Delivering value based health and care: a vision for Scotland

Sets out the challenges our system is facing and how practising Realistic Medicine can deliver a more sustainable system. It includes six commitments on what we’ll do to support health and care professionals deliver care that people value.

5. Areas of Focus

In order to achieve our vision for Value Based Health & Care in Scotland there are three areas where we intend to focus our efforts:

Identifying, rethinking and defining outcomes that matter to the people we care for

With a focus on personal value, we can:

– provide better value care for the people we care for and for our health and care system.

– help tackle health inequalities, by ensuring those who need our help the most access care that they will benefit from.

– help to address the climate emergency through shared decision making and reducing waste, and harm.

In order to know whether we are delivering personal value we need to invest in and develop person reported outcome measures, and analytical and digital resources that will help measure outcomes that matter to people.

Supporting the workforce to practise Realistic Medicine to deliver VBH&C

Staff wellbeing is a hugely important aspect of our vision and is core to all of our aims. The power of human connection and learning cannot be underestimated. Our ability to share ideas, spread good practise and innovate, all stem from it. If we value and strengthen our human connections, we can foster a culture of stewardship that will deliver a more sustainable system.

We must continue to support our workforce to practise Realistic Medicine, which underpins the delivery of VBH&C.

Improving use of resources

We can improve the use of health and care resources by supporting all health and care colleagues to deliver VBH&C through the use of approaches such as:

Active Clinical Referral Triage (ACRT) and Patient Initiated Review (PIR), CfSD best practice pathways, EQUIP and the Right Decision Service and knowledge services. These are essential to making sure people are accessing the right care at the right time and help ensure only people who will benefit are waiting for a procedure, which will also improve equity of access.

We will also continue to work closely with Public Health Scotland (PHS) and the Centre for Sustainable Delivery (CfSD) to develop and ensure use of the Scottish Atlas of Healthcare Variation, to support healthcare professionals to identify and tackle unwarranted variation. The Atlas of Variation data is transparent and publicly available and can reduce unwarranted variation and improve equity of access and utilisation of resources.

An example of improving our use of resources which is already underway is the use of Patient Initiated Review (PIR):

Case Study : Scottish Access Collaborative Modernising Patient Pathways Programme Discharge PIR (Patient Initiated Review)

"Putting the patient in charge" after a joint replacement


Modern hip and knee replacements deliver consistent and excellent clinical outcomes. Traditionally, patients attended for long-term clinical and radiological (X-ray) outpatient follow-up. In 2017, an audit in Glasgow Royal Infirmary suggested routine check-ups might be unnecessary for asymptomatic patients. Regular follow-up is not only inconvenient, but can create anxiety for patients and carers, and reduces access for urgent cases due to the volume of routine appointments.


A pathway was developed where patients were discharged after uncomplicated surgery and offered review at their request (patient initiated review without time limit). Patients were routinely provided with verbal and written information about self-care, and how to contact the appropriate clinician should they feel further advice was required. At that point, and with shared decision making, advice is provided virtually, with a face-to-face appointment only if necessary. Over the past three years, colleagues in Greater Glasgow and Clyde and the Golden Jubilee Hospital in Clydebank have cared for 85% of their patients on the discharge PIR pathway.


The discharge PIR pathway avoids unnecessary attendance for follow up and X-rays in asymptomatic patients after hip and knee replacement, thereby reducing waste. It allows patients and families to access care if and when it is required, enhancing the personal value of their care. Discharge PIR supports a decreased carbon footprint through reduced travel. This contributes to societal value and the overall sustainability of the NHS. And because the majority of orthopaedic centres in Scotland now use this discharge PIR pathway, there is a positive impact on provision of orthopaedic appointments with time and skills being deployed where they are needed most. This provides technical value, with better distribution of resources within this group of patients.

Discharge PIR is being used increasingly across many more specialties. By putting the patient in charge, and offering timely information and support, it enables patients and families to provide self-care whilst offering re-engagement with the service if required.



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