The bodies responsible for community health services say a national programme to transfer a number of aspects of primary care in Scotland from GPs to health boards has undoubtedly led to improvements – but is still failing to meet the expectations of GPs because of funding and workforce challenges.

A national assessment, alongside official papers seen by healthandcare.scot, suggest that the ambitions of the primary care improvement programme are yet to be fully realised, with doubts being cast that they can be without a lot more money from the Scottish government.

The 2018 General Medical Services (GMS) (GP) contract began a process of reform that saw a number of services previously the responsibility of GP practices – like taking bloods, vaccinations, medicines management, minor injuries treatment, and chronic disease monitoring – being taken out of their hands to be provided by NHS boards instead.

As the investment phase of the primary care improvement programme comes to an end, a national progress report shows a mixed picture of delivery across Scotland.

While patients of almost all GP practices had access to some level of board-provided pharmacotherapy (medicines management) support provided by pharmacists and pharmacy technicians as of March 2023, only 56% of practices say they had at least partial access to chronic disease monitoring.

NHS boards, Integration Joint Boards (IJBs) and the British Medical Association (BMA) say they have ‘consistently highlighted’ to the Scottish government that full implementation of the contract will require more resources than current primary care improvement programme (PCIP) funding allocations allow.

In one instance, despite ‘best efforts from local partners’ that have yielded ‘thousands’ of extra weekly appointments, Falkirk IJB reports that delivery of the GMS contract is yet to meet the expectations of GPs.

The IJB says in recent meeting papers that NHS Forth Valley as a whole is facing a £1.786m shortfall in the full delivery of all PCIP services, and that GP sustainability remains one of the most significant risks in the health and care system.

Falkirk is not alone in this assessment – integration partners across Scotland are reporting that shortfalls in funding for primary care improvements, an inability to carry forward underspends, and a shortage of staff and premises suitable for community-based services means full delivery of the GMS contract is ‘unrealistic’.

 

Changes to phlebotomy and community treatment and care (CTAC) services

Guidance issued by Ministers in April 2023, telling GP practices they are no longer required to manage medicines or deliver phlebotomy and long-term condition monitoring, has further complicated matters according to IJB papers.

GPs are now being asked to address any gaps in the programme, in return for a ‘transitory payment’ – however this will no longer be met by the Scottish government, despite an earlier commitment by Ministers to offer this to unserved practices until services are fully provided by boards.

BMA Scotland says this, and Ministers’ failure to issue enforceable directions setting out exactly what health boards are expected to provide, has created a ‘considerable contractual gap’ in the provision of key services which could lead to patients waiting longer to be seen.

However, IJBs have warned that formal directions could risk local flexibility and damage the relationship between health boards and GPs, with them being held accountable for what they consider ‘undeliverable’.

 

Paying for the changes

East Dunbartonshire IJB is one of several IJBs that says it has no funds available to make any transitory payments to its GPs.

It estimates around 28% of its GP practices currently have access to board delivered CTAC, and 42% to pharmacotherapy, according to recent papers.

IJBs say they have a new funding concern. Underspending by integration authorities within the programme – often caused by an inability to fill vacant new posts – can also no longer be carried forward to the next year and, instead, money that hasn’t been spent is expected to be returned to the Scottish government.

Renfrewshire IJB estimated that it would cost more than £12m to fully achieve delivery of the contract – it has received less than half of this, just £5.72m.

Glasgow Local Medical Committee (LMC), which supports GPs across the Greater Glasgow area, says its members do not feel as if their time is being freed up to care for patients, as was the intention of the 2018 contract.

Dr Patricia Moultrie, Medical Director at Glasgow LMC, tells healthandcare.scot that the efficiency of services passed onto health boards needs to be closely examined:

“The ongoing lack of national directions detailing the service the board is required to provide is having a detrimental impact on the development of service provision. The other significant barrier to full delivery of the services is insufficient funding commitment from the Scottish government.

“It’s fair to say that many practices currently struggling with excessive workload are looking to the health board to show a greater commitment to full delivery of these services and remain concerned that the health board does not fully recognise the sustainability crisis that is unfolding in general practice, and is not taking sufficient steps to support general practice which is so critical not only to patients accessing GP services but to the wider NHS.”

 

Read more: Scotland's doctors ‘trying not to lose hope'; College: More GPs needed to tackle health inequalities; Planned primary care improvements on pause

 

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