Chapter 1 - Transforming Care and Delivering Improved Outcomes
'At the heart of the framework for improvement and change is the vision for a Scotland where everyone can live longer, healthier lives at home or in a homely setting'
Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.
Recent NHSScotland Chief Executive's Annual Reports have focused on how NHSScotland has been driving greater improvements and addressing the numerous challenges of developing a health and social care system that is fit for 21st century Scotland. The challenges have been well rehearsed. As a whole, people are living longer and increasingly need services that can support multiple health conditions, while 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 delivering improved outcomes.
NHSScotland and its partners across Scotland have been responding to the challenges faced through innovative, sustained approaches to reform, many of which have gained recognition outside Scotland. In its recent report Learning from Scotland's NHS, the Nuffield Trust highlighted the Scottish approach to quality improvement – exemplified in the Scottish Patient Safety Programme, and set out in the Healthcare Quality Strategy for Scotland  – as one of the nation's outstanding strengths:
'In our judgement, the Scottish health system, with the high levels of trust leaders show in their colleagues and an emphasis on skills and autonomous testing at the front line, generally appears to be more flexible than the English and to some extent Welsh 'control' systems… There is a genuine orientation towards delivering better care to patients, and a willingness to test this against clear indicators'  .
Our approach to maintaining the level and commitment to improvement has not altered. Indeed, what has changed over the last year has not been the scale of the challenges Scotland's health and social care system is facing, the actions needed to meet those challenges over the coming years, or the overarching vision for the health and social care of Scotland. What is new is the determination to put in place a framework that brings together the priority actions to drive improvement and adaptation in health and care, and sustains that change through the present Parliament and beyond.
At the heart of the framework for improvement and change is the vision for a Scotland where everyone can live longer, healthier lives at home or in a homely setting, and we have a health and social care system that:
- is integrated;
- focuses on prevention, anticipation and supported self-management;
- will make day-case treatment the norm, where hospital treatment is required and cannot be provided in a community setting;
- focuses on care being provided to the highest standards of quality and safety, whatever the setting, with the person at the centre of all decisions; and
- ensures people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.
To realise this vision, the Scottish Government published the Health and Social Care Delivery Plan  in December 2016. The Delivery Plan provides the framework that brings together key change programmes and sets out the priority actions to be taken forward in this Parliament under the following 'pillars' of activity:
- Health and social care integration;
- The National Clinical Strategy;
- Public health improvement; and
- NHS Board reform.
As a whole, these pillars aim to have the greatest impact on delivery by focusing on three areas based on the 'triple aim':
- Better care: we will improve the quality of care for people by targeting investment at improving services, which will be organised and delivered to provide the best, most effective support for all;
- Better health: we will improve everyone's health and wellbeing by promoting and supporting healthier lives from the earliest years, reducing health inequalities and championing an approach based on anticipation, prevention and self-management; and
- Better value: we will increase the value from and financial sustainability of care, by making the most effective use of the resources available to us, and the most efficient and consistent delivery of services, ensuring that resource is spent where it achieves the most, focusing on prevention and early intervention.
These priorities fit with what we know matters to people through the Creating a Healthier Scotland national conversation  , particularly in supporting: people to lead healthier lives; better connected communities; person-centred care; more seamless journeys of care; a focus on social care and caring; and dealing with the pressures on the system.
We need to change our approach to medicine and how and where the services that support people's health are delivered. Services should not be 'doing things' to people but working with them on all aspects of their care and support. It is not always a question of 'more' medicine, but making sure that support fits with, and is informed by, individual needs and desires, so people can become equal partners with their clinicians, working with them to arrive at the right decisions about their care quickly. That requires changes to how medical professionals work with people – especially through Realistic Medicine  – and how that support can be provided more quickly within primary/community and secondary/acute services.
