PCIP Update March 2022
Welcome to the latest PCIP update. Apologies for the absence of recent updates. The delay is the result of LMC resources being stretched in a multitude of directions during the latest Covid pandemic peak. For reassurance, PCIP progress has been maintained despite the pandemic pressures and progress has not been halted at any stage. It has come to our attention that many other Boards in Scotland are sitting with significant underspends of PCIP funds but this is not the case locally. All available PCIP funds in the Borders have been fully spent due to the determined efforts of the PCIP Exec committee and the large team of colleagues responsible for workstream delivery.
Overarching Principles
Of late, there have been numerous enquiries made by practices about the structure of PCIP services and the allocation of resources. Colleagues should note that decisions made around PCIP are done so in accordance with the triumvirate approach (GPs, Health Board and IJB) and are not the result of any one party sitting at the PCIP Exec committee.
PCIP delivery should be equitable, accessible and resilient.
| ANP | Advanced nurse practitioner |
|---|---|
| CSLW | Community support link worker |
| CLO | Central legal office |
| DN | District nurse |
| LAC | Local area coordinator |
| MoU | Memorandum of Understanding |
| NHSB | NHS Borders |
| SBC | Scottish Borders Council |
| SG | Scottish Government |
| TR | Treatment Room |
| VTP | Vaccine Transformation Programme |
50 week service
The aim of workstream delivery has always been on the basis of 50 week cover (52 week provision minus the allocated public holidays). Anything less than this would not be deemed a “service”. It is expected that workstreams will be modelled to provide cover to practices in the event of annual leave and sickness absence. This is the expectation placed on workstream leads in planning the distribution of resource. In practical terms, it may not always be possible for full cover to be provided during periods of staff absence but some cover is expected at all times. In making this decision, the PCIP Exec members have been mindful of the inequity that could result from a service that did not aim for cover during periods of leave and the impact on practices if services are halted in an unpredictable manner.
Opting Out
PCIP Exec committee have received enquiries about practices “opting out” of some or all of the services offered under PCIP. As the delivery of these services is a contractual obligation placed on NHS Borders, there is no ability for practices to select which parts of the GMS contract they wish to engage with or decline. The contract is a single, comprehensive package of changes which Health Boards are obligated to deliver. Therefore, all workstreams will be modelled to provide services to every practice in the Borders (the only exception being as below). The extent to which practices engage with the services offered cannot be mandated but practices should consider the effect that poor engagement may have on the long-term financial viability and stability of their practice. Practices that fail to utilise the services offered may be increasing their vulnerability and placing themselves under avoidable and unnecessary financial risk.
Remote & Rural
PICP Exec have sought the opinion of SG as to whether any Borders practices meet the criteria of remote and rural. One practice may meet these criteria locally so conversations with this practice about the possibility of entering the optional appraisal process for exemption from normal contract implementation are being held. Otherwise, this cannot be applied to any other practices.
IT
There are numerous IT requirements for the support of PCIP delivery some of which need urgent attention to prevent delays in contract delivery. An electronic ordering system for investigations is a priority for the delivery of CTAC. Additional funding from SG to assist with note scanning to free up space in practices is available but server capacity for this process may be a rate limiting factor. Steps are being taken to ensure that PCIP requirements are appropriately prioritised against other bids for IT support as it is imperative that the essential infrastructure is in place to assist with progress.
Individual Practice Requirements
Some of the recent enquiries to the PCIP Exec committee have focussed on practices asking for individual, tailormade delivery of PCIP resources. This approach is not practical, achievable or suitable for the long-term sustainability of practices. There is no mechanism by which practices can request more or less of the services included in the new contract according to their current wishes. PCIP resources are all allocated proportionally (as much as practically possible) on the basis of practice list size.
Likewise, the PCIP Exec committee has also recently discussed the relationship between practice size and interaction with PCIP services. The tripartite group is clear that all practices are considered equal regardless of size and that no practice should be permitted more influence or consideration within the PCIP delivery process.
Funding
There is no mechanism within the GMS contract arrangements whereby practices can be simply allocated their proportional share of total PCIP funding. This is not a local decision so this position applies across Scotland. Whilst some practices may feel that this would provide more flexibility and allow for greater scrutiny over spend, this approach contradicts one of the core aims of the new contract to reduce financial costs and liability for practices.
Allied Professionals
PCIP delivery has brought many allied healthcare professionals into practices to work alongside established practice teams for the benefit of patients. It is expected that our colleagues are respected for working autonomously and that collaborative, professional relationships are established throughout. Queries from GP practices about their role and the model of service delivery should always be made in a polite, constructive and considered manner via the correct route.
Communication
PCIP has recently invested in a 0.5wte additional resource to support the NHSB Communications Team in sharing the PCIP messaging. Please see the accompanying summary presented by the Comms Team at a recent PCIP away day. The team introduced the concept of PCIP to the public last month using an infographic alongside supporting information. For practices wishing to use material related to PCIP on their websites, please contact the Comms Team for assistance. A new NHSB PCIP page has been launched. It has been agreed that a PCIP Comms group will be established to help coordinate information sharing with the public, practices and health / social care colleagues.
