Transforming primary care in Scotland: a critical policy analysis

[摘要] Strong primary care is central to effective health systems, but both in the 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 GPs, 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’.3In 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 policy4 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.SCOTTISH PRIMARY CARE REFORM: A SUMMARY From performance management to quality improvementFrom April 2004 until March 2016, the performance of primary care in Scotland was managed by the UK-wide Quality and Outcomes Framework (QOF), within the framework of a single General Medical Services contract used across the UK. The QOF allocated funding to GP practices for specific chronic disease-focused tasks as well as organisational management targets.8 In Scotland, the QOF was abandoned in April 2016 following protracted negotiations between the Scottish Government and the Scottish General Practitioner Committee of the British Medical Association on the first Scottish GP contract. This new GP contract aimed, among other things, to shift general practice away from an ‘industrialised’ biomedical, single-disease-focused model of care towards a more holistic, values-based approach.8 A Memorandum of Understanding in 2021 acknowledged that agreed measures to achieve this shift — for example, shifting responsibility for vaccinations from GPs to health boards — were not in place by April 2021 as planned.9 The very mode of policy communication here is notable: a carefully worded joint document, rather than competing statements looking to allocate blame.

[学科分类] 卫生学