Scotland's Chief Medical Officer ( CMO) has continued to pursue a public debate over how the principles of Realistic Medicine can drive improvement in how professionals can better support members of the public. Through the CMO's annual reports and a programme of widespread engagement, Realistic Medicine has resonated across numerous health and social care professions. It has been critical in building a shared understanding of what it means across different health and social care contexts, and throughout 2016, Chief Professional Officers in health and social care discussed what Realistic Medicine meant in their professions, and how professionals and services could work together to achieve its aims.
Following publication of the first CMO annual report focusing on Realistic Medicine, people felt energised by the potential inherent in Realistic Medicine through greater shared decision-making and stepping up our efforts to reduce harm, waste and variation. A number of national initiatives are supporting this by creating the conditions for Realistic Medicine to flourish:
- The Scottish Health Council and The Health and Social Care Alliance Scotland (the ALLIANCE) have been exploring with people what Realistic Medicine means to them during 2017, and how best it can be co-produced;
- The national health literacy plan Making it Easy:  a Health Literacy Action Plan for Scotland will support Realistic Medicine by helping everyone in Scotland to have the confidence, knowledge, understanding and skills to live well with any condition they have;
- The consent process for people we care for and support in Scotland will be reviewed by the Scottish Government, General Medical Council and the Academy of Medical Royal Colleges to update advice to clinicians following the Montgomery Supreme Court judgement  ;
- The Professionalism and Excellence in Medicine Action Plan  will be refreshed aligning and prioritising high impact actions that will support clinicians with Realistic Medicine;
- A Scottish atlas of variation will be published and a collaborative training programme for clinicians initiated to create better understanding and aid identification of unwarranted variation and promote high-value care;
- A single national formulary will be developed to help achieve more equitable, greater value-based care so that the potential population benefit from medicines use can be maximised; and
- The principles of Realistic Medicine will be incorporated as a core component of lifelong learning in medical education, through undergraduate and specialty training programmes as well as continuing professional development.
Primary and Community Care
Our vision of health and social care envisages more care being provided locally to avoid the need to go into hospital where a better alternative can be provided in the community. People should benefit from community care with a wider range of available support, and practices would typically consist of complementary teams of professionals, bringing together clusters of health support and expertise. Communities would have access to quicker and joined-up treatment – this might be the GP, but supported by a team including highly-trained nurses, physiotherapists, pharmacists, mental health workers and social care workers. Through this multi-disciplinary approach, local practices will be able to provide more information and better advice to people locally without the need to attend hospitals to get specialist consultancy.
To achieve this, community and hospital-based care needs to be integrated and rebalanced to ensure that local health services are more responsive and supportive to the needs of people, not least those with chronic conditions who would be better supported in primary and community care. Spending on primary care and GP services will increase by £500 million by the end of the current Parliament so that it represents 11 per cent of the frontline budget. Moreover, action has been taken to:
- Support people, families and their carers to understand fully and manage their health and wellbeing, with a sharper focus on prevention, rehabilitation and independence;
- Expand the multi-disciplinary community care team with extended roles for a range of professionals and a clearer leadership role for GPs;
- Design and implement changes to the Scottish General Medical Services ( GMS) contractual arrangements for 2017 (the terms and conditions of work which apply to GPs in Scotland) in agreement with the British Medical Association, with the aim of focusing the contract on person-centred, sustainable healthcare;
- Develop and roll out new models of care that are person- and relationship-centred and not focused on conditions alone through investment from the Primary Care Transformation Fund;
- Enable those waiting for routine check-up or test results to be seen closer to home by a team of community healthcare professionals;
- Ensure the problems of multiple longer-term conditions are addressed by social rather than medical responses, where that support is more appropriate; and
- Reduce the risk of admission to hospital through evidence-based interventions, particularly for older people and those with longer-term conditions.
At the same time, we need to address the current workload pressures and recruitment challenges facing many GP practices and cannot simply result in a crude redistribution of pressures between different parts of the health service. Through the Health and Social Care Delivery Plan, this will include:
- Continuing the investment in the expansion of the primary care workforce so that, by 2022, there will be more GPs, every GP practice will have access to a pharmacist with advanced clinical skills and 1,000 new paramedics will be in post;
- Increasing health visitor numbers so that every family will be offered a minimum of 11 home visits, including three child health reviews;
- Refreshing the role of district nurses;
- Training an additional 500 advanced nurse practitioners by the end of the Parliament; and
- Creating an additional 1,000 training places for nurses and midwives.
