Inadequacies of the present system
48. The present system does not, in some respects, adhere to the principles for good design of indicators and targets described.
49. Systems thinking is not made easy by having three separate suites of targets and indicators with different organisations accountable for delivery. This fragmentation makes it difficult to think of the public sector as a single, complex system. Organisