Partnership for Care: Scotland's Health White Paper
CHAPTER FIVE PARTNERSHIP, INTEGRATION AND REDESIGN
Redesigned services, to meet national standards and deliver quicker treatment
Legislation to create new Community Health Partnerships matched better with Social Work services and with stronger roots in the community
New ways to involve health professionals in redesigning services
A challenge to NHS Boards to improve public involvement in service redesign
New Scottish Health Council to help the public engage with the Health Service
Additional funding for service innovation
Support from the Centre for Change and Innovation
1. As the NHS modernises services it must keep its eye sharply focused on the changing demand for health services. By 2021, the number of older people (over 75) will increase by around 27%, while the number of young people is expected to fall by around 20%. These changes are already happening, and the impact can be seen in the rise of emergency admission of older people. Within Scotland the pattern of falling population will be unevenly felt. The specific challenge that NHSScotland faces, particularly in primary care, to provide a range of health services for our remote, rural and island communities, will not be made any easier.
2. Just as the overall population ages, so the proportion of the population of working age will decline. The health and caring services will face particular pressures in trying to recruit the staff they need to look after increasing numbers of older people. These changes are also likely to affect the number of people acting as informal carers, and the pattern of care they provide.
3. But there is a more urgent challenge for the health service workforce. The New Deal contract for junior doctors and European employment regulations will increasingly limit the hours worked by doctors in training and others. This will be of real benefit to staff and patients. However, it also has profound implications for the delivery of health services, especially in the hospital sector, where staff groups, including doctors in training, have contributed to out-of-hours cover.
4. NHS organisations must be aligned with the nature and scale of change required. Healthcare improvement will best be delivered when the different parts of the health system work in partnership as teams of professionals and with patients. We believe that this approach is most likely to come up with integrated solutions in line with the wants and need of patients.
5. We now require a major programme of service redesign across Scotland. This means looking at the pathway of care from a patient's point of view and making it smoother, more accessible, less complicated and less subject to delays. Sometimes it may involve changes in hospital arrangements. For example, over 300 one-stop clinics have been established to provide a number of tests and procedures at one rather than several hospital visits. At other times it will result in treatment being carried out in primary care rather than a hospital setting, or by a different member of the healthcare team than previously.
6. A wider range of services will be provided in community settings. Diagnostic and outpatient services are already provided in local health centres so that people wait less for specialist opinions or decisions about their care or treatment. More clinics will be held for the management of chronic disease and direct access clinics will be developed for services such as physiotherapy. More specialist treatment will be available in community facilities, sometimes from a General Practitioner (GP) who has acquired specialist expertise and sometimes from a traditional specialist who is based to a greater extent in the community.
7. Certain health services, however, which require a concentration of specialist skills, may have to be located in designated centres if they are to be sustainable over the long term. Such change will have to be managed with full public consultation, so that people understand the reasons for the change. This process is already under way, for example in acute maternity services.
8. Within such facilities, patients will be confident that professional staff are working with well-defined protocols, consistent with national standards, and subject to independent inspection and performance review. Within such centres, staff will have the necessary range of supporting facilities.
9. Changes in service delivery will require clinicians and managers to make best use of resources. The speed of change will depend on the level of new investment in hospitals and community health centres, in information systems and also on building the capacity and skills of the NHS workforce.
10. Our focus is on developing services within local communities and strengthening partnerships with Local Authority services. We will achieve this through a massive programme of service redesign, sometimes working across NHS Board boundaries, through partnership working at all levels, and by empowering staff locally to make change happen.
HEALTH SERVICES IN THE COMMUNITY
11. For most people contact with the NHS begins and ends in primary care. The professionals who provide these services are in every community: GPs, nurses, health visitors, community pharmacists, optometrists, dentists, physiotherapists, occupational therapists, podiatrists and speech and language therapists and dieticians. They manage 90% of patient contacts with the health service, co-ordinating diagnosis, treatment and care and ensuring that more of these services are provided as close to home as possible. They also have an expanding role in improving health, by helping patients to take more responsibility for actively managing their own health.
Support for Primary Care
12. Radical service improvements can happen when people at the frontline are given the opportunity, skills and resources to do a better job. This requires:
the right number and mix of staff with the right education, training and skills;
premises which are flexible enough to support a broad range of community services and a better environment for care teams;
clinical and care information systems which support the primary care team; and
quicker access to a wider range of services.