Secondary and Acute Care
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. This will mean reducing inappropriate referral, attendance and admission to hospital; better signposting to ensure the right treatment in a timely fashion; and reducing unnecessary delay in people leaving hospital. All partners will need to work together to reduce the levels of delayed discharges and ensure services are in place to facilitate early discharge and avoid preventable admissions in the first place.
At the same time, hospitals need to make more-effective use of resources. There is increasing evidence that better outcomes are achieved for people when complex operations are undertaken by specialist teams and some services are planned and delivered on a population basis. This might mean some services currently delivered at local level would produce better outcomes for people if delivered on a wider basis. This kind of service change needs to be accompanied by investment in new, dedicated facilities to ensure that the capacity for high-quality, sustainable services can be delivered at the appropriate level.
To take forward the work begun by the National Clinical Strategy for Scotland  , the Health and Social Care Delivery Plan sets out a number of areas where this will be pursued:
- Addressing unscheduled care, particularly through national roll out of the Six Essential Actions  which will improve the time-of-day of discharge, increase weekend emergency discharges and establish a more effective use of electronic information in hospitals;
- Enhancing scheduled care, through the roll out of the Patient Flow Programme (reducing cancellations and private care spend), £200 million investment in elective care capacity and the expansion of the Golden Jubilee Hospital, and investment of £100 million in cancer care; and
- Improving primary care, by reducing unnecessary attendances and referrals to outpatient services through the Modern Outpatient Programme.
Shifting the Balance of Care
Good quality community care should mean less unscheduled care in hospitals, and people staying in hospitals only for as long as they need specific treatment. Integration of health and social care has been introduced to change the way key services are delivered, with greater emphasis on supporting people in their own homes and communities and less inappropriate use of hospitals and care homes. As the population ages, the demand for care and support grows and the nature, complexity and acuteness of that demand grows as well. These changes mean that delivering even the current levels of service in the same way as has been done in the past is not sustainable. The integration of health and social care is one of the most significant reforms since the establishment of the NHS. It is about ensuring that those who use services get the right care and support whatever their needs, at any point in their care journey.
Health and Social Care Partnerships (sometimes referred to as Integration Authorities) – which bring together NHS Boards, Local Authorities and others to ensure the delivery of efficient, integrated services – have real power to drive change. They are managing more than £8 billion of resources that NHS Boards and Local Authorities previously managed separately, representing more than 50 per cent of territorial NHS Board expenditure, and more than 80 per cent of Local Authority social care expenditure. They are being provided with a range of recurring funding to support integration, including an Integrated Care Fund of £100 million to support delivery of improved outcomes from health and social care integration, and £30 million a year to support Health and Social Care Partnerships to reduce delayed discharges, including the development of a range of community-based services like intermediate care beds, re-ablement at home and other preventative services.
To improve the health of the people of Scotland, the traditional 'fix and treat' approach to our health and social care needs to change to one based on anticipation, prevention and self-management. The key causes of preventable ill-health should be tackled at an early stage, and there should be a more comprehensive, cross-sector approach to ensuring healthy behaviours are the norm, starting from the earliest years and lasting throughout people's lives. This can only be achieved by all public services working together systematically to be sensitive to individual health and social care needs, with a clear focus on early intervention. They need to be designed around how best to support people, families and their communities and promote and maintain health and healthy living. You can read more about what is being achieved in Chapter 3.
NHS Boards need to work together differently to ensure their services deliver better outcomes for people and better value. Collaboration and joint working need to become increasingly the norm, not only between NHS Boards but also with Health and Social Care Partnerships, Local Authorities and other partners across disciplines and boundaries to plan and deliver services over the next 15 to 20 years.
