3 National Clinical Strategy
3.1 The National Clinical Strategy, set out a framework for developing health services across Scotland for the next 10-20 years. It envisaged a range of reforms so that health care across the country could become a more coherent, comprehensive and sustainable high-quality service - one that is fit to tackle the challenges we face.
3.2 At its heart was a fundamental change in the respective work of acute and hospital services and primary and community care, and a change in the way that medicine is approached. As a result, the Strategy aimed to:
- Strengthen primary and community care.
- Improve secondary and acute care.
- Focus on realistic medicine.
3.3 Primary and Community Care
What we have done
3.3.1 A key element supporting the reform of primary and community care services is the new GMS contract which came into force on 1 April 2018. It set out the distinctive new direction for general practice in Scotland which will improve access for patients, address health inequalities and improve population health including mental health, provide financial stability for GPs, and reduce GP workload through the expansion of the primary care multidisciplinary team.
3.3.2 It also increases support for GPs and GP infrastructure, increases transparency on funding, activities and workforce to assist strategic planning and quality assurance; and makes general practice a more attractive profession for existing GPs, junior doctors and undergraduate medical students.
3.3.3 New models of primary care in every NHS board have been tested and evaluated to assess their stage of implementation. Following early evidence of mutually supportive sharing of experience, collaborative learning across different parts of the system, and sharing of good practice, these models are now being implemented by Health and Social Care Partnerships through their Primary Care Improvement Plans, which support the implementation of the new contract. Initial Primary Care Improvement Plans covering all 31 Integration Authority areas in Scotland have been developed and shared with the Scottish Government. This represents a significant collective achievement of local partners, and a strong endorsement of the collaborative approach between Health and Social Care Partnerships, Health Boards and the GP profession in creating and agreeing the plans in a short period of time.
3.3.4 As well as emerging local networks of support, learning and best practice sharing continues to happen in a number of key national networks such as the National Chief Officer Special Interest Group on Primary Care and the national Primary Care Leads group. In addition to the mutual support offered through these networks, the Scottish GP Committee of the BMA is engaging with local GP Sub Committees to support their critical role in collaborating and developing plans.
3.3.5 The majority of the recommendations of the Improving Practice Sustainability Short Life Working Group have been implemented, or are being actioned as part of the implementation of the 2018 GMS contract, or are an integral part of the service redesign underway.
3.3.6 Three of the five recommendations made by the GP Premises Short Life Working Group have been fully implemented (a survey of GP premises to understand the state of the GP estate; moving to a service model which does not entail GPs owning their practice; and the development of a national Code of Practice for NHS Boards). Revised Premises Directions are due to be issued by the end of 2019, and Integration Authorities and NHS Boards are ensuring that GP premises are included within integrated capital plans. The GP Premises Sustainability Loan Scheme was launched at the end of 2018, and loan offers will be issued to practices shortly.
3.3.7 We have made good progress to implement the vision of the Improving Together Advisory Group. There are now 147 GP Clusters around Scotland with the intention of learning, developing and improving together for the benefit of local communities. There has been dedicated national funding in place since 2016 to enable Practice Quality Leads to participate in GP Cluster working. The important role of GP Clusters is referenced in the 2018 GMS Contract and supported by a MoU that sets out the key role they will serve in quality improvement. The Scottish Government will shortly publish national guidance on GP Clusters that will set out recommended minimum expectations for Clusters and the wider system support required to enable and develop the Cluster role and function.
3.3.8 We are building up capacity in Primary and Community care through a range of measures:
- We now have at least an additional 509.1 whole time equivalent Health Visitors in place, meaning that the commitment to have an additional 500 WTE Health Visitors has been achieved.
- We now have 320.2 whole time equivalent pharmacists and 90.6 whole time equivalent pharmacy technicians in place, providing direct pharmacy support to over two thirds of Scotland's GP practices.
- Over 700 additional paramedics have been recruited and trained since 2016.
- We have agreed a refreshed role for district nurses; almost 500 nurses have been funded to undertake Advanced Nurse Practitioner modules since 2016; and we have created an additional 2,145 training places for nurses and midwives since 2016/17.
- From 2016 we increased the number of undergraduate training places by 50 meaning that by 2022 we will have an additional 250 undergraduates studying medicine.
