns
or suggestions for
change, and thus
hinders improvements in
processes or systems.
A significant variation has
been found in the ability
of GPs to receive easily
accessible clinical decision
support when required
to help inform clinical
management and to avoid
referral or admission.
RCGP Scotland’s Being
Rural report describes
how ‘Rural practices
... are often limited in
services provided by
having inadequate or
unreliable connectivity’.
SupportingStatements
Manifesto 2016 Royal College of General Practitioners (Scotland) page v
patientandGPexperiences
3. Promote the interface
1 Health boards require
dedicated primary
and secondary care
clinical ‘interface
leads’, recognised
and resourced within
job plans to allow
autonomy and to
become involved in
system change.
2 Specific endorsement
is required of the
key role of GPs as
equal partners to
secondary care in any
key policy statements
affecting the wider
NHS, and in NHS
processes such as
Significant Event
Analysis.
3 Increase resourcing of
existing IT structures
to enable safe and
efficient communication
across the interfaces,
especially that between
primary and secondary
care and with Out of
Hours care.
4 Improve integrated
patient records and
care plans to ensure
they are available to all
clinicians looking after
patients in the Out of
Hours period.
5 Provide appropriate
broadband and mobile
coverage across
Scotland to ensure
adequate interface with
and within remote and
rural practice.
6 Extend, further
develop, and
maintain existing
successful means
of, clinical decision
support. For example,
establish dedicated
emails and phone lines.
‘The GP is the
hub of the wheel for
everyone’s problems,
medical or not.’
‘There is a common issue
here in my experience of problems
occurring in the interface between
secondary and primary care as well as
GPs and Nurses regarding
blood tests etc.’
‘this is a
high risk area
that receives scant
attention...we need
SEAs [Significant
Event Analyses]
that focus on the
interface with
shared learning
on both sides’
Calls for action
Interface is the point of interaction
between different systems. In
healthcare, interfaces exist where a
patient journey crosses from one area
of care into another – such as between
primary and secondary care or between
health and social care. General practice
is the hub of the NHS because of the
multiple interfaces it works across
to provide co-ordinated patient care.
Due to the individual complexity of
these different systems, interfaces are
recognised as areas of potentially high
risk with factors including different
cultures, different professional
boundaries, different governance
systems, different performance targets
and different IT systems.
‘I passionately
believe that GPs and
their teams are at the
‘heart of the matter’ for
better patient care, health
and wellbeing. They
are/should be the key
interface to secondary
and tertiary care and
should be key to
liaising and
progressing issues
to support the
patient.’
‘if we don’t challenge
things, we will continue to be
buried under inappropriate and
dysfunctional NHS systems
and our patients will suffer
more and more’
‘So an IT system that
allows us to work more efficiently,
and reduces admin, instead of increasing it,
would be my priority … The Press recently
said GPs were unwilling to embrace modern
tech! Well we wanted it yesterday, and
investment is needed to make it
happen tomorrow.’
‘Open access to
diagnostics such as CT and
MRI would reduce referrals to
secondary care and allow speedier
diagnosis of significant pathology
such as cancer.’
‘[We need] a true primary-
secondary care fund to allow discussion
on the interface between the two with
practical outputs on how patients might
benefit from closer working.’
6. NHS Scotland’s
Information Services
Division (ISD) reported in
2015 that 997,000 OOH
patient contacts, involving
894,000 patients and
over 200,000 home visits,
took place within twelve
months.
A RCGP Scotland survey
of First5 GPs found that
roughly only 1% of those
who were involved in OOH
care only worked in OOH
care. The rest worked
throughout general
practice.
SupportingStatements
Manifesto 2016Royal College of General Practitioners (Scotland)page vi
patientandGPexperiences
4. Promote Out of Hours, The Green Light Service
1 Recognise the vital
contribution of general
practice to OOH
services since 2004,
and into the future,
to encourage those
presently undertaking
the work, and aid
present and future
recruitment.
2 GP Out of Hours needs
a clear identity –
potentially The Green
Light Service –through
which to define its remit
and communicate its
offering to the public
as central to OOH care
provision.
3 Reduce barriers for GPs
at all stages of their
careers to contribute to
OOH care provision.
4 The OOH GP service
must capitalise on
the core values and
skills of GP clusters,
be multi-disciplinary,
supportive and secure,
and utilise the skills of
nurses, paramedics,
pharmacists and others
to ensure safe, effective
care is provided for
patients.
