Transforming primary care in Scotland: a critical policy analysis

Abstract

Strong primary care is central to effective health systems, but both in the United Kingdom (UK) and internationally, primary care has proved one of the most challenging areas for health policy reform (1,2). Across the UK's four health systems, there are currently some strong resonances in policy ambitions, including broadening the multidisciplinary team to support general practitioners, encouraging place-based collaboration between practices, and innovating for quality improvement. However, especially when comparing England and Scotland, contrasting policy approaches to pursuing these goals reflect different governmental "styles of intervention" (3).In Scotland, where health policy was devolved to the Scottish Parliament in 1999, primary care has undergone continual evolution as policymakers have sought to improve the quality of care delivered, and to address underlying -and still stubborn -population health inequalities. The seismic, top-down reorganisations that have characterised recent English health policy (4) have been absent in Scotland. There have, though, been significant developments. The wider health system was reconfigured by Scotland's 2014 Public Bodies (Joint Working) (Scotland) Act which mandated the statutory integration of health and social care, creating new integration authorities on a legal basis(5). Then in 2018, a Scotland-specific GP contract was introduced for the first time, removing the Quality and Outcomes Framework (QOF) from Scottish primary care.Despite international interest, there remains relatively little peer-reviewed academic literature on Scottish health policy, as opposed to Scottish health services. One reason for this might be that Scottish reforms over the years of post-devolution health policy have been more incremental; lacking the 'big bang' system reorganisations we have seen in England (6). However, primary care in Scotland has been far from static: researchers have noted that the pace of layered reforms over the last decade complicates the potential to learn from and about specific policy interventions (7). We need new, and more nuanced conversations about how primary care in Scotland has changed, why, and to what ends. As a prompt for these conversations, we offer a critical summary of research on the Scottish reforms, contrasting the underlying approaches to reform taken by policymakers in Scotland and in England.

Evaluating primary care transformation: synthesis of findings from UK pilot project reviews

“…Approaches to primary care across the UK are still evolving, with governments continuing to invest in plans for further service or system redesign (2, 8-10). However, differences exist in the way in which policies are delivered across the four nations (11).…”

“…2 , 8 – 10 However, differences exist in the way in which policies are delivered across the four nations. 11 …”

Reflections from Research Practice

“…The question of why attempts to change often works out differently, also concerns the making of large-scale policy to instigate change (an area I'm currently active in as a research fellow) (Stewart et al, 2022;Huang et al, 2021;Mercer et al, 2021). A most recent example of this, in the ongoing responses to COVID national policies from citizens across the globe.…”

Strengthening attributes of primary care to improve patients’ experiences and population health: from rural village clinics to urban health centres

“…It aims to provide a mechanism for a focus on quality improvement to encourage primary care to adjust clinical foci to local aims and needs, alongside the expansion of multidisciplinary teams to address workload and population health inequalities. 2 In Hong Kong, strategies to foster continuity of care have been developed, such as the Elderly Health Care Voucher Scheme to encourage a regular source of care best suited to people's needs, the integration of the medical workforce in Community Health Centres, which is particularly important for patients with multiple healthcare needs, and the expansion of the Electronic Health Records Sharing System to enable smooth information transfer of patient records to achieve coordinated care. 3 In mainland China, the 'family doctor teams' which are built on the national basic public health service package have been gradually translated into routine primary care practice.…”