Thoughts on the Programme for Government

4 September 2020

The Scottish Government has this week published their Programme for Government 2020-21.

The Programme for Government sets out the actions that the Government intends to take over the year ahead and includes the Bills that they intend to publish.

This is a set piece event in the Scottish parliamentary calendar, but this year it has been delivered in unique circumstances, with the COVID-19 pandemic continuing to dominate the direction of travel across all policy areas.

The Scottish Government’s Programme for Government

This year’s Programme for Government is focused on ensuring Scotland’s economic, health and social recovery from the COVID-19 pandemic.

A major focus of the Programme was on improving the mental health wellbeing of the nation.

This, of course, includes those who work in caring roles, and I was delighted to see a commitment from the Scottish Government to establish a Workforce Specialist Service, which will provide confidential assessment and treatment for mental ill-health to staff working across the health and care sector.

We have long called for the establishment of a dedicated health service for doctors in Scotland, similar to the Practitioner Health Programme in England, to help address some of the well-reported issues of doctors being at a higher risk of mental health problems than the average population, but also being far less likely to seek professional help.

The establishment of this Workforce Specialist Service is a very welcome announcement and we support its inclusive approach to support the wider health and social care workforce, as we know that many face similar challenges to doctors in accessing mental health care due to concerns around stigma and confidentiality.

I want to offer my particular thanks to Dr Kirsten Woolley, our Clinical Lead for wellbeing in the RCGP Scotland team, who has worked tirelessly and collaboratively over the last two years to develop a service that will be of enormous benefit to those who have struggled to access services in the past.

We look forward to seeing its launch over the next few months.

Remote consultations

There is also a clear drive within the Programme for Government for greater access to digital enabled appointments for patients.

I have written in previous blogs about the massive transformation in care delivery that we have experienced in general practice over the last few months, with the widescale roll-out of NHS NearMe, the video consulting platform, and increasing use of digital platforms such as e-consult.

This has largely been driven by necessity and the need to maintain safe and flexible access to vital GP care during the pandemic.

There have been many silver linings along the way, with prioritisation of remote working options, installation of NHS NearMe software and an enhanced confidence in using new technology.

Many patients report that they find digital appointments more convenient. It has significant potential in more remote and rural settings, and for access to specialist support, with interest in the option of three-way consultations.

However, we are also acutely aware of the potential risks with this model of healthcare delivery if it is viewed as the default option for consultations.

We know that certain patient groups struggle with access, and many patients do not feel comfortable or able to consult with their GP over phone or video.

We know that the IT infrastructure and support is not always reliable.

We don’t yet know what the long-term outcomes are for patient care in terms of the potential to worsen health inequalities, and the impact on investigation, referral and admission rates and our ability to deliver 'Realistic Medicine' remotely. 

We are also aware of the potential impact that delivering care in this way can have on clinicians working in these new ways.

It can be tiring, and it is often more time-consuming that face to face consulting to do safely and well. It means holding more risk without the ability to quickly examine. It doesn’t enable the same building of relationships, trust and continuity of care that is such a cornerstone of general practice.

And so, while we welcome and support digital consulting as an essential part of how we consult now, and in the future, we view this very much as an additional option, rather than the default approach.

I am also interested to learn more about whether these new digital ways of working will influence whether or not medical students choose a career in general practice.

While there are many benefits to remote consultations, it is clear that time and resource is required to continue to fully evaluate the impact of switching to digital consultations for both patients and general practice teams.

I’d like to also take this opportunity to thank Clare Morrison, the national clinical lead for NHS NearMe, for her leadership over the last few months in the rollout, evaluation and development of guidance, and crucially, her desire to ensure that all these additional factors are considered as we recover and redesign services.

Redesign of unscheduled care

The Programme for Government also announces plans to redesign unscheduled care across Scotland with the introduction of a new 24/7 service operated by NHS24 on 111 which will encourage people who are not in need of immediate emergency treatment to arrange a clinical assessment by phone prior to travelling to A&E.

This service can then make a direct referral to a clinician who could provide a consultation with the patient and if required arrange for them to be seen at an Emergency Department.

This redesign aims to reduce crowding in Emergency Departments and allow patients to access care as close to home as possible.

These plans have been in development for some time and as Chair of the College in Scotland I have been consulted extensively on them and have fed in constructively at every opportunity.

I am extremely worried about the workload levels that general practice will be facing over the coming months and while I wholeheartedly believe that we must do all that we can to ease pressure in A&E, this applies equally to all frontline services.

I firmly believe that a pan-NHS approach in the most appropriate way to deal with the challenges facing the health service to ensure that we achieve a consistent, person-centred approach to patient care and that no service is disproportionately impacted by redesign in other parts of the system.

Crucial to all of this will be clear, supportive, realistic and consistent public messaging on how to make best use of services.In light of the workload concerns that I have for GPs, I have strongly advocated for the bolstering of the COVID-19 community pathways over autumn and winter to enable patients who feel unwell with symptoms of new persistent cough, fever, and/or loss of taste or smell to continue to be seen safely and separately from general practice.

With the usual rise in all respiratory infections that we see in general practice with school return and seasonal change, we will have the added complication that many respiratory infections will mimic COVID-19 infection and have to be assumed and managed as such until proven otherwise with a negative test.

There is an urgent ongoing need to keep the assessment of potential COVID-19 separate from practices, to keep patients and staff safe, and to allow us to continue to prioritise non-COVID problems and deal with our clinical backlog.

I am therefore pleased that the Programme for Government also contains a commitment to bolstering these existing pathways in Scotland, as part of their plans for redesigning unscheduled care.

While this is a positive development, I do continue to have concerns around how these pathways will be staffed, given their new additional requirement to triage those who would ordinarily self-present to A&E.

The concerns that myself and colleagues across primary care have regarding these plans largely align with three key areas:

  • the potential for complex and confusing public messaging
  • the potential for negative workforce implications for primary care (given an already overstretched Out of Hours workforce)
  • the potential impact of these plans to worsen health inequalities for those patients who routinely access A&E as their safety net.

I want to reassure you that over the past couple of months, I have used every opportunity at my disposal to constructively raise these concerns and offer potential solutions and I will continue to do so over the weeks and months ahead.

I will endeavour to keep you updated on these plans and what they mean for general practice as they develop.

I think we are all feeling the loom of winter and the cumulative tiredness of the last few months, and I am enormously proud of what we do, as GPs.

I want to assure you that your voices and concerns are being heard.

Post written by

Dr Carey Lunan, Chair RCGP Scotland

Dr Carey Lunan is a GP partner in one of Edinburgh's Deep End practices and is the current Chair of RCGP Scotland.

Prior to this, she held the role of Executive Officer for Patients and Public and Interface working. She also sits on the RCGP Ethics Committee.

Her priorities during her time as Chair include a focus on practitioner wellbeing, improving the interface between primary and secondary care, and growing and retaining the GP workforce.

She has made tackling health inequalities a high priority and has consistently called for the need to engage the public in a national conversation about the realistic role of the modern NHS and the importance of collective social responsibility.

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