5 Teamwork must
be supported
by appropriate
communication
systems, such as linked
IT systems, to facilitate
care within OOH and
interface seamlessly
with other stakeholders.
6 The welfare of
staff employed
must be ensured in
terms of security,
accommodation,
and sustenance.
7 The service must
be integrated within
the wider health and
social care service and
adequately funded to
allow the fulfilment of
its objectives.
‘My GP is now retired;
the service, although changing,
continues to be delivered locally
24 hours a day – out-of-hours too –
by our local GPs and
primary team.’
‘OOH
is in melt-
down.’
‘She visited us, often twice a
week during the last months before
he died. She also put on his notes that
he was not to be taken to hospital
if we needed a doctor at
the weekend.’
Calls for action
Out of Hours services (OOH) are a
crucial part of primary care, used by
those in need of care once their usual
practice has closed.Yet OOH services
have seen a 3.3% drop in funding in
real terms since 2004. RCGP Scotland
welcomed, and has participated
fully in, the Scottish Government’s
National Review of Primary Care
Out of Hours Services in Scotland.
It is a core professional value of
general practice that GP driven care
in the community is available at any
time.The College sees it as essential
that GPs remain a central part of
the OOH service to ensure holistic,
co-ordinated patient care and that In
Hours and OOH should be linked up.
‘[We need]
more secure
arrangements
for OOH’
‘Being the
only GP covering
for an extensive region
in chronically short staffed
rotas is not a desirable job.
I regularly get job offers
from Australia or the USA
with offers of at least
double my salary and
if OOH workload
is not addressed
I may leave.’
‘I regularly work in _____
OOH as well as full time as a partner
in GP and OOH needs urgent
investment/overhaul before complete
meltdown occurs.’
7. Manifesto 2016 Royal College of General Practitioners (Scotland) page vii
patientandGPexperiencespatientandGPexperiences
6. Promote GPs in Integration and the 2020Vision
5. Promote Mental Health
1 Integration Joint Boards
must initiate urgent and
adequate engagement
with general practice,
beginning with the
development of specific
planning groups.
2 Integration should seek
to utilise the developing
structure of GP clusters
within localities.
3 Appropriate time and
funding must be made
available for GPs
involved in this process
and in the subsequent
work of providing
satisfactory integrated
care.
4 Social prescribing
development, such
as that provided by
Links practitioners,
must be resourced to
allow people to access
non-pharmacological
services where these
would be beneficial to
their wellbeing.
1 Mental health should be
given parity with physical
health, erasing the barrier
between the two terms.
2 Adequate consultation time
must be available to safely
care for those suffering
mental distress.
Calls for action
Calls for action
‘Dr _____ continued
to see me at least every
few weeks even during good
periods even if it was just to “check
in”. I really appreciated her doing
this as it allowed her to remain up
to date and me to develop a trusting
and good, strong therapeutic
relationship, vital for identifying
and stopping any
relapse early.’
‘Time to allow the
primary care team to
contribute meaningfully
with the integration
agenda will be essential.
If colleagues cannot leave
their practices to engage
with partners there will
be a serious risk that the
changes will flop.’
‘[We need}
funded time for
grass roots GPs to
contribute and influence
strategic planning by
IJBs. If integration is to
succeed the voice of GPs
working at the ‘coal face’
and struggling to meet
increasing demand
is essential.’
The Integration of Health and Social
Care has been one of the main
objectives of Scottish Government
since the establishment of the 2020
Vision.
Delivering care at home or
in a homely setting, will rely
absolutely upon the work of GPs.
To date, despite clear and evidenced
willingness on its part, general
practice’s involvement in the
establishment of Integration has been
limited. RCGP Scotland recognises
the efforts of Scottish Government to
encourage Integration Joint Boards
(IJBs) to engage.Timescales are now
such that more than encouragement
is required.
The Scottish Government’s Mental
Health Strategy for Scotland: 2012-2015
is now due to be replaced. RCGP
Scotland believes that mental and
physical health need to be given
equal standing. We welcome
intimation of increased funding to
prevent mental health distress and to
care for those in distress.
