Draft respiratory care action plan: consultation

Chapter 2

Our Priorities

Priority 1 – Prevention

Priority 2 – Diagnosis, management and care

Priority 3 – Person centred and self-management

Priority 4 – Equal access

Priority 5 – Workforce

Question 2 – Our Priorities

Do you think we have included the most important priorities in this draft Plan?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Priority 1 - Prevention

Preventing respiratory conditions where possible, and reducing the risk of their development, means reducing or avoiding exposure to common risk factors.

The biggest risk factors include tobacco, air quality and respiratory infections.

The Scottish Government has set out ambitious aims through our strategies and Plans to combat the health implications in respect of smoking, clean air, healthy weight and the importance of vaccinations, as outlined below.

Tobacco

Smoking is the primary preventable cause of ill-health and premature death. Each year, tobacco use is associated with 100,000 smoking attributable hospital admissions and 9,000 smoking attributable deaths per year in Scotland^[8]; a fifth of all deaths.

The Scottish Government’s Tobacco Control action Plan, published in June 2018, sets out our 5-year Plan to address the ongoing harms which smoking causes in Scotland. We are determined to tackle the inequalities of smoking, to prevent the uptake of smoking among young people and to provide the best possible support for those people who want to give up.

We have introduced a 2034 tobacco free target. Our aim is to reduce smoking rates to 5% or below by 2034, creating a generation of young people who do not want to smoke and are protected from the harms of smoking.

As well as reducing the levels of people taking up smoking we are achieving a year-on-year increase in the proportion giving up smoking. Scotland’s NHS stop-smoking services were commended in the July 2018 Cancer Research UK report as the only services in the UK to tackle inequalities, focussing efforts in more deprived communities where prevalence is higher and the impact of smoking greater. This is being achieved by giving health boards and integration authorities specific targets for supporting people in our most deprived communities.

The NHS free stop-smoking service was rebranded in 2018 with the emphasis on helping people find their own way to stub out the habit. Quit Your Way provides a uniform service across Scotland with smokers offered specialist support and advice coupled with free nicotine replacement treatments such as medication, patches, gum etc. The re-brand was supported by the successful national TV and radio campaign ‘Get Through 72’ which focussed on the critical first three days of a quit attempt.

The health impact of smoking, not only in relation to respiratory conditions, cannot be underestimated. Therefore it is important that the commitments and actions already being undertaken in wider Scottish Government policies to combat smoking must be reflected in this Plan. Whilst this draft Plan contains specific commitments in relation to respiratory conditions, we must not lose sight of broader aims.

Air quality

The Scottish Government is also taking decisive action to improve air quality. We recognise the impact that poor air quality can have on human health, especially on the young, elderly and those with pre-existing health conditions. Compared to the rest of the UK and other parts of Europe, Scotland enjoys a high level of air quality.

We have already set more stringent air quality targets than the rest of the UK.

Our commitment to introducing Low Emission Zones in our four largest cities is a key initiative in further improving urban air quality, the first of which has already been introduced in Glasgow.

An independently led review of our air quality strategy ‘Cleaner Air for Scotland – The Road to a Healthier Future’ to assess progress and identify priorities for further action, has been completed and will be used as the basis for developing a revised and updated strategy. A report setting out the conclusions and recommendations of the review has been published^[9].

Flu vaccination

The majority of flu vaccines in Scotland are currently provided by GPs. While there are pilots planned for flu vaccination delivery in some areas, GPs remain responsible for providing flu vaccinations until such time as the transformation programme can be transferred safely to the ownership of the Health Board. Local communications will inform parents/ patients in pilot areas about the arrangements for receiving the vaccination.

Diet and healthy weight

In July 2018 the Scottish Government published ‘A Healthier Future: Scotland’s Diet & Healthy Weight Delivery Plan’, following consultation with stakeholders.

