Chapter 1 – Transforming Care and Delivering Improved Outcomes
‘The key … is transforming the care people receive from the NHS and other public services, working together to deliver improved outcomes.’
Visit www.nhsscotannualreport.scot for the online version of the Annual Report, including peoples’ stories and key facts and figures.
The challenges of driving greater improvements and addressing the numerous challenges of developing a health and social care system that is fit for 21st century Scotland are well-rehearsed. People are living longer and increasingly need services that can support multiple health conditions. At the same time, parts of Scotland continue to experience health inequalities. While all public services are affected by financial challenges, these are being particularly felt in health and social care due to the increasing demand for services. The key to meeting these challenges is transforming the care people receive from the NHS and other public services, working together to deliver improved outcomes.
The Health and Social Care Delivery Plan, published in December 2016, set out our framework for reform. Action to transform care and improve outcomes under the Delivery Plan is progressing across the whole of the public sector. This chapter focuses on four areas where the pace of change and ambition is growing, and where partnership across the public sector and a shared commitment to act is driving forward change: public health; health and social care integration; Realistic Medicine; and digital health. This chapter also provides information on the measures of health and social care in 2017/18.
In 2015, the Public Health Review made a number of key recommendations to strengthen the public health function in Scotland. Given the significant and rising costs associated with ill-health and resulting demand on services, this renewed focus on prevention will have both health and economic benefits; the shift to focus on prevention, integration and closer collaboration, as set out in the Health and Social Care Delivery Plan, will improve health outcomes for people, whilst also contributing to Scotland’s long-term sustainable economic growth.
This underpins the public health reform programme with its vision of ‘a Scotland where everybody thrives’, and its ambition for Scotland to be a world-leader in improving the public’s health. The reform programme is being led in a partnership between the Scottish Government and the Convention of Scottish Local Authorities (COSLA). It is recognised, however, that this ambition cannot be achieved by any one body or organisation alone. It requires the combined efforts of partners from across the public, private and third sectors and, importantly, from within local communities as well.
Our Shared Priorities
Agreeing Scotland’s public health priorities is an important first step in the public health reform programme. Having a set of jointly-agreed and jointly-owned public health priorities will enable partners to focus together on the things that will improve healthy life expectancy and reduce inequalities. The priorities have been developed using a ‘bottom-up‘ approach involving national and local stakeholders. Following extensive engagement, a clear set of themes emerged around:
- Place and community;
- Early years;
- Mental health and wellbeing;
- Harmful substances (including tobacco, alcohol and other drugs);
- Poverty and inequality; and
- Diet and physical activity.
The new priorities will be the focus of collaborative effort, nationally and locally, to improve people’s health and to reduce health inequalities. It is, therefore, important that they are owned and shared by everybody in Scotland. Public health work more generally is discussed in Chapter 3.
A New Public Health Body
At the same time, work has begun on the design of a new public health body to drive these new priorities. The new body is being co-designed by the Scottish Government, NHS and Local Government. Partners and stakeholders are being commissioned to take forward the key themes, with each being co-led and bringing together public health expertise across the partners.
It is expected that the new body will maximise the potential to support work across the activities of Local Government to ensure health objectives are embedded, with a strong focus on the role of Community Planning Partners in involving and empowering communities. It is intended that this shared responsibility for developing the various commissions will lead to a shared ambition for the programme, together with greater commitment and improved collaborative working.
Health and Social Care Integration
Health and social care integration is helping to improve people’s lives. Increasingly, the shared goal across the public sector is for truly integrated services focused on the needs of citizens – individuals, carers and families – and on the health and wellbeing of local communities. This is bringing together the planning, design and delivery of health and social care services.
Health and Social Care Partnerships are already starting to make significant progress. The Partnerships have continued to reduce delayed discharges. The number of bed-days associated with delay reduced by 6 per cent in 2017/18. This builds on a 3 per cent reduction in the previous year and a 9 per cent reduction in 2015/16. Many Partnerships are developing intermediate care and re-ablement services to support the confidence and skills people need to live safely and independently at home after a stay in hospital or period of illness, and introducing discharge-to-assess schemes, aimed at ensuring more people can be cared for in their own homes.
Health and Social Care Partnerships have also made clear progress in 2017/18 on the commitment to reduce unscheduled bed-days by reducing bed-days during 2017/18 by 2.4 per cent. This means fewer people are staying in hospital for longer than necessary. Forward plans from Health and Social Care Partnerships highlight a continued focus on addressing both unnecessary admissions and length of stay to continue to reduce the number of unscheduled bed-days, projecting a reduction by the end of 2018/19 of around 7 per cent since the publication of the Health and Social Care Delivery Plan in 2016/17.