- The ScotGEM Graduate Entry Programme commenced in October 2018. The programme, designed to develop doctors interested in a career as a generalist practitioner in Scotland, offers 55 places on a unique and innovative four-year graduate entry medical programme tailored to meet the contemporary and future needs of the NHS in Scotland and focuses on rural medicine and healthcare improvement.
3.3.9 The Best Start Plan a five year forward plan for the improvement of maternity and neonatal services in Scotland - set out a number of recommendations which are being taken forward either locally, or at a national level. A number of recommendations have been completed, which are already delivering benefits, including:
- Combining the three regional neonatal Managed Clinical Networks (MCNs) into one single neonatal MCN, which is creating a more joined up, coherent approach to neonatal care across Scotland taking a 'Once for Scotland' approach across all regions and providing a better opportunity for shared learning. Building on the experience of the three region MCNs, the national MCN is bringing together a range of stakeholders from across the neonatal landscape.
- The launch of a neonatal expenses scheme to have consistency in approach to out of pocket expenses which is enabling parents whose babies are in neonatal care to spend more time bonding with their baby rather than worrying about the financial concerns that come with travel and additional meals costs as a result of having a baby in hospital.
- The publication of a revised edition of Ready Steady Baby as a 'one stop shop' for parental information on pregnancy and early parenthood. A wide range of stakeholders have worked together to develop this refreshed comprehensive information guide for parents which every pregnant women receives from her midwife. We have also now given every midwife a copy of Ready Steady Baby to allow them to signpost women to relevant information when required.
3.3.10 Five "Early Adopter" Boards were selected to lead a package of recommendations to deliver the national actions including introducing continuity of the carer; local delivery of care, and a focus on keeping mother and baby together in neonatal care where possible. The Boards are currently testing the new models of care prior to establishing full implementation plans. Some Boards are also testing the use of technology in maternity care and this is having positive feedback from staff and women, especially in rural areas where their travel time to consultant appointments has been replaced by a virtual clinic with the consultant which also allows their midwife to be part of the appointment and hear first-hand the plan of care.
3.3.11 In addition we are moving towards a new model of neonatal care that will see development of neonatal community outreach services, supporting well, preterm babies to be discharged home earlier to be with their family. The implementation of Transitional Care across Scotland means that babies with moderate additional care needs (for example, late preterm) can be kept with their mother and cared for in postnatal wards. The implementation of Transitional Care is already underway in five Boards and results are showing this is having a positive impact in reducing admissions to neonatal care - by around 25% in some areas- and we intend that all of our Early Adopter Boards will have Transitional Care established by the end of 2019.
3.3.12 For the most preterm and sickest babies, evidence tells us that their outcomes are improved when they are born and cared for in a centre with a high throughput of activity. Based on the numbers of these babies in Scotland, The Best Start recommends we should move to three neonatal intensive care units in Scotland.
3.3.13 We are testing this approach in two areas in Scotland covering four units, between Edinburgh Royal Infirmary and the Victoria Hospital in Kirkcaldy, and between Glasgow Queen Elizabeth University Hospital and Crosshouse Hospital in Kilmarnock. Babies who require care in one of these units will only stay in the designated intensive care unit for a short period of time for specialist treatment and will return back to their local neonatal unit as soon as possible for follow up care. The pilots started in August and will run for several months before review. The learning from the pilots has already been very useful in considering wider roll out of the model.
3.3.14 The ambitious programme of work contained within our Oral Health Improvement Plan builds on some substantial achievements to date, including the record figure of 5.1 million people registered with a NHS dentist, equating to over 94% of the Scottish population. The Plan focusses on three key priorities: Prevention; Inequalities; and the Ageing Population. Key areas of focus include:
- The expansion of the Childsmile Programme to ensure that all children in the 20% most deprived areas benefit from tooth-brushing instruction and fluoride varnish application.
- The Oral Health Community Challenge Fund was launched in February to allow organisations to bid for funding to work in deprived communities and support people to change their oral health behaviours. There are 22 projects from across Scotland which received funding to deliver a range of oral health interventions. Projects will run from 1 July 2019 to 31 March 2022.Two initial engagement events with all the funded projects have also taken place in Glasgow and Dundee, bringing together funded projects to build networks, connections and raise their awareness of Scottish Government's public health priorities and its link to their funded work.
- Work is underway to establish a formal training and mentoring programme in order to accredit General Dental Practitioners with the necessary skills and equipment to see patients in care homes. 30 dentists were selected by NHS Boards for inclusion in the early adopter programme of training and mentoring for enhanced skills in domiciliary care. All these dentists have successfully completed the training element. The process of designating the domiciliary care dentists and assigning them to care homes continues. The roll out of the national programme commenced in June 2019. NHS Boards have identified 27 dentists for the next cohort of training and mentoring.
3.3.15 We have rolled out the Family Nurse Partnership Programme to all territorial NHS Boards in Scotland. The programme is an intensive, one-to-one, home visiting activity that is delivered to young, first time mothers aged 19 and under by specially trained nurses and lasts from early pregnancy until the child reaches the age of two years old. Its main aims are to improve pregnancy outcomes, child health and development and the economic self-sufficiency of the family. The Family Nurse Partnership has brought a new approach to nursing, working with the parent to help them build up their own skills and resources to parent their child well, but also to think about their own future aspirations.
3.4 Secondary and Acute Care
3.4.1 The Delivery Plan committed to take intensive and coordinated action in several key areas of secondary and acute care: reducing unscheduled care; improving scheduled care; and improving outpatients, in order that people should only be in hospital when they cannot be treated in the community and should not stay in hospital any longer than necessary for their care.
What we have done
3.4.2 In order to help address the challenges around unscheduled care, the national roll out of the 6 Essential Actions (6EA) is underway, focussing on systems and processes across the hospital to support patient flow for every patient every time. Implementation is almost 90% complete with every health board engaged in the programme. Work continues with the boards to support further implementation. Elements of the 6EA have been implemented in community hospitals where appropriate as some of the actions are specific to emergency departments.
3.4.3 A significant amount of work has been delivered both locally and nationally that has resulted in performance improvements. There is a correlation between compliance with 6 Essential Actions (6EA) and performance and therefore a series of activities has commenced to ensure sustained improvements against each of the 6EA locally and nationally. There will also be a greater focus on whole system working and collaboration including arranging regional events to share the plans and encourage peer review with partners across the health service - NHS, IJB and primary care and out of hours.
3.4.4 The Modernising Outpatient Programme (MOP) commenced in 2017 in order to support the reduction in unnecessary attendances and referrals to outpatient services. To date the programme has focused on opportunities to maximise current capacity, create capacity and manage demand generated out with and within secondary care. Significant activity has taken place focusing on the following areas:
- Working with the Digital Health and Care Division to develop proof of concept decision support tools and a "mega-app" bringing together pathways, tools and resources to support clinical decision making. As part of this pilot phase, the first version of these tools was launched in October 2018, and the Beta-version was released in July 2019. A national Decision Support Oversight Group has been established to take this forward and will be co-chaired by the Chief Executive of the Digital Health and Care Institute and by the Clinical Lead for Quality and Safety in the Scottish Government Planning and Quality Division.
- The Modern Outpatient Programme has used these tools to develop a mobile app for new Gastrointestinal Pathways, and an alerting system for coeliac disease risk factors, for future embedding in primary care clinical systems. These tools are being tested and reviewed in early adopter sites.
- Supporting the implementation of Active Clinical Referral Triage (ACRT) to ensure patients do not wait in a queue to attend unnecessary appointments. This involves ensuring, either as a one-off or dynamic process, that all referrals received into secondary care are considered by a senior clinical decision maker who has both the systems and the organisational expectation to support person-centred referral triage to any one of a number of locally and nationally agreed pathways including virtual attendance, opt-in, diagnostic or face-to-face appointment. We are working to measure the current and potential impact of ACRT. A minimum dataset has been established to capture data from those sites carrying out ACRT with a view to understanding the opportunities across specialties to avoid patients waiting unnecessarily for outpatient appointments. Further development of ACRT is now being taken forward through the Access Collaborative.
- Where appropriate, there is an opportunity to avoid patients attending for follow up unnecessarily by offering patients the opportunity to initiate their own interaction with the service when they require input. As with ACRT, many areas are already doing Patient Initiated Reviews (PIR) and are seeing clinic attendances decrease, freeing up capacity. Work is underway to understand the potential impact of PIR across NHS Scotland.