To drive forward the changes required, regional delivery plans are being developed by NHS Boards and partners for three regions across Scotland (North, East and West). These regional delivery plans will set out the services which can best be planned and delivered at regional level and support the services that can best be delivered closer to home. In doing so, they will focus on the safest and most effective way to provide specialist services unconstrained by bureaucratic boundaries. Through close working with partners, the plans will also fit seamlessly with the planning of local services through existing NHS Boards and Health and Social Care Partnerships, and provide a comprehensive vision for service development over the coming years.
Outline plans are due to be produced for wide public and stakeholder discussion commencing in autumn 2017, with the aim to produce detailed documents by the end of March 2018.
At the same time, a single national delivery plan is being produced jointly by the national NHS Boards to set out their collaborative contribution to the Health and Social Care Delivery Plan and the regional delivery plans including, where appropriate, taking a 'Once for Scotland' approach in areas such as radiology, digital services, clinical demand management and support services.
Progress Against Measures of Health and Social Care in 2016/17
What Independent Reports Say About Progress
In 2016/17, the Scottish Government commissioned Sir Harry Burns to review health and social care targets and indicators in Scotland to improve outcomes  . This was a demanding ask as it covered the whole of health and social care and inevitably covered the use of data in quality improvement collaboration, policy-making, performance management and planning. One of the key messages that the Scottish Government took from the review is the need to take a rounded view when considering health and social care systems – not simply focusing on one or two dimensions or a handful of indicators.
The recent analysis by the Commonwealth Fund looked at healthcare system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States  . It considered 72 indicators in five domains: care process; access; administrative efficiency; equity; and healthcare outcomes. It found that the UK achieves superior performance compared to those other countries; however, no country ranks first consistently across all domains or measures, suggesting that all countries have room to improve.
The already-referenced Nuffield Trust report Learning from Scotland's NHS  looked at what it described as Scotland's unique healthcare system, and explored how other parts of the UK might be able to learn from it. It found that Scotland has a unique system of improving the quality of healthcare that focuses on engaging the altruistic professional motivations of frontline staff to do better, and building their skills to improve. It also found that the Scottish NHS has benefited from a continuous focus on quality improvement over many years using a consistent, coherent method where better ways of working are tested on a small scale, quickly changed, and then rolled out.
Current Measures of Health and Social Care in Scotland
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  .
The majority of the direct health and social care measures within the NPF remained steady in 2016/17, however we want to see more improvement and this Annual Report highlights some of the actions that were taken this year to support improvements in population health. We are also clear that the health and social care system has to do all it can to help tackle poverty.
In the case of LDP Standards, last year's Annual Report noted the on-going challenges in meeting the elective, cancer and mental health waiting times standards. These challenges continued in 2016/17 and in August 2017 the Cabinet Secretary for Health and Sport announced the establishment of an Elective Access Collaborative Programme to provide support to NHS Boards to improve the way elective services are configured  . In 2016/17, diagnostic waiting times statistics showed that 86.7 per cent of elective patients had been waiting six weeks or less at the end of March 2017  . Just over 260,000 or 87.4 per cent of patients received their treatment within the 12 week legal treatment time guarantee in 2016/17, while 80.7 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2017  . During the quarter ending March 2017, 88.1 per cent of patients started treatment for cancer within the 62 day standard and 94.9 per cent of patients started treatment for cancer within the 31 day standard  . During the quarter ending March 2017, 83.6 per cent of children and young people started treatment at Child and Adolescent Mental Health Services ( CAMHS) in Scotland within 18 weeks of being referred  . Unscheduled care waiting times in Scotland are the best in the UK  , and Healthcare Associated Infection measures in Scotland remain steady after years of improvement  .
We are seeing improvements in some of the high-level indicators within the Integration Indicators  , including encouraging signs on delayed discharge  and emergency bed days  . Data on individuals' experience of social care support is developing and so limited trend data is available in relation to this aspect of care in Scotland  . 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  . There is an upward trend in positive experiences of care in Scotland shared online at Care Opinion (previously Patient Opinion)  and this 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 play 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: www.nhsscotannualreport.com.