Given the complexity of the problem we face, the Plan is wide-ranging, but its central aim is to make it much easier for everyone across Scotland to eat well and have a healthy weight.

Our ‘Diet and Healthy Weight Delivery Plan’ aims to significantly reduce diet-related health inequalities by taking action at a population-wide level that will benefit everyone in Scotland, and delivering targeted and tailored support specifically to those individuals, children and families who need it most.

Priority 2 - Diagnosis, management and care

Diagnosis

Early and accurate diagnosis of respiratory conditions is critical, as any treatment and support can begin before the disease has progressed. People are better placed to manage their condition and to take positive choices.

Late diagnosis, under-diagnosis and misdiagnosis can have a large impact on health outcomes including quality and length of life.

Early and correct diagnosis of respiratory conditions are a priority

To diagnose respiratory conditions correctly and provide the best care possible, healthcare professionals need ongoing education on these conditions, including in primary care, and those in rural and remote areas.

Commitment 1

We will support respiratory health training and education for healthcare professionals by working with NHS Education Scotland and other partners to ensure that education and training on respiratory conditions is delivered/is available to healthcare professionals.

We will support education to be available in a variety of formats to optimise accessibility.

Commitment 2

We will improve equitable access to evidence based diagnostic tests by working with partners to reduce variation in the quality of spirometry testing across the Country and design pathways for complex respiratory function testing.

Commitment 3

We will support consistent disease specific pathways and work with the sector to ensure they are embedded in the health services and partners.

Question 3 - Early and correct diagnosis of respiratory conditions are a priority

Do you agree with commitments 1, 2 and 3?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Management and care

Several different healthcare professionals are involved in the care of people with respiratory conditions. Healthcare professionals need access to easy to use evidence-based clinical practice guidelines and care pathways for respiratory conditions in order to provide consistent best-practice care.

Pulmonary rehabilitation offers a structured exercise and education programme designed for those with respiratory conditions. Pulmonary rehabilitation encourages increased physical activity within the person's limitations. It also offers advice about drugs and how to use them, pacing activities, eating, weight management and psychological issues.

90% of people who complete the programme experience improved exercise capacity or increased quality of life^[10].

However, Chest Heart and Stroke Scotland (CHSS) estimates that just between 2% and 21% of those who might benefit are being referred to pulmonary rehabilitation^[11].

We expect NHS Boards to provide access to accredited pulmonary rehabilitation programs based on current clinical guidelines^[12].

It is imperative that we expand pulmonary rehabilitation services over the next 5 years. This will enable people to manage their health better and reduce costs.

Commitment 4

We will support NHS Boards to increase access to pulmonary rehabilitation. We will design pulmonary rehabilitation pathways based on examples of best practice and test them in areas where improvement is required. We will look at ways of providing support to a wider group of people with rehabilitation and self-management support.

Question 4 - Increase access to pulmonary rehabilitation

Do you agree with commitment 4?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Mental health Support

Coming to terms with a diagnosis of a respiratory condition can affect mental health and wellbeing. People with a diagnosis of a respiratory illness have different levels of need for mental health support.

Commitment 5

We will work with NHS Boards, clinicians and third sector to promote good practice and reduce variation in the quality of mental health support access across the Country.

Question 5 – Mental health support

Do you agree with commitment 5?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Transition from child and young people services to adult services

One of the most important aspects in the management of asthma is the period of transition from childhood to adulthood. Healthcare teams need to support patients and carers in getting ready to move from children’s healthcare to adult healthcare.

A good asthma care transition plan should give plenty of time to prepare for this transition.

Commitment 6

We will work with key partners to develop policies and procedures for a good transition from children and young people services to adult services for asthma.

Question 6 - Transition from child and young people services to adult services

Do you agree with commitment 6?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Palliative care

A palliative approach is central to best-practice end of life care. In some cases it should begin when a time-limiting disease is diagnosed, with increasing input as required.