Variation in healthcare exists for all sorts of legitimate reasons. Identifying and tackling unwarranted variation in healthcare – variation that cannot be explained by need, or by explicit patient or population preferences – is essential to improving outcomes derived from healthcare across Scotland.
At the same time, in order to meet the demand for services, we must consider how to make optimal use of the resources we have, ensuring the best possible care for our patients. While the quality and safety, effectiveness and cost-effectiveness of care remain vitally important, we need to prevent harm and waste from overuse and overtreatment. Reducing these unwarranted medical interventions can free up resources that have little or no clinical outcome in order to address under-provision and more appropriate care in other ways.
Global healthcare successes in helping people to live longer, often with multiple conditions and additional complexity of care, mean it is more important than ever to have an honest and open dialogue with people about their needs – and to support them in a way that is helpful to them and their families. The ethos of Realistic Medicine is that people who use health and social care services will have meaningful conversations with their healthcare professionals to help plan and agree care based on what matters most to them.
The shared vision is that by 2025, everyone providing healthcare in Scotland will be practising Realistic Medicine. Delivering this, however, needs a collective desire to change the focus of care. It will take strong clinical leadership and well-informed patients. The aim of Scotland’s Chief Medical Officer’s third report, Practising Realistic Medicine, is to help the discussion about Realistic Medicine move on; to take it from a set of guiding principles to providing practical advice, tools, guidance and best practice examples of how we can make Realistic Medicine the way healthcare is ‘done’ in Scotland.
A number of planned actions will start to deliver on these aspirations:
- A Citizens’ Jury held over three days in October and November will support public engagement on Realistic Medicine. The Jury’s conclusions will help to provide further valuable insight into how people understand the principles of shared decision-making and what might be done to foster it.
- In September 2018, the initial work on the Scottish Atlas of Variation was published. This has started to highlight areas where there is variation in health and care services and will support clinicians to seek out variation that is unwarranted and develop healthcare provision that is appropriate to people’s needs.
- Realistic Medicine Leads have been appointed in all 14 territorial NHS Boards and five of the public-facing national NHS Boards. The Realistic Medicine Leads will support their colleagues to embed Realistic Medicine in their area by championing its principles and by sharing good practice.
A focus on digital health will lead to improved information-sharing across health and social care. It will enable people to take greater control of their health and wellbeing, support the shift in balance of care out of hospital and into the community, and it will lead to greater remote working for staff and remote access to services for patients.
Scotland’s Digital Health and Care Strategy: Enabling, Connecting and Empowering, published jointly by the Scottish Government and COSLA, is informed by an independent panel of world-leading UK and international experts chaired by the acclaimed Professor David Bates of Harvard School of Public Health. The Strategy sets out the vision for how technology will support the delivery of the person-centred, integrated health and care services people need and expect. It sets out six ‘domains’ or key areas of work that will be implemented in the coming years to achieve this vision:
National Direction and Leadership – the establishment of a national decision-making board with representatives from national and local government, NHS Scotland, academia, industry and the third sector to: make key decisions on standards; identify areas for development and improvement; identify potential synergy and reduce duplication; streamline current groups and committees; and establish a financial framework for implementation.
Information Governance, Assurance, and Cyber Security – people expect their health and care information to be available to them, and to those responsible for helping them, when and where they need it. At the same time, they want assurance that their personal information is being handled appropriately, safely, securely, and in an approved and controlled way. Through public involvement and professional advice, a clear national approach, consistent with the law, will provide clarity around the required information assurances and appropriate choices for citizens about how their information will be used.
Service Transformation – spread and adoption at scale of proven digital technologies within services across Scotland is critical to success, requiring service change and redesign supported by national approaches and models. The Strategy envisages co-designed person-centred approaches, the need for a national ‘once for Scotland’ approach, and adoption of evidence-based technologies and rapid national scale-up.
Workforce Capability – workforce development in digital skills and capabilities across the whole health and care sector underpins the successful uptake and use of digital technologies. We need to ensure that our workforce is fully digitally connected wherever they are, suitably skilled to use the technology, and sufficiently flexible to adapt to new ways of working.
A National Digital Platform – the development of a Scottish health and care national digital platform with relevant real-time data and information from health and care records, and the tools and services they use, will be available to those who need it, when they need it, wherever they are, in a secure and safe way. It will be delivered through the development of a new architecture, and the use of secure cloud-based services and common shared international standards.
Transition Process – the transition from the current position will be challenging, will take time, and will require significant input from delivery partners. There will be a technical transition plan to ensure that the current technical environment is securely and timeously transitioned to fit with the new national digital platform where appropriate.
You can read more about how digital health innovation is helping to transform care and improve outcomes for people in Chapter 2.