13. Patients and communities need to recognise that many NHS services will be provided locally by an increasingly wide range of skilled staff working together as a team. Such teams will be less confined to particular buildings and will work across communities and care settings so that patients can access services at a range of locations from a range of professional staff. This multi-disciplinary and multi-partner approach is particularly critical for the provision of local, integrated mental health services.
14. Professionals are continually extending the scope of their practice and also developing areas of special interest as they work together to deliver improvements to patient care. We will continue to invest in staff development and clinical leadership to encourage and support such improvements. For example:
GPs with special expertise provide additional services in specific clinical areas;
pharmacists and nurses have supplementary prescribing rights;
Allied Health Professionals are working more in the community to support rehabilitation;
hygienists, therapists and other members of the Dental team are making full use of their skills;
optometrists in the community provide more extensive services for those with diabetes and cataracts; and
community nurses can access Local Authority equipment.
15. All primary care premises need to be modern, accessible and welcoming to patients. 51 million has already been allocated to support over 100 community projects to improve premises and we will continue to use the Modernisation Programme to develop new premises. In many cases this will mean multi-agency community resource centres which provide easier public access to a wider range of integrated services. We will also promote the use of local pharmacies as walk-in centres where people can receive health advice and services.
16. For example, the Dalmellington Area Centre is a 'one stop shop' that integrates community services and promotes better services and advice for the 11,000 population of Doon Valley, all provided from premises befitting the delivery of primary care services in the 21st century. It is an excellent example of good working practices between a NHS Board, Local Authority, and other partner organisations including Strathclyde Police and the Princess Royal Trust for Carers.
17. We are investing in NHS 24 to provide 24-hour access to health advice and information about healthcare services by telephone from trained health professionals. This new service is already available to almost one-third of the population of Scotland and will be rolled out across Scotland by 2004. Its key objective is to get patients to the right point of care at the right time and to simplify contact with the NHS. NHS 24 will offer an integrated out-of-hours service with GPs, which means that patients need only make one telephone call and NHS 24 will arrange for them to seen by a GP if necessary.
18. Patients often complain about the time they have to wait to see a GP or other member of the primary care team. Our target is that by April 2004 no one will have to wait longer than 48 hours to access the appropriate member of the primary care team. We are providing support for this by establishing a Primary Care Collaborative which focuses on improving access. Primary care teams will come together to share experience about different ways of improving access, and to test out what works for them. This approach will also be appropriate for other areas such as diabetes and cancer services.
Developing Community Health Partnerships
19. The key building blocks for primary care services are the Local Health Care Co-operatives (LHCCs). LHCCs have made good progress in developing into responsive and inclusive organisations which are now the main focus for planning the development of community health services. But this is not the end of the road. We want to see a more consistent and strengthened role for LHCCs at the heart of a decentralised but integrated healthcare system. We therefore expect to see LHCCs evolve into Community Health Partnerships to reflect their new and enhanced role in service planning and delivery. In particular these Partnerships will:
ensure patients, and a broad range of healthcare professionals, are fully involved;
establish a substantive partnership with Local Authority services;
have greater responsibility and influence in the deployment of resources by NHS Boards;
play a central role in service redesign locally;
act as a focus for integrating health services, both primary and specialist, at local level; and
play a pivotal role in delivering health improvement for their local communities.
20. As a first step NHS Boards will review the organisation and operation of their existing LHCCs by early 2004 with these objectives in mind. This review should ensure that Community Health Partnerships maintain an effective dialogue with their local communities, which we envisage will be achieved through the development of a local Public Partnership Forum for each Community Health Partnership. If necessary, we will bring forward legislation to require NHS Boards to devolve appropriate resources and responsibility for decision-making to frontline staff and ensure that Community Health Partnerships provide an effective basis for the delivery of local healthcare services.
21. Boards will also work with Local Authority partners to produce plans aimed at ensuring more effective working with social care in appropriate locality arrangements within the same timescale.
22. Primary care is pivotal to the NHS. It is the right place to promote good health and to manage illness, particularly chronic diseases, such as diabetes, asthma and heart disease. Primary Care is particularly well placed to meet these challenges, as one of its strengths is the ability to provide a generic and holistic approach to care, which is so vital when a patient presents with more than one condition. When people need more specialist care, Managed Clinical Networks will support primary care practitioners to work with others to provide the best possible integrated care to their patients.
23. By working in partnership within the NHS and with other agencies, primary care is uniquely placed to influence and promote system-wide seamless care. It has enormous strengths on which to build in providing convenient, accessible and high-quality care to people in their own communities. If it can be done in primary care it should be done in primary care.