The disease progression in some lung conditions is unpredictable. It should be recognised that active disease management and a palliative approach are complementary, not mutually exclusive, the introduction of palliative measures does not preclude active management, rather there is a continuum of care that progresses towards a more end of life approach as the disease progresses.

Increasing access to specialist services is important, alongside training and education of all health professionals involved in respiratory conditions in palliative care principles and practice including anticipatory care planning, discussions around attempt at resuscitation, and escalation of care decisions.

Commitment 7

We will work with NHS Boards, clinicians and the third sector to reduce inconsistencies in the provision of best practice palliative care for people with a lung condition as they near the end of life.

Question 7 – Palliative care

Do you agree with commitment 7?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Priority 3 – Person centred and self-management

The important role of self-management for people with chronic conditions is well established.

By supporting people with respiratory conditions to increase their knowledge and confidence in self-management practices, we can empower them to play an active role in their own health care and better manage their condition.

To do this, evidence-based tools, information and support services that allow for shared decision making between people with respiratory conditions and healthcare professionals are critical. Innovative technologies also have a role to play in supporting people to be actively involved in their healthcare.

Anticipatory Care Plans

It is also very important to support people in planning ahead and discussing their wishes for future care. Anticipatory Care Plans (ACP)^[13] can benefit people with living with respiratory conditions and can also be beneficial to individuals towards the end of their life.

A national programme to support the implementation of Anticipatory Care concluded in June 2018; an anticipatory care Planning approach is now being embedded across all areas of work in Healthcare Improvement Scotland and the Living Well in Communities Programme.

Unpaid carers

Unpaid carers play a key role in supporting their loved ones.

The Carers (Scotland) Act 2016 sets out a range of measures intended to improve the support given to carers. This includes the introduction of new duties on local authorities to support carers who are assessed as needing support and who meet eligibility criteria^[14].

Commitment 8

We will provide tools, and information for people with lung conditions to support effective self-management practices by:

• working with NHS Inform, and stakeholders across the Respiratory Community to improve the range of information available on respiratory conditions;
• supporting further development of a local Information System for Scotland (ALISS) as a national resource for sign-posting people with respiratory conditions to care and support;
• supporting health literacy to ensure that people have the knowledge, skills, understanding and confidence to use health information, to be active partners in their care, and to navigate health and social care systems;
• working with partners to increase access to community-based support for an effective self-management that complements clinical management and care.

Commitment 9

Support innovative technologies to enable people to be actively involved in their respiratory health.

Commitment 10

Support unpaid carers accessing appropriate information and support their health and wellbeing.

Question 8 – Person centred and self-management

Do you agree with commitment 8, 9 and 10?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Priority 4 – Equal Access

We know that the current model of primary, secondary and tertiary care works well for some of the respiratory conditions as it allows people to be referred to specialist teams to benefit from appropriate care, therapies and medicines.

However, there are instances where there are barriers to people accessing care and support when and where they need it.

We value the critical role of third sector organisations as key partners in developing, delivering and trialling new services and look to actively support them in creating a sustainable environment, particularly in areas where these organisations may be best placed to deliver services and support. We will also look to actively support third sector organisations as key partners by striving to create a sustainable environment for the care and support they provide.

We know that incidence and mortality rates of chronic diseases are higher in disadvantaged groups and areas of social deprivation, where there is often higher smoking incidence, exposure to higher levels of air pollution, poor housing conditions and exposure to occupational hazards.

This Plan is focused on the delivery of best care for all. Particular focus is needed in supporting people that experience barriers to accessing the appropriate care, such as rural and remote communities, culturally and linguistically diverse groups, protected characteristic and socioeconomically disadvantaged people.

Realistic medicine

Tackling unwarranted variation is essential to improving outcomes derived from healthcare across Scotland. Unwarranted variation is variation in healthcare that cannot be explained by need, or by explicit patient or population preferences. We need to ensure the prevention of harm and waste from overuse and overtreatment, freeing up resources currently used without benefit to clinical outcomes in order to address under-provision of care.

