Primary care transformation in Scotland: a qualitative study of GPs’ and multidisciplinary team members’ views

Background The Scottish Government’s vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018. Aim To explore practitioners’ views on the expansion of MDT working in Scotland. Design and setting Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland. Method In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews. Results Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems. Conclusion Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality.


Introduction
In response to an ageing population, growing numbers of people living with multiple long-term conditions (multimorbidity), and widening health inequalities, the Scottish Government has a policy vision of better integration of care, and shifting the balance of care from hospital to community. 1,2[5] Expansion of the general practice workforce is fundamental to the Scottish Government's aim of moving more care into the community and, in December 2017, it pledged to increase GP numbers by 800 within a decade. 6However, an ageing GP workforce, and GP recruitment and retention problems, have made it difficult for the Scottish Government to meet its target. 7,8Between 2018 and 2021, GP numbers in Scotland increased by 209, but this was solely because of an increase in female GPs, who mostly work part-time. 9The most recent data published in November 2022 showed a 3% fall in the number of full-time GPs in Scotland, the lowest level since 2009. 10 address problems with GP recruitment and retention, and to facilitate primary care transformation, in April 2018 a new General Medical Services contract was introduced in Scotland. 11,12The contract aimed to reduce GP workload and refocus the role of GPs towards becoming expert medical generalists, allowing them to focus more of their time on patients with complex care needs such as people living with multimorbidity. 11,12A key part of the new contract is the expansion of the multidisciplinary team (MDT) in primary care so that patients can receive care from the most appropriate member of the MDT and at the right time and place with the intention of also helping to reduce GP workload.Wider primary care transformation in Scotland has also seen the integration Primary care transformation in Scotland: a qualitative study of GPs' and multidisciplinary team members' views Eddie Donaghy, Huayi Huang, David Henderson, Harry HX Wang, Bruce Guthrie and Stewart W Mercer

Background
The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018.

Aim
To explore practitioners' views on the expansion of MDT working in Scotland.

Design and setting
Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland.

Method
In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022.Interviews were audiorecorded and transcribed verbatim.
Thematic analysis was conducted to identify commonalities and divergences in the interviews.

Results
Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance.External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale.Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased).In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue.Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems.

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6][17] Between March 2018 and March 2022, the Scottish Government reported that there were 3220 whole-time equivalent new MDT staff appointed in primary care, with the largest group being pharmacists and pharmacy technicians (just under 1000). 18e aim of this study was to explore the views of GPs and MDT staff on these factors, and the wider progress of primary care transformation (and its impact on ageing people with multimorbidities and on health inequalities) in three different health board areas of Scotland (urban high deprivation, urban mixed affluent/ deprived, and remote and rural).

Method
This research is presented using the standards for reporting qualitative research framework. 19The research was carried out and reported in accordance with the consolidated criteria for reporting qualitative research. 20

Study design
Qualitative methods were used to explore the views of frontline primary care staff working in Scottish general practices.
Data were collected using in-depth semi-structured interviews.As a result of COVID-19, all interviews were conducted by telephone, something commonly done by researchers during the pandemic. 21

Sampling and recruitment
This study is the second phase of an ongoing programme of funded research led by the corresponding author on primary care transformation in Scotland.As part of this broader programme, 12 GP clusters were recruited across three Scottish health boards (out of a total of 14) for qualitative and quantitative evaluation.This number of health boards was established by the funding limit of the research grant.The participating health boards were selected to provide a variety of population characteristics, including urban areas of high deprivation (health board 1), urban mixed affluent/ deprived (health board 2), and remote and rural populations (health board 3).Frontline primary care staff working in GP practices across participating health boards and 12 participating GP clusters were initially approached by cluster quality leads who had participated in phase 1 of the qualitative data collection. 17Potential participants were provided with details of the research through a participant information sheet.The research team was accessible to answer any questions about the study.Recruitment stopped when the core research team agreed that data saturation had been reached.The health boards and the participating GP clusters and practices are not named to preserve the confidentiality of the participants.

Data collection
One-to-one telephone interviews with frontline GP practice staff, lasting approximately 40-60 minutes, were conducted by two authors between May and June 2022.Interviews were audiorecorded and transcribed verbatim.The interview topic guide was influenced by phase 1 of the authors' previous qualitative work in this current study, a scoping review of literature on primary care transformation in Organisation for Economic Co-operation and Development (OECD) countries.Areas covered with participants included their views on the original intentions of the GP contract/ reforms and expected outcomes at that time, their views on actual progress locally in the GP practices they worked in (particularly MDT expansion and its impact on GP workload and support and training