PARTNERSHIP WITH SOCIAL CARE
24. As more people receive their care in the community they will rely increasingly on joint responses from the NHS and local partners. The development of LHCCs and the Joint Future agenda have provided real opportunities to improve care in Scotland; and Community Planning provides a local focus for NHS Boards and Local Authorities to improve the health and wellbeing of communities. The commitment by the NHS and Local Authorities to joint working has never been greater and was endorsed by the Joint Summit of Ministers and leaders from NHSScotland and Local Authorities.
25. There is evidence that significant progress in developing more person-centred and integrated care in the community has been made, and the Community Care and Health Act 2002 takes joint working to new levels by enabling local partners to delegate functions and to pool budgets. In those areas where the greatest advances have been made, there are clear benefits - particularly in services provided to older people:
faster and better assessment of their needs (down from several weeks to a few days);
better access to more integrated services (through professionals accessing each others' services);
more comprehensive care packages (though information sharing across boundaries and a single shared assessment); and
better and more detailed information about services (through new developments such as information on equipment on the Web).
26. NHS Boards and Local Authorities will be required to make significant further progress, including the extension of joint resourcing and joint management from older people's services to the rest of community care from April 2004.
27. We are strongly committed to learning what works from Joint Future as we take forward our work on developing better integrated services for children through implementation of the Action Plan 'For Scotland's Children'. The National Child Health Support Group will support the NHS in joining up with partners in Local Authorities and the voluntary sector to promote a combined and integrated Child Health Service which is responsive and evidence-based.
28. NHS Boards should work with Local Authorities to review jointly how service planning and delivery can be better designed to meet community needs including:
maximising co-terminosity of service provision and organisational boundaries;
targeting funding at integrated services - a major focus for new capital development should be on community infrastructure, including modernised integrated community resource centres and joint information systems; and
empowering those who provide care - NHS Boards and Local Authorities should jointly develop clear schemes and processes for the delegation of responsibility, accountability and resources.
29. Joint working is particularly important in improving mental health services. Within this broad framework, networks of mental health service professionals can address the problems of patients or service users as they move from one service provider, or partner organisation to the next. Such care networks can improve the patient's pathway of care and promote the better use of the shared resources. To drive this network approach, we invite NHS Boards, Local Authorities and other partner organisations to work together to redesign the way mental healthcare is delivered. To complement the care network approach we will work with local Joint Future partners to extend joint management and joint resourcing to mental health services from April 2004.
30. NHS Boards should work with Local Authorities to develop their Local Partnership Agreements to include targeted plans by early 2004 to:
reduce bureaucracy and duplication;
develop a network of modern, sustainable and integrated community services focused on natural localities;
integrate community-based services and specialist healthcare services through clinical and care networks; and
develop organisations to support the necessary changes in service delivery.
31. Patients expect to move from one part of the health service to another quickly and easily. They expect each part of the service to work with a shared understanding of their needs, and with common, high standards of service. Integration involves a greater emphasis on systems of care rather than separate institutions, with management arrangements and budgets increasingly focused on them.
32. To achieve this the NHS needs to bridge the divide between services delivered in primary care and those delivered by specialist services, usually in hospitals. If patients are to receive integrated healthcare, then multi-professional teams need to work together to redesign the patient's pathway of care.
Managed Clinical Networks
33. One important way of developing integrated services is through Managed Clinical Networks (MCNs). They are linked groups of health professionals and organisations from primary, secondary and tertiary care, working together in a co-ordinated manner, unconstrained by professional and NHS Board boundaries, to ensure equitable provision of high quality, clinically effective services throughout Scotland.
34. Key objectives of MCNs are to:
involve patients and their carers;
set and demonstrate evidence-based standards of service;
ensure that patients are managed in the right setting at the right time;
ensure that appropriate management is available to sort out difficulties arising in the care of individuals and the network as a whole;
underpin the network with an information infrastructure that informs service planning and redesign; and
regularly report on the network performance to the public.
35. Networks already exist: cardiac services in Dumfries and Galloway; diabetes in Tayside; regional cancer services; and the national MCN for cleft lip and palate (Cleftsis). National Demonstration Networks in Lanarkshire for vascular services and neurology with particular reference to stroke are being evaluated. MCNs are also being developed for multiple sclerosis, epilepsy, asthma, and a wide range of other conditions.
36. MCNs have already proved that they can produce benefits for patients. The cancer MCNs have shown that patients welcome the development of clearly defined pathways of care, which reduce delays and duplications and tackle bottlenecks. They also lead to clearer information for patients and carers.