3.4.5 Some of the ongoing work of the Modernising Outpatient Programme now supports the Scottish Access Collaborative (SAC). The SAC is a Scottish Government initiative that started at the end of 2017. The focus of this ambitious programme is to seek a sustainable balance between demand and capacity in the NHS by safely reducing demand, developing new models of care or increasing capacity within existing resources. Involving a wide range of health and care partners including NHS, patients, professional organisations and third sector representatives the Collaborative seeks to maximise the connections between existing initiatives as well as develop new links to support the nine current challenge areas:
- Active Clinical Referral Triage (ACRT, building on the work carried out under the Modern Outpatient Programme)
- Enhanced Recovery After Surgery (ERAS)
- Waiting List Validation
- Effective and Quality Interventions Pathways (EQuIP)
- Flying Finish
- Accelerating the Development of Enhanced Practitioners (ADEPt)
- Clinical Pathways Infrastructure
- Virtual Attendance
- Team Service planning
3.4.6 A series of workshops through 2018 and early 2019 focused on specialty and clinical pathway issues for a range of clinical areas which have been summarised in a suite of Specialty Group Reports.
3.4.7 In order to ensure there is longer term high-quality and adequate provision of elective care services to meet the needs of an ageing population, investment in a number of Elective Treatment Centres is taking place. In addition to the implementation of two additional MRI scanners at the Golden Jubilee Foundation, which are providing additional capacity of around 7-8000 scans per year, construction has now commenced on the expansion of the hospital to provide additional Ophthalmology capacity.
3.4.8 Business Cases for centres in NHS Highland, NHS Lothian, NHS Grampian, NHS Tayside and for Phase 2 of the Golden Jubilee expansion (Orthopaedics, General Surgery and Endoscopy) are progressing as planned.
3.4.9 The work of the Scottish Access Collaborative and the Outpatient Programme now forms a key part of the Waiting Times Improvement Plan, which was launched in October 2018, in order to substantially and sustainably improve waiting times by Spring 2021.
3.4.10 As part of the improvement work through the Scottish Access Collaborative we are undertaking a national piece of work to consider the causes of the current variable rate of cancelled planned operations across NHS Scotland. This work will include identifying causes, timing and impact of cancellations as well as the process of re-filling cancelled slots. This work, which aims to compete within six months, will produce a series of recommendations that will support the sustained reduction of cancelled operations.
3.4.11 While initiatives from the Patient Flow Programme, and other improvement programmes, continue to yield benefits such as improving Enhanced Recovery After Surgery, optimising Intravenous Fluids, and reducing Pre-operative Anaemia, the spend in private care spending in relation to elective waiting times is unlikely to have reduced since 2017 as a result of the publication of the Waiting Times Improvement Plan (WTIP). Through the WTIP, published in October 2018, we committed to move to a new single contract for any use of the independent sector. The new approach, which ensures an equitable approach to available capacity as well as value for money, will only be used while NHS capacity is expanded over the longer term. It is intended that following the lifetime of the WTIP plan that the use of the independent sector will taper off as NHS capacity comes on stream at a national level.
3.4.12 In 2019/20 we have invested almost £20 million in the national contract. However, Health Boards have also utilised some of the waiting times funding to secure capacity through the private sector.
3.4.13 The 5 year Cancer Strategy, published in 2016 committed to investing £100 million to support the aims of more people surviving cancer; closing the gap in survival rates; reducing inequalities; ensuring a better patient experience; and reducing the growth in the number of people diagnosed. To date, £59 million has been invested, with early successes including:
- a simpler "FIT" test introduced for Bowel Screening across Scotland in November 2017, which has led to an increase in participation; statistics show that from November 2017 to April 2018, 64% of those eligible returned their FIT. This is up from 56% in the same period the year before and has exceeded the Health Improvement Scotland standard of 60% for the first time.
- To date we have invested £2.7 million through the Screening Inequalities Fund to fund 26 projects across Scotland aimed at reducing inequalities in access to the three cancer screening programmes.
- a 90% reduction in the incidence of pre-cancerous cells since the HPV vaccine was introduced in 2008, with the incidence of cervical cancer in women aged 20-24 reducing by 69% since 2012.
- Improved attitudes around early detection of cancer since the Detect Cancer Early Programme was launched, for example of people with bowel, breast or lung cancer, over 25% were diagnosed at the earliest stage (Stage 1) - an increase of over 8% from 2010/2011. The largest increase has been in the most deprived areas which have seen an increase of over 11%.
Detect Cancer Early - a Real Life example
William Laidlaw, 63 from Govan, was diagnosed with lung cancer after going to see his GP with a tickly cough he'd had for a while.