Measures of Health and Social Care in 2017/18
It is important that our use of indicators and targets helps deliver improvements in outcomes for people.
Responding to the Independent Review of Targets and Indicators
The Scottish Government, with the support of COSLA, commissioned Sir Harry Burns to undertake an independent review of targets and indicators in health and social care. This followed a Programme for Government commitment to ensure the approach to performance is outcomes-based. The report, Review of Targets and Indicators for Health and Social Care in Scotland, was published in November 2017. Sir Harry noted that indicators should reflect evidence for drivers of improvement. He was also clear that any new indicators should be pragmatic, and be co-produced with staff and those who access the services they measure. They should be subject to regular review to ensure they remain relevant, and should provide information on the whole performance of a system and not be based on a snapshot of one aspect of that system.
The Scottish Government and COSLA welcomed the report, noting that it provides key principles to help set the future direction for understanding progress and performance across health and social care.
As noted earlier in this chapter, the new public health body will have a particular focus on making the best use of Scotland’s data and intelligence assets. The vision is for these to be used in the future to inform and support communities in work to create wellbeing, and to support progress against our public health priorities.
Improving the way we use data has helped to deliver some of the improvements in health and social care integration described earlier. Health and Social Care Partnerships were asked to set out their 2018/19 improvement objectives against six priorities: accident and emergency (A&E) performance; unplanned admissions and occupied bed-days for unscheduled care; delayed discharges; end-of-life care; and balance of care spend. The focus is on improvement and supporting Partnerships to make local changes that improve the sustainability and quality of services. While the indicators focus on hospital services, they nonetheless provide a good insight into patterns of care across the system as well as specific challenges, such as tackling delayed discharges. The data is also being used to support the development of planned trajectories for improvement.
Local hospitals and their primary and community partners are now regularly carrying out Day of Care Surveys to assess every patient to identify whether they still need continuing acute care and, if not, the reason why they have not been discharged. Analysis is carried out at site-level to identify common themes and areas for improvement. A standard methodology is now being used, with all acute sites in Scotland carrying out the survey in April and October. This new approach is supporting local systems to share information with each other. New analysis that provides comparable information on the distribution of the time spent in A&E for those patients that go on to be admitted and those that go on to be discharged home from A&E (non-admitted) is also being shared with local hospitals. The information enables local systems to compare themselves with others and learn from other initiatives that help prioritise improvements on the pathways for admitted and non-admitted patients, rather than simply looking at numbers of patients spending more than four hours in A&E.
Access to System Watch has been widened to enable NHS Boards to share operational information on activity and demand for healthcare with Health & Social Care Partnerships. System Watch is a tool for predicting and monitoring urgent care and emergency services in NHS Scotland. The system is updated regularly and provides information on potential demand pressures.
A Mental Health Framework consisting of a collection of currently obtainable data that together can illustrate the mental health and wellbeing of Scotland at a population level has been created. It contains a number of indicators grouped around four themes: childhood determinants of a mentally healthy life; the impact of mental health and wellbeing; population mental health and wellbeing; and parity of mental and physical health.
As referenced earlier, the Scottish Atlas of Variation aims to highlight geographical variation in Scotland’s population health, the provision of health services and associated health. The Atlas will facilitate discussion and raise questions about why differences exist and help to promote quality improvement through conversation. In time, the Scottish Atlas of Variation will be an important tool to help identify and eliminate unwarranted variation, and to support the reduction of harm and waste within healthcare. The Atlas will initially focus on helping to identify overtreatment (unwarranted medical interventions) and undertreatment (insufficient treatment) across Scotland, supporting clinicians to address this by providing information in an accessible and informative way. In time, the Atlas will highlight areas where access to health and care services differ and stimulate questions and debate about the health and care needed by people in those areas.
Further information on the National Health and Social Care Workforce Plan (published in June 2017) is provided in Chapters 2 and 5. Recommendations across the different parts of the Workforce Plan aimed to bring together existing data sources in a new supply side platform, to improve support for health and social care workforce planning in Scotland, and to further consider data requirements in the context of integration. NHS Education for Scotland (NES) is working alongside the Scottish Government and other stakeholders to: align workforce data to better inform workforce planning; determine the data required for effective decisions on workforce; and improve scenario planning and analysis of future demand and supply, including the ‘pipeline’ between education and employment. The integrated Workforce Plan being published by the end of the year will set out how these improvements to workforce data can also contribute to better-targeted, more-effective services.