37. MCNs also offer benefits to health professionals by giving them:
a leading role in the shaping of services;
a wider range of professional contacts;
a greater understanding of the role their colleagues play in the patient's journey;
a chance to extend their professional roles within a supported context so that patient safety is not compromised; and
new tools, such as data collection and quality assurance system, which help to achieve continuous quality improvement.
38. We wish to see MCNs developed more widely but this will only happen where they can deliver clear benefits for patients. NHS Boards will be required to support this development by:
undertaking a systematic assessment of the MCN developments in their area; and
working through the new regional planning machinery to agree the most appropriate geographical coverage of future networks.
39. We will consult NHS Boards, the Royal Colleges, NHS Education for Scotland, and other professional organisations on how to best promote the clinical leadership required by MCNs, considering what incentives might be made available to Lead Clinicians of MCNs. NHS Boards will be expected to identify resources for clinical sessions devoted to Network development, to complement Departmental funding already available for Network Managers.
40. No single NHS Board can provide the full range of modern health services. We need to strike the right balance between the provision of highly specialised treatment centres and the need to provide services closer to people's homes where it is possible and safe. We also have to address the issues facing remote, rural and island communities and the challenges of providing services in areas of urban deprivation. This requires better planning and co-operation at regional and national level.
41. For example the three Regional Cancer Advisory Groups are based on partnership working and collaboration and have established links with regional planning groups. Their aim is to secure better access to services, quicker diagnosis and reduced waiting times for treatment - and continuous quality improvements in services in line with NHS Quality Improvement Scotland clinical standards.
42. Each NHS Board will have a formal duty to participate in regional planning groups and cross-Board Managed Clinical Networks. The existing three regional planning groups will be supported by a full-time co-ordinator, working closely with the new regional workforce co-ordinators, with NHS Board planning staff, MCNs, and with others planning regional services, such as the Scottish Cardiac Intervention Network. We will also expect regional planning groups to put in place open, structured and transparent public involvement strategies.
43. A key task for regional planning groups will be to consider the sustainability of services. Where specialist services cannot be delivered by individual NHS Boards they will plan for the continuing availability of clinical expertise at a regional level, taking account of clinical standards and the availability of experienced staff. Their plans will identify the best way to configure acute hospital and other services at a regional level in order to provide the best service possible to the people of the area.
44. Over time, service redesign will have a major impact on the configuration of services. For example, more acute services will be delivered in hospitals on a day-case basis, in ambulatory care and diagnostic centres. New intermediate care and rehabilitation services will be required particularly for older people and we will need to sustain and develop our Community Hospitals.
45. For example, as birth rates fall, changes will take place in paediatric and maternity services. More care will be provided in the community. However, to get the best and safest clinical services, some inpatient and other specialist clinical care will be concentrated in fewer centres. Implementing such change will require continued investment in the infrastructure of NHSScotland and also in the training and professional development of the health service workforce.
46. In Lothian, Glasgow and Tayside we have taken the first steps for new diagnostic and treatment centres at a local level. These will speed up the patient's journey, bring down waiting times and deliver better healthcare. We are determined to see these facilities develop right across Scotland and NHS Boards will make their development a priority.
47. The emphasis will continue to be on reducing the need for people to stay in hospital. Reducing pressure on hospital beds will help with the increasing number of people with chronic illnesses, including the elderly and frail, who require hospital care urgently, especially in winter. Service redesign is essential to ensure that we can provide that emergency care, without disruption for people who are waiting for operations and other treatment. Working with Local Authorities to reduce delays in discharge, and working with primary care staff to provide better alternatives to hospital admission will be crucial.
48. Any change that takes place must take into account patient safety, the best clinical standards and the availability of the right clinical staff. It is not possible to provide emergency and elective care for every condition in every hospital or NHS Board area. Trying to do too much in too many places creates staffing difficulties, and complaints about standards of care. Some acute services can best be delivered locally, some on a regional level and some at a national level. It may be feasible to provide some services locally during core daytime hours, and on a regional level at other times. If patients need specialist clinicians and other services overnight, this may not be possible on every hospital site. NHS Boards, regional planners and the Scottish Executive will review what kind of service is appropriate at each level. This will result in a reduction in waiting and cancelled elective procedures, and more effective supply of specialist staff for NHSScotland as a whole.