Workstream Updates
Pharmacotherapy
A letter of “no confidence” in this service was recently delivered to the Board. This was as a result of practices reporting insufficient service provision and a failure to deliver against the specification of the MoU 2. As a result, a review of progress to date is required. Practices have recently been asked to rate their priority tasks and feedback this information to Dr Mollart. This information will be collated and used to inform discussions around service development. A new Board lead has been identified to progress this work.
Premises
NHSB has recently commissioned an independent, external review of GP practice premises. This summarises and prioritises the work that is needed to support the delivery of PCIP and maintain the infrastructure of our premises. PCIP has been allocated a small amount of funding for specific purposes to assist progress but it is evident that a significant investment is needed to ensure practice premises are fit for the future. The NHSB estates department does not currently have the capacity and manpower to deliver against even the small PCIP funded projects so there are now substantial delays in getting work done despite funding being available to the Board. Exec GPs have raised concerns about this unsatisfactory position. We have asked for a clear understanding of the prioritisation process for estates work, greater use of local contractors to improve value for money and timescales for completion plus benchmarking of premises spend against other Board areas. We have been advised that a request to expand the estates team will be considered by the Board within the next month.
Musculoskeletal
This workstream is now fully staffed with all physiotherapists in post. A second 0.5wte admin assistant is currently being appointed to ensure full time admin support. Practices are reminded that this is a triage service for the diagnosis and management of acute MSK problems. The workstream lead (Wilna-Marie van Staden) has issued clear guidance to all practices about the role and remit of the service which is very different from the MSK physio service. The FCP team has had a recent away day and they have a goal to be the best FCP team in Scotland!
Renew
This service is currently receiving in the region of 300 referrals / month. PCIP has funded up to 400 referrals / month so there is currently spare capacity with the service. Practices are encouraged to continue to refer to the service to maximise use of the available resource. The PCIP Exec team recognise that a high proportion of referrals into Renew are being handed on to the Wellbeing service (approximately 90 out of 300 referrals / month). This may in part be due to the fact that one to one psychology work has been suspended during Covid. There is a proposal to review the outcomes data from Renew in the coming months.
Urgent Care
A new workstream lead has recently been appointed to this service and will start work this month. There are currently 10 trainee ANPs and 1 qualified ANP in the service. 4 of the trainee ANPs have now qualified as independent prescribers. It is anticipated that the trainee ANPs will be fully qualified for the role in 2024. Concerns have been raised by some of the trainees regarding the quality of the practitioner course so feedback will be sought prior to any future commitments to training. The service currently has 4 vacant posts. Alternative workforce options (such as DNs, paramedics and physician assistants) have been and will be considered as options for this workstream but any future recruitment will focus on the delivery of defined tasks and clinical outcomes. A piece of work will be done to define the duties of the urgent care workstream so that these can be mapped to defined outcome measures.
Vaccines
The VTP is now providing the vast majority of vaccines within the Borders. There may still be occasional, additional requests for practices to support the delivery of some vaccines but these should reduce over the coming months. This workstream continues to develop to refine the service and adapt where problems arise. Recent uncertainty around the responsibility for administration of tetanus vaccine has arisen and will be addressed between VTP and CTAC.
CTAC
This workstream is the last to be established but a tight schedule of delivery is now needed to have CTAC operational by 1st April 2023. Borders is fortunate to already have Treatment Room nursing provision in the majority of GP practices but this is not universal. The CTAC leadership team is still currently gathering background information to estimate the hours of workforce time needed to deliver the service. In order to deliver CTAC successfully, some form of electronic ordering system (eg Order Comms) will be needed. CTAC cannot be delivered without investment in this type of software. The provision of minor injury services also needs to be reviewed (alongside the rescheduling urgent care agenda) in order to minimise advantage / disadvantage to practices as the current provision is patchy and unpredictable. Many practices have raised a concern about availability of clinical space to accommodate the CTAC service. In time, once the quantity of service to be delivered in each location can be defined, more targeted discussions may be needed to fully understand the space limitations of practice premises. The CTAC delivery group have now defined the core CTAC service specification as well as the current TR provision above core CTAC tasks and the broader remit of an aspirational, enhanced CTAC service jointly resourced and utilised by primary and secondary care. Lastly, one of the most critical tasks of the CTAC workstream is to formulate a workforce plan. Currently, it is thought that there may be a mixed model of staffing requiring some recruitment to new posts and some transfer of practice staff (nurses and phlebotomists) to employment in CTAC. Advice about the correct legal mechanism to transfer the employment of practice staff to NHS Borders is being sought. The CLO will advise the Board whilst PCIP will fund group independent legal advice to practices (within an agreed funding allocation). A scoping exercise with the lawyers is being planned for next month. This will hopefully provide greater clarity and confidence around the transfer process for all involved. Ashley Durie (from Merse Medical practice in Duns) will be joining these conversations to provide a Practice manager perspective and assist with liaison with practices.
Community Link Workers
The function of CSLW and the LAC service has been significantly hindered by the pandemic. PCIP currently funds 2wte LAC workers and 2.5wte CSLW within a larger service run by SBC. Unfortunately, despite some initial, pre-pandemic introductory work by the service, referrals from practices are well below the level of resource contributed by PCIP. In 2020 there 30 referrals to the service from 11 practices with an additional 8 referrals to other LAC services (eg learning disability or older adults). This fell to 24 referrals form the same number of practices plus 15 to other LAC services in 2021. A review of the PCIP investment in this service is underway to consider the role of the service and the referral routes from practices.