‘I was feeling
suicidal and had
went to the Forth Road
Bridge with the intent to
jump off it. Dr _____ spoke
with me and spoke me down enough
for me to turn around and go home to
keep myself safe till I seen him the next
day I think it was. This is just one of
many incidents Dr _____ has enabled
me to continue the fight for life.
Dr _____ has gotten to know
myself pretty well over the
last seven years and I can
see he believes I can
manage my mental ill
health rather than
it manage me.’
8. Manifesto 2016Royal College of General Practitioners (Scotland)page viii
patientandGPexperiences
7. Promote a clear political strategy
1 A clear political
strategy should be
published by the Scottish
Government describing
the safeguarding and
development of general
practice.
2 Any development in
general practice in
Scotland must be
underpinned by the
‘Four Cs’ of general
practice.
3 As far as possible,
patients must be
partners in the
development of their
healthcare, enabled
to actively protect and
enhance their wellbeing.
Government should
continue to support
the development of the
House of Care model
and its empowerment of
patients.
‘It was
fantastic to have
the continuity
of care’
‘GPs [are] the
vital bedrock of the
NHS and healthcare
and wellbeing’
Calls for action
The perceived lack of a political
strategy for primary care has
encumbered its development. Current,
long-term funding trends could be
interpreted as a strategy of a deliberate
reduction of general practice for
Scotland.The Primary Care Fund,
announced by Scottish Government
in June 2015, is a welcome beginning
towards addressing problems but is
very clearly far from enough. A much
larger, strategic financial response
is called for.With the Scottish
Government committing to the trial
of new models of primary care in the
development of the planned 2017
General Medical Services contract,
it must be acknowledged that any
new model can only be made fit for
purpose with the full engagement
of the profession. As a minimum
requirement, we need a clear political
strategy for general practice, allowing
delivery of safe, person-centred
care, underpinned by the‘Four Cs’
of general practice (see below), in an
adequately resourced and empowered
environment.
RCGP Scotland believes that high
quality GP consultations are the key
focal point for enabling patient centred
care and patient safety in the future.
‘He asks about the
different aspects of my care
to ensure he has an overview
of what is going on and is
ready to listen.’
‘Politicians and
the media constantly talk
up public expectations of a
consumerist type health service
but they don’t fund it at a level
to provide that service.’
Contact: General practice is the default
place, the first point of contact, for the
vast majority of patients seeking access
to healthcare for the first time.
Comprehensiveness: It’s not just about
seeing the person and their presenting
complaint. GPs see people in their
holistic lived experience. GPs are
uniquely placed to deal with aspects
of medical, social, and psychological
factors. GPs ask people about something
they didn’t come in for and take the time
to listen, identifying major issues.
Continuity: GPs are there from cradle to
grave, with care benefitting from long-
term relationships with patients.
Co-ordination: Critically, GPs are able to
oversee care from multiple providers and
act as a ‘system failure service’ for the
NHS. When anything goes wrong, GPs
are usually the ones to hear about it.
The co-ordination of services at primary
care level is an important determining
element in the responsiveness of health
services provision and the health system
as a whole.
Acknowledged from Barbara Starfield
The ‘Four Cs’ of general practice
‘If more
money was
available for general
practice it would allow
more money to recruit and
train GPs. With more GPs the
practice could provide a better
service … increase the number
of patient appointments and
extend appointment times to
15 minutes to give time to more
complex cases. It would allow
more nursing and ancillary
staff to be appointed so
that more services would be
available for patients
not requiring the attention
of a GP. It would allow
facilities to educate
patients on how to
manage their long
term health
conditions and how
to be a good
patient’.
‘The
practice I am
registered with has
already reached crisis
point and they have had
to urgently prioritise all
their services which has
resulted in such things
as the withdrawal of the
medical service to a local
cottage hospital. All I would
ask for, therefore, is to stop
this happening elsewhere
and for proper resources
to be made available and
a reduction in paperwork,
to ensure that I and fellow
patients equally receive
the appropriate care
when needed no
matter where we
live in Scotland
and no matter
what time of
the day.’
‘He is generally the
first point of contact if I’m
in crisis or going towards crisis
because I trust him and in general
he is my main support and at
times has been my
only support.’
‘I don’t think I
would be here, if it wasn’t for
them ... It doesn’t matter what
the problem is.’
‘As a child
our family GP was the central
point in all our family care. The
level of care has carried on for
most of my life. Always
our first point of care.’