49. NHSScotland must work with the public, staff and patients to demonstrate that the changes in hospital provision are in order to improve care for patients. The changes are to make sure that the highest clinical standards are achieved and that staff are available in the right place, at the right time, with the right skills to provide the care that is needed. Making this happen is a great challenge for leaders in acute services and in NHS Boards.
50. The public should be involved at an early stage in discussions about the changing pattern of healthcare services. The Service has not always handled such consultations with local communities well, and it must learn to engage the public far more effectively in future.
51. Traditional forms of consultation on options for change or service development are no longer enough. If the public feel that health providers are consulting them only after they have developed a preferred option, then involvement is too late. People must be involved earlier so that their views are available at the formative stage of any new proposals.
52. We need to develop genuine public involvement in the NHS if we are to have a service in which patients are confident that their needs are being met. Of course this will sometimes mean difficult decisions.
53. What is important is that all decisions are taken in an open, honest and informed way, and that the public are involved in the choices and decisions which need to be made. This means seeking public views from the earliest stages, defining issues clearly, exploring possible options, and examining these in an open way with good evidence. It means using modern methods of communication and involvement to ensure that the widest range of individuals and communities affected by changes are reached. It also means feedback to those consulted.
54. The Scottish Consumer Council has helped us consult widely inside and outside the NHS on the best ways to involve local communities and the public. We will issue final guidance reflecting that consultation and publish proposals to strengthen public involvement structures and establish a Scottish Health Council in the NHS.
55. The Scottish Health Council will be set up as part of NHS Quality Improvement Scotland reflecting the close link that needs to exist between quality and involvement. Its role will be to provide leadership in securing greater public involvement in NHSScotland; to support the development of good practice in public involvement; and to ensure that quality improvement is driven by the needs of patients and service users.
56. We have asked NHS Boards to develop sustainable frameworks for public involvement which take account of the local Public Partnership Forums which we envisage for each Community Health Partnership and of the need to involve patients in the work of Managed Clinical Networks. The new Scottish Health Council will in future monitor the performance and effectiveness of Boards in relation to public involvement, and will report regularly on the results. This will ensure that there is external scrutiny and quality assurance of what Boards are doing to involve the public.
SUPPORT FOR SERVICE REDESIGN
57. Strengthening the delivery of community health services and ensuring they are fully integrated with more specialised care will require a significant commitment to redesign. We believe that this will be driven by an increased focus on the needs of patients and the framework of national standards for healthcare, but also by empowering staff to initiate change locally in response to these demands.
58. We expect NHS Boards to co-ordinate redesign activity by putting in place service redesign programmes. These programmes should ensure that sufficient staff time is freed up to concentrate on redesign and be supported by development programmes for staff to enhance their knowledge, skills and ability to lead service change. This includes ensuring that staff have access to examples of best practice both locally and nationally.
Change and Innovation
59. We will require NHS Boards to develop Change and Innovation Plans that are specific, prioritised and resourced to support local redesign activity. Plans must:
demonstrate active participation by patients and leadership by clinicians;
challenge traditional boundaries of service delivery;
develop sustainable services; and
ensure information systems support changing patterns of care.
60. We expect local plans to address service improvements in key priority areas by:
developing community health services through Community Health Partnerships; and
increasing integration of primary care and specialist care, and in particular strengthening MCNs.
61. We will distribute a Change and Innovation Fund to NHS Boards where we are satisfied that local Change and Innovation Plans will deliver these objectives. Progress in implementing these Plans will be reviewed as part of the annual Accountability Review process.
62. We will also strengthen clinical involvement in service redesign by requiring all NHS Boards to establish a Service Redesign Committee. These Committees will link to the Area Clinical Forum, where the leadership of health professionals come together within each NHS Board area, and include members drawn from each Community Health Partnership, in order to ensure strong clinical input to the development and delivery of Change and Innovation Plans.
Support for Change and Innovation
63. We will also provide national support for service redesign through the work of the newly created Centre for Change and Innovation (CCI). The CCI will provide practical support and expertise to help NHSScotland improve the way in which care is provided for patients. It will do this by:
supporting service improvement in national priority areas such as mental health, cancer, coronary heart disease and stroke and chronic diseases such as diabetes;
using well tried techniques such as 'collaboratives' to help staff develop solutions to their own problems;
developing a database of national and international good practice in clinical and service design;
providing expert support for NHSScotland to help address local service problems;
tackling national initiatives such as outpatient appointments, access to primary care and mental health services;
creating networks to develop improvements in clinical practice; and
encouraging flexible and innovative ways of working and supporting the professions and other people in the development of different roles.