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The Healthcare Quality Strategy for NHSScotland

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3. Introduction - The Challenges

're-focusing alignment and integration'

This document sets out the details of the new Quality Strategy for our NHS in Scotland. The Quality Strategy is about more than renewing policies and approaches to planning and delivering healthcare. It is about a change in culture across Scotland in the way that we deliver, and engage in our healthcare. It weaves through everything we are already doing, and will be supported by the re-focusing, alignment and integration of much of our existing work.

'...a change in culture across Scotland in the way
that we deliver, and engage in our healthcare.'

The strategy is based on our knowledge about what works well in Scotland, and builds on the range of excellent progress and work already underway at local, regional and national levels. It has been developed through wide-ranging discussions with the people working in NHSScotland, with patients and with carers, through opportunities such as the Patient Rights (Scotland) Bill consultation and the Big Cancer Conversation, and a range of events and discussions with NHSScotland, third sector and other public sector partners which took place during winter 2009/10. It also reflects some of the output of a series of events held around Scotland with primary care contractors. The strategy refers to the leading international thinking and is our key response to the future challenges we will face in delivering high quality and sustainable health services now, and into the future.

When the Scottish Government set out its plans for improving Scotland's health and healthcare in its action plan Better Health, Better Care (2007) , it made a commitment to:

  • improve the health for the whole Scottish population and reduce health inequalities;
  • improve the quality of healthcare and healthcare experience, and develop a mutual NHS - offering the people of Scotland new rights and a stronger voice;
  • maximise the value of our investment in health services in Scotland; and
  • integrate health, care and other related services.

'...accelerate, join-up, re-position or indeed wind up...'

Considerable progress has already been made over the last two years through the range of programmes developed through Better Health, Better Care. As part of the implementation of the Quality Strategy, we need to assess the contribution of these and other programmes to the new Quality aims. Then we will need to accelerate, join-up or re-position these programmes or indeed wind them up where they have delivered their aims.

The NHSScotland Chief Executive's Annual Report for 2008/09, published in December 2009 4 set out an overview of the progress which has been made in addressing the priorities for action set out in Better Health, Better Care. This progress has been made through the successful pursuit of national targets ( HEAT) and through a range of achievements, many supported by the work streams established to implement the Better Health, Better Care Action Plan.

To improve health and reduce inequalities across the Scottish population, a number of national approaches are in place to tackle some of the underlying causes of poor health in Scotland. Some of the key programmes are as follows:

  • extending targeted health checks through Keep Well and Well North;
  • implementation of Equally Well and the Early Years Framework;
  • screening programmes;
  • smoking cessation and prevention;
  • promoting healthy living and preventing overweight and obesity;
  • alcohol brief intervention and treatment support services;
  • breastfeeding programmes;
  • reintroducing school-based preventative dental services; and
  • implementing of national immunisation programmes, e.g. to combat cervical cancer.

In acute care, waiting times are at their lowest ever levels. We are implementing strategies to ensure that people with cancer, dementia, heart disease, stroke and other long-term conditions and comorbidities are getting better quality and quicker care than ever before. The Scottish Patient Safety Programme is delivering major improvements in care in our hospitals.

We have also recently been leading the world in our collaborative approach to minimise the impact of the AH1N1 strain of flu. This is an excellent example of what our NHSScotland, working with contractors, the public and with public services across Scotland, can achieve. It illustrates how focused and effective NHS effort can achieve impact and global recognition.

The work we have done in recent years on improving patient safety is an excellent example of how well Scotland is placed to embrace new and effective ways of improving the quality of our healthcare services. Don Berwick (Institute of Healthcare Improvement), a recognised international expert on patient safety, has said, " NHSScotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety. The dedication of NHS leadership at all levels to this endeavour is clear, and bodes well for success. In its scale and ambition, the Scottish Patient Safety Programme marks Scotland as leader - second to no nation on earth - in its commitment to reducing harm to patients dramatically and continually." This confirms that we start from a real position of strength in developing and implementing a new quality strategy.

'...patient safety is an excellent example of how well Scotland
is placed to embrace new and effective ways of improving quality...'

We are continuing to build the basis for our mutual NHS through pioneering work such as the Patient Rights (Scotland) Bill, the Patient Experience Programme, the development of a Carers Strategy and the improvements in support for the self-management of long-term conditions and for people at high risk of developing these. Through this mutual approach our NHS will continue to learn from, and improve on, what is most important to the people of Scotland, taking account of the needs of our diverse population - this approach will permeate all our programmes of work. In the Quality Strategy, we seek to embed the mutual approach of shared rights and responsibilities into every interaction between patients, their families and those providing healthcare services.

The publication of A Force for Improvement in January 2009 has already provided the foundations for agreeing the actions required to ensure that the NHS workforce is supported, developed and equipped to respond to the challenges of the future. We will ensure that this action is aligned with the priorities and commitments agreed in our Quality Strategy.

'...challenging ourselves, sharing the pursuit of our ambitions
with every person in Scotland, focusing our efforts and raising the bar.'

This is not about pulling the plant up by the roots and starting again, it is about challenging ourselves, sharing the pursuit of our ambitions with every person in Scotland, focusing our efforts and raising the bar. To do this will require leadership, urgency, and a fundamental shift in culture focused on the delivery of effective, safe,
person-centred care.

Future Challenges

'...tightening financial resources available to
respond to the increasing demands...'

For many years we have been well aware of the range of drivers of change which will create very real challenges in the delivery of high quality healthcare services:

  • The next 20 years will see an ageing population, a continuing shift in the pattern of disease towards long-term conditions, and growing numbers of older people with multiple conditions and complex needs and the impact of this on them and their immediate carers. There will be more older family carers - many of whom will have their own health needs. These demographic changes and associated shifts in the pattern of ill-health will increase the demands on the whole healthcare system;
  • Continuing public health challenges such as the rise in overweight and obesity, physical inactivity, harmful use of alcohol, Hepatitis C and the ongoing need to reduce smoking rates;
  • Workforce pressures and sustainability will be critical in determining how we are able to respond to these changes in demand;
  • Developments in technology and in information and communications technology in particular, will give us the tools to fundamentally reshape how healthcare is delivered; and
  • Increased public awareness, diversity and intelligence creating different expectations and requirements around treatments, equipment, access, drugs and therapies.

Added to these drivers are the new challenges we face in the current economic climate with tightening financial resources available to respond to the increasing demands suggested by these demographic, cultural and technological changes.

Implementation of the Quality Strategy will be the means by which we ensure that these longer-term transformational challenges are addressed. In the short term, the NHSScotland Efficiency and Productivity Strategic Oversight Group will support Boards to identify immediate opportunities for achieving efficiencies, based on the Delivery Framework which was published in June 2009, with action and decisions which are consistent with, and in the context of the Quality Strategy.

'...the Quality Strategy will be the means by which we ensure
that these longer-term transformational challenges are addressed.'

Example of possible short-term national efficiency and productivity high-impact change:

Reviewing the use of bank and agency nurses/locum doctors, and establishing a more efficient approach which does not reduce the quality of care.

Examples of potential medium/long-term quality approaches which will reduce costs:

Disinvestment in drugs/treatments for which there is new evidence of low value added in terms of cost versus benefit to patients.

Investment in telecare/telehealth to support more people at home achieving better outcomes at less cost.