William had ignored the symptom as he thought it was just a winter cold, but his family pressured him into getting it checked out. His GP sent him for an x-ray and following a CT scan he was diagnosed with lung cancer.
William underwent surgery a month later at the Golden Jubilee National Hospital where a third of his lung was removed. The forklift driver required no further treatment as the cancer hadn't spread.
"When I found out I had lung cancer, it was a big shock, but I tried to stay positive and let the doctors do their magic.
"The tumour was removed in February, on my birthday. The treatment was fantastic with everything going to plan and I wasn't in a great deal of pain after. Now, apart from the odd twinge in my side and needing an inhaler, I'm back in my old routine.
"I'd say to anyone, if you think there's something wrong, get it checked out. The quicker they get it, the better your chances."
3.5 Realistic Medicine
3.5.1 Realistic Medicine aims to deal with the dual challenge of providing care that has greater worth to individuals, while also addressing the need to improve health and wellbeing at a population level. To do this we need a strategic approach to strengthening relationships between professionals and individuals and tackling unwarranted variation. We also need to provide our healthcare professionals and individuals with the information, tools, training and support they need to help realise the Chief Medical Officer's vision for Realistic Medicine.
What we have done
3.5.2 In order to support everyone in Scotland to have the confidence, knowledge, understanding and skills we need to live well with any health condition we have, we published a refreshed Health Literacy Action Plan "Making it Easier" in February 2018. As part of this, we committed to develop a citizens' jury to explore how we further strengthen relationships between healthcare professionals and individuals. The Our Voice Citizens' Jury on Shared Decision Making was held over three weekends in October and November 2018. The Chief Medical Officer has considered and responded to each of its findings.
3.5.3 A key element in transforming the relationship between individuals and medical professionals is the enhancement of the current consent process for patients. The General Medical Council has carried out a consultation on draft updated consent guidance which is likely to be published by the end of 2019.
3.5.4 A collaborative training programme for clinicians to help them to reduce unwarranted variation has been established, with the first two workshops covering the key concepts of value based healthcare evaluating well. Work is now underway to look to embed and expand the training across Scotland.
3.5.5 The Professionalism and Excellence in Medicine Action Plan has been refreshed and high-impact actions aligned to Realistic Medicine.
3.5.6 In order to incorporate the principles of realistic medicine as a core component of lifelong learning in medical education, we have worked with key stakeholders to co-produce a framework of Realistic Medicine principles and values. Medical Education providers are now reviewing their curricula to ensure it is in line with the agreed principles, identify any gaps and develop associated plans to address those gaps.
3.5.7 We are also working with stakeholders to develop a Single National Formulary (SNF) for medicines to reduce unwarranted variation in the medicines prescribed in different parts of the country.
3.5.8 There are currently 11 individual local formularies used by the 14 Health Boards in Scotland. There is a high degree of commonality in the medicines included within the existing formularies, but elements of variability remain in prescribing practice across some therapeutic areas. In some cases this variation is warranted in that it reflects local care pathways.
3.5.9 Work to develop an initial version of the new national formulary website platform has been completed. This has been achieved with wide stakeholder input and utilises the NHS Dictionary of Medicines and Devices (dm+d) as the underlying medicines dictionary to support future interoperability with prescribing systems. The website evolves the traditional 'list of medicines' approach into a condition-based formulary organised by therapeutic 'chapters' that aligns recommendations to the treatment of the patient.
3.5.10 Condition-based chapter structures and content have been developed for four therapeutic areas to date (endocrine, gastro-intestinal, infections and respiratory) and work is underway to complete this for all the other therapeutic areas. This will provide a complete content platform ready to receive formulary recommendations for all the therapeutic chapters. The formulary recommendations themselves have still to be agreed.
3.5.11 The next steps will be to transition from the 11 local formularies towards the new National Formulary, building upon proven local formulary governance and decision making and working closely with existing local formulary teams. Implementation has commenced in the East Region with learning being regularly shared with the other Boards and Regions. The SNF will be rolled out to the North and West in 2020.
3.5.12 Although initially not formally part of the Delivery Plan, we have also developed the "Atlas of Variation" for Scotland, highlighting any geographical variation that exists in the provision of health services and associated health outcomes. A range of indicator based maps are presented at Health Board of Residence and Local Authority of Residence level, by financial year. It is designed to facilitate discussion and raise questions about why differences exist and help to promote quality improvement through this conversation. There are also opportunities to align this with the National Formulary work programme.