There are a number of initiatives underway that aim to tackle unwarranted variation. For example, the Scottish Atlas of Healthcare Variation aims to highlight geographical variation in the provision of health services and associated health outcomes. It is designed to facilitate discussion and raise questions about why differences exist and promote quality improvement through the conversation.

The Scottish Atlas of Healthcare Variation is an important tool to contribute to eliminating unwarranted variation, realising Realistic Medicine and support reducing harm and waste within the health service. The tool is designed to highlight variation and no judgement on the performance or inferences on quality of care of one geographical area against another should be concluded^[15].

We will engage with clinicians and patients to identify which areas to add to the Atlas to help ensure that it reflects the needs of the population, is relevant to clinicians and evolves with innovation.

Variation in care is not confined to health services. We also heard about care and support services not being accessible to people in neighbouring localities because of partnership boundaries, differences in funding essential equipment, and lack of access to therapy services due to place of residence. We need to remove barriers to improve access to care and support so that people can move easily between acute and community, and move in and out of services as appropriate to their needs, and at the right time.

Commitment 11

We will work with the Scottish Atlas of Variation Group to explore developing an Atlas on respiratory conditions.

Question 9 – Equal access

Do you agree with commitment 11?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Data

High quality data is important to the NHS as it can lead to improvements in care and safety. Quality data plays a role in improving services and decision making, as well as being able to identify trends and patterns, draw comparisons, predict future events and outcomes, and evaluate services.

Commitment 12

We will work with NHS Information Services Division and others to:

• understand the gaps in prevalence, and how best to improve the data;
• enhance capture of already routine collected data;
• further develop systems and processes that support service planning and workforce development based on this information;
• explore the feasibility of developing a national reporting framework that includes key performance indicators for respiratory care and support and measures improvements in care and support.

Question 10 – Data

Do you agree with commitment 12?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Priority 5 - Workforce

The delivery of joined up and holistic services require us to think more widely about workforce and those who support the health and wellbeing of people with respiratory conditions.

A number of people experience multiple morbidity. Care coordination is essential to reduce multiple appointments where possible to improve experience and outcomes.

The NHS is the biggest employer in Europe, and the world’s largest employer of highly skilled professionals. But our staff are feeling the strain.

Care workers, practitioners and professionals are a huge asset to health and social care and support, therefore it is important to support them in their current roles and in developing new roles.

Medical staff

Medical training is managed at a UK level; the Shape of Training review proposed an important evolution in the development of specialties and their role within provision of healthcare, particularly in the acute sector.

Innovative ways of encouraging applications at consultant level need to be considered. This need not be financially driven - improving study leave provision and training budgets may be one way to enhance the attractiveness of working in Scotland.

Nursing staff

The diversity of the specialist respiratory nurse role across Scotland is not underestimated. This group are open to the challenges associated with supporting a variety of respiratory condition and at times in the rurality of some areas of Scotland.

The integrated community nursing teams which include district nurses, general practice nurses, care home nurses, specialist community nurses and prison health nurses, play a key role in supporting people with respiratory conditions, anticipating care needs, preventing exacerbations through early intervention, supporting self-management and providing palliative and end of life care at home or in a community setting.

Areas where disease treatments are developing, including the introduction of biologic therapies in asthma mean the requirement for people to have more support, education and ongoing follow up all of which the specialist nurse teams can provide.

The Scottish Government’s Transforming Nursing, Midwifery and Health Professions (NMaHP) Programme’s aim is to ensure nationally consistent, sustainable and progressive NMaHP roles and career pathways, which will see an appropriately skilled workforce contributing to new models of care delivery. The Transforming NMaHP Roles Programme aims to support shifting the balance of care, reducing unscheduled care, unnecessary admissions, supporting people to be at home and the thereafter prevention and anticipatory care. As part of this programme the role and education of Clinical Nurse Specialists is being reviewed and a report outlining this work will be published in spring/summer 2020.