How this fits in
The Scottish Government introduced expansion of multidisciplinary teams (MDTs) as part of its vision to transform primary care in early 2016, formalised in a new Scottish GP contract in April 2018.These changes aimed to reduce GPs' workload, improve patient care, and better meet the needs of patients with complex problems.This qualitative study with GPs and MDT staff reveals that, although most GPs welcomed the expansion of the MDT, there are many internal and external challenges to the effective implementation of integrated MDT working in primary care in Scotland.Most GPs reported that their workload had not decreased (and in many cases had increased) and the care of patients with complex multimorbidity had not improved.Challenges were most marked in deprived areas and in remote and rural settings.These barriers to effective MDT working need to be addressed if the ambitions of the new GP contract and the transformation of primary care in Scotland are to be fulfilled.for MDT staff), the impact on health inequalities and addressing the needs of older people living with multimorbidity, and the effect of COVID-19.Table 1 shows the wide range of ages, experience, and professional roles of the interviewees across the three health boards.The professional roles included covered most of the key professions involved in MDTs in primary care in Scotland. 18ta analysis Thematic content analysis was conducted 22,23 to identify commonalities and divergences regarding the significance and operationalisation of the GP contract/wider reforms in the context of the three diverse population groups in each health board, and from the perspective of the different frontline professionals interviewed.Three authors independently identified and developed initial codes based on individual analysis of selected interview transcripts from the three health boards, and agreed on the coding frame through discussion.The transcripts were coded using NVivo Pro (version 12).The phases of thematic analysis outlined by Braun and Clarke 22,23 were applied by the core team of researchers in the six following steps: familiarisation with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the final report.The agreed themes were also discussed with the wider research team, including the four members of British Journal of General Practice, January 2024 the patient and public involvement group established for this programme of research, and sent to participants for comments.The key findings are reported below with examples of quotations.See Supplementary File for details of more quotations on all the themes identified.

Results
Most interviewees spoke positively about an increase in MDT working, and reported that patients were seeing a range of MDT staff since the introduction of the new GP contract in Scotland: 'We're quite far on in having other health professionals in the practice.We've got a physiotherapist, a pharmacist, a physician's assistant.We're signposting through reception a lot of our patients directly to them at first point of contact.' P23 (GP, partner, male, urban mixed affluent/ deprived practice) 'It just feels like certain problems lend themselves really well to being managed by those AHPs [allied health professionals] as a first point of contact.That's been a really positive change.On the days or the weeks in which those professionals are not available, we really notice the difference.'P24 (GP, female, urban mixed affluent/deprived) However, three key common themes were identified in the analysis in terms of challenges of MDT implementation: the intrinsic challenges of MDT expansion

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in primary care, the extrinsic challenges relating to the COVID-19 pandemic and post-pandemic period, and the impact on GP workload and the GP's expert generalist role.Issues were also identified that differed between the three sites.'I would say about thirty to forty per cent are face-to-face appointments.It's only by making phone calls that I can get through the number of patients that need to be seen … Hybrid working is here to stay.' P15 (GP partner, male, urban deprived) However, many felt that hybrid working carried significant risks: 'Telephone triage has become the new norm which incorporates much higher risk.Quite often we will say at our coffee meetings "I saw this, it sounded nothing like that on the phone.I'm so glad I brought them in and saw them."We've had some near misses, we've had some delayed diagnoses from that.' P23 (GP partner, male, urban mixed affluent/deprived)

Staff morale. Most interviewees reported damage to staff morale during and since the pandemic:
'Morale is very low at the moment, just kind of feels like you're not ever going to get out of this and get back to normality.I think people have lost any resilience they had.' P03 (senior prescribing support pharmacist, female, urban deprived) Theme 3: Impact on GP workload and the GP's expert generalist role Seven of the eight GPs interviewed reported no decrease in workload, and most reported increased workload postpandemic.Consequently, most GPs had not been able to give targeted longer consultations to patients with complex needs: 'Am I spending more time as an expert medical generalist?No.Because there's nobody that can actually take the work off us.I don't have longer appointment times … Patient demand, it's doubled in the past couple of years, since COVID.' P15 (GP partner, male, urban deprived) GPs also spoke about the increased responsibilities they have in supervising and training MDT staff: 'A lot of our time as GPs will be supervising AHPs … To train and develop autonomous working in AHPs takes a long time … Time is precious.You often don't feel as though you have the time to be able to properly input and teach them.' P23 (GP partner, male, urban mixed affluent/deprived) Health inequalities.Most interviewees believed the new contract had done little to reduce health inequalities; indeed, several noted that health inequalities had widened during and following the COVID-19 pandemic: 'The impact of COVID on health inequalities?It's widened that further.A good example is that there was a map disseminated in the first lockdown of all the hotspots of where the most prevalent areas of COVID were, they were all the most deprived areas.So that's just a huge sign of health inequalities.These are the people getting COVID, where the people with chronic health diseases are most vulnerable and more of them are getting it in these areas.So, COVID definitely has emphasised and worsened that further.' P27 (GP, partner, male, urban deprived) Differences between affluent/ mixed, deprived, and remote and rural settings Deprived.In the deprived areas, interviewees more commonly reported insufficient resources to deal with the high numbers of patients with complex multimorbidity (spanning mental, physical, and social problems): 'In areas of high deprivation people have multiple medical problems, social and mental health issues … It's a challenging demographic, trying to encourage selfmanagement, and health promotion and wellbeing … Also it's still a hard sell getting patients used to not seeing a GP … In the more affluent practice area, patients are coming in primarily with single musculoskeletal problems.'P17 (advanced physiotherapy practitioner, male, urban deprived) Interviewees reported that the pandemic had exacerbated health inequalities, and staff morale was lower in these interviewees compared with those from more affluent or remote and rural settings.