Progress Against the Three Suites of High-level Measures
In Scotland, there are currently three suites of high-level measures: (i) the direct health and social care indicators within the National Performance Framework (NPF), which primarily focus on high-level outcomes such as improving self-assessed general health, improving mental wellbeing and reducing premature mortality; (ii) the Local Delivery Plan (LDP) Standards, which primarily focus on waiting times for scheduled, unscheduled, cancer and mental health services, and volumes of intervention activity to support behaviour change such as smoking cessation and Alcohol Brief Interventions, and Healthcare Associated Infections; and (iii) Integration Indicators, which focus on two broad areas – people’s experience of care and high-level indicators of how care is being delivered, for example in emergency admissions, delayed discharge, and where the last six months of life is being spent. Data is widely available through the website Scotland Performs, official statistics, and local system annual reports.
National Performance Framework
The majority of the direct health and social care measures reported in the NPF during 2017/18 show as ‘performance maintaining’. This Annual Report highlights some of the actions that were taken this year to support improvements in population health. In June 2018, the Scottish Government launched the new and updated NPF. This revised NPF, ‘has been developed together with the people of Scotland to reflect our values as a nation and the aspirations we hold for our future. It has also been formulated to link with and promote our commitment to the United Nation’s Sustainable Development Goals which are aimed at improving wellbeing across the world’. Future Annual Reports will report against the indicators contained in this updated NPF.
This winter was particularly challenging with significant increase in demand for unscheduled care in December 2017 and impacts of severe weather in February and March 2018. In December 2017, we saw A&E attendances up 10 per cent, respiratory emergency admissions up 40 per cent and flu emergency admissions up seven-fold. While patients did spend more time in A&E, almost nine out of ten spent less than four hours, and core site performance in Scotland (88 per cent) remained significantly above that in England (79 per cent), Northern Ireland (64 per cent) and Wales (74 per cent). In addition, there were increased levels of planned theatre operations being cancelled due to capacity or non-clinical reasons in January (4.5 per cent) and March (4.1 per cent), but by June (1.4 per cent) some of the lowest levels of cancellations for these reasons on record were being experienced. It is believed that the Six Essential Actions to Improve Unscheduled Care programme is supporting frontline staff to strengthen unscheduled care process, including reducing unwarranted lengths of stay.
In addition to the challenges faced this winter, some NHS Boards are also reporting increased numbers of urgent elective referrals which are impacting on elective services. NHS Boards have reported significant increases in the numbers of patients being referred urgently with a suspicion of cancer in the last few years. During 2017/18, we saw a reduction in 31-day cancer, 62-day cancer, 12-week outpatient and 12-week inpatient and day-case waiting times standards of 1.5, 3, 6 and 6 percentage points, respectively. The Scottish Access Collaborative was established in the autumn of 2017 and is making progress to reform elective services. The Collaborative includes a focus on improving referral processes, giving patients more choice on when they have return outpatient appointments, and improving capacity planning. The Waiting Times Improvement Plan was launched in October 2018 and sets out the actions that will deliver improvements in waiting times over the next 12, 24 and 30 months.
During 2017/18, performance against the two principle waiting time targets on mental health continued to be poorer than required, with 74.1 per cent of children and young people being seen by Child and Adolescent Mental Health Services (CAMHS) within the 18-week target, and 76.5 per cent of people being seen within the Psychological Therapies 18-week target. The demand on services is increasing, with 33,270 referrals to CAMHS during 2017/18 – up from 32,677 the previous year – and an equivalent increase for Psychological Therapies from 109,370 to 136,029. Further information on mental health services is provided in Chapter 2.
Continued improvement in some of the high‑level indicators within the Integration Indicators was seen over 2017/18. Delayed discharge, emergency bed‑days, emergency admissions and re‑admissions to hospital within 28 days in particular all showed positive progress. Other indicators which relate to people’s experiences of social care support have seen less progress since 2013 and some have decreased over this period. Work will continue with local partners to help drive improvement and deliver better outcomes for service users.
There is, however, a range of data about experiences of care in both primary and secondary care which shows that people’s experiences of care in these sectors remain high. Recent results from the 2018 Scottish Inpatient Experience survey, for example, show that 86 per cent of people rated their overall care experience positively and over a third said that their overall care was ‘10 out of 10’. There is also an upward trend in positive experiences of care in Scotland as shared online at Care Opinion (previously Patient Opinion). More information about people’s experiences of their care is covered later in the report.
This Annual Report
The following chapters in this report concentrate on the key areas that are about how we are transforming care and delivering improved outcomes for people based on the triple aim: Chapter 2 – Improving Quality of Care; Chapter 3 – Improving the Health of the Population; and Chapter 4 – Securing Value and Financial Sustainability. Chapter 5 focuses on the important role that our workforce plays in making change happen.
The report is complemented and supported by an interactive website that includes a video introduction, real-life examples of people’s experiences of care and improved outcomes, and key information presented in graphic form. The website can be accessed at:
Email: Andrew Wilkie