Commitment 13

We will support a programme of innovation and the development of a phased approach to implementation where emerging evidence supports changing models of workforce, such as testing new roles of Advanced Practice for nurses.

Question 11 – Workforce

Do you agree with commitment 13?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Wider workforce

It would be helpful for staff working in services such as other medical specialties, community teams, or care homes to receive training in understanding the needs of people with respiratory conditions and this should be available.

There is a need to develop guidance on the use of equipment and interventions by appropriately trained staff.

We support the critical role of third sector organisations in providing services and support. There needs to be consideration as to the sustainability of this workforce, while still recognising the independence of the sector.

Employers are responsible for ensuring their staff have the skills and knowledge to carry out their roles. This responsibility is set out in the Codes of Practice for Social Service Workers and Employers^[16] and the Care Inspectorate use the codes in their inspections of services. The National Health and Social Care Standards are also relevant, in setting out what a person can expect from their service provider.

Part 2 of the National Health and Social Care Workforce Plan: Part 2 - a framework for improving workforce planning for social care in Scotland proposes the development of a Framework for Practice in Social Care^[17]. This is being led by the Scottish Social Services Council, and will work with stakeholders to consider how such a framework will contribute to ensuring that there are clear routes identified that reflect the development of appropriate expertise in the social services workforce, who provide personal care and support for people at home or in a care setting alongside other professionals.

Commitment 14

We will work with stakeholders, in the context of the work taking place under the National Health and Social Care Workforce Plan, to explore how best to further support the development of appropriate expertise in the health and social care and support workforce for those working with people with respiratory conditions.

Commitment 15

We will discuss a national or regional approach to workforce planning with stakeholders, to test the extension of existing workforce planning tools and their application to the wider respiratory workforce in Integration Authorities and NHS Boards.

Question 12 – Wider workforce

Do you agree with commitment 14 and 15?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

Partial Equality Impact Assessment (EQIA)

The Equalities Impact Assessment aims to ensure that any new Scottish Government policies or legislation help promote opportunities where possible for a range of equalities groups and at the very least avoid any discrimination or other unfair treatment of any particular groups of individuals, based on, for example, their gender, race, religion or disability.

We do not feel that the proposals in this consultation would be likely in most cases to impact on individuals in any equalities group differently from others, although there may also be some implications for some people from minority ethnic groups if they do not have a good understanding of English, as well as those with visual or hearing impairments.

We would be grateful for your views on any equalities impacts to ensure that they can be fully considered as part of the Impact Assessment.

Question 13 - EQIA

Do you think there are particular impacts or implications for any equalities groups from any of the commitments in this consultation, either positive or negative?

Yes/No/Don’t Know

Please expand on your answer if you wish to.

In the question above, equalities groups should be taken to mean any different impacts the proposals might have on any particular groups of people based on their:

• age
• disability
• gender reassignment
• race
• religion or belief
• sex, or sexual orientation

Implementation

We will consult on this draft Plan to ensure there is wide support for our aims. We want to hear the views of a wide range of stakeholders on our proposals, the priorities, implementation, and - looking ahead - what more should be done.

Responses to the consultation will be analysed and used as part of the decision-making process, along with a range of other available information and evidence. We will publish a report of this analysis.

This report will help shape the final content of the Respiratory Care Action Plan.

We will then work with partners to develop an implementation plan, to take forward our vision for Respiratory Care in Scotland over a 5-year period.

Having worked with the respiratory community to identify the priorities, the

expectation is that over the coming years NHS Boards will commit themselves to implementing a programme of work to improve the quality of care and outcomes within these identified priority areas.

An Implementation Lead will be appointed to support Scottish Government, NHS Boards and integrated authorities in working together, develop local Plans for their relevant populations and agree on appropriate actions, targets and timeframes.