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many cases had increased) and the care of patients with complex multimorbidity had not improved.Challenges were most marked (although different) in deprived areas and in remote and rural settings.
The introduction of growing numbers of MDT staff working in general practice, but not employed or line managed by senior practice staff, has clearly introduced a new dynamic into Scottish general practice.The findings of this study indicate that tensions can arise as a result of these new line management processes, especially where there are competing priorities between individual GP practices and health board and HSCP priorities.Although there has been substantial expansion of the primary care MDT, many challenges to effective implementation remain, which must be addressed if transformation of primary care in Scotland is to become a reality.

Strengths and limitations
A strength of this study was the involvement of the four members of the patient and public involvement group in all stages of the study.A further strength was that clusters were purposively sampled in three health boards, in clusters serving urban deprived areas, urban mixed affluent/deprived areas, and remote and rural areas, in order to gain the views of GPs and MDT staff working in these diverse settings.However, as the first 12 clusters that agreed to participate in the research programme were recruited, it may have introduced a bias, in that those who volunteered to participate may have held stronger views, either positive or negative, than GPs and MDT staff as a whole.A further limitation was that not all types of MDT staff were recruited although most were covered; paramedics, mental health nurses, and healthcare assistants were not included in the sample as they did not volunteer to take part. 18Finally, as in all qualitative research, the findings of this study cannot be assumed to be generalisable.

Comparison with existing literature
This study raises questions about the general integration of new MDT staff into primary care and how they adapt to the unique demands of general practice and individual practice contexts and culture.[26] The findings of the current study indicate that efforts to consciously build professional relationships and facilitate the best conditions for new MDT healthcare professionals to work effectively in GP practice teams are essential.8][29][30] Recent research has likewise also noted that, to realise the potential of MDTs, local implementation needs to be carefully planned and supported by ongoing monitoring and evaluation. 31e importance of training and professional development was raised by participants, especially for MDT staff new to general practice and working in new general practice roles; research elsewhere also suggests that a lack of training and professional development can be a barrier to primary care transformation. 32,33nsequently, acknowledging the importance of building relationships and having processes in place to support this are fundamental for the development of effective multidisciplinary working in general practice.These two components are intertwined, as building positive working relationships can only be developed if the right processes are in place to facilitate them, along with shared understandings and agreements on MDT roles and responsibilities, as noted elsewhere. 29,30However, this remains problematic, as highlighted with, but not limited to, the integration of pharmacists into general practice, [34][35][36] something also found in the current study.Our findings also agree with studies on the increased number of pharmacists working in GP surgeries that report challenges related to the working environment, as well as available support around training and time allowed for learning 'on-the job' to understand how primary care works.These studies concluded that, if integration of pharmacists into general practice is to be successful, flexibility is required to develop their roles based on individual general practice needs while performing within a recognised competency framework.

Implications for practice
Introducing changes to general practice is challenging and policies aimed at transforming primary care frequently underestimate the time required from clinicians who already have very large workloads to take time out to support the implementation of policy goals. 37,38oing so in light of the unprecedented challenges facing Scottish general practice as it emerges from the COVID-19 pandemic, as GP leaders in Scotland have highlighted, 39 makes this a major test.A recent Scottish British Medical Association survey found that 81% of GP practices that responded to the survey reported that demand is exceeding capacity, underlining the scale of the challenge. 40ile it is not possible to generalise the findings from such a small number of GPs interviewed, the feedback from the GPs who participated suggests that, while the introduction of more MDT staff into Scottish general practice has increased MDT working, it has not reduced GP workload.Indeed, many MDT staff interviewed corroborated this.With the increased responsibilities on GPs for training and supervision of new staff it has, in the short term at least, increased time pressures on GPs, echoing similar findings in England. 41,42st interviewees believed that the new GP contract and wider reforms to transform primary care have had little impact on the care of older people living with multimorbidity or in addressing health inequalities.As recently highlighted by others, 43,44 most interviewees, especially those working in deprived areas, believed the COVID-19 pandemic has exacerbated health inequalities.
Concerns over growing unmet need as general practice emerges out of the pandemic were raised by many interviewees, especially in deprived practices, suggesting a need for urgent answers to the inverse care law that continues to exist in Scottish general practice. 45The growing concerns of remote and rural GPs regarding the suitability and applicability of the GP contract where they practice, 46 along with the growing problems of recruiting and retaining sufficient numbers of MDT staff, must also be considered by the Scottish Government.

Health board 3, remote and rural (n = 8)
Interviewees from the urban affluent/mixed health board more often had a positive view of the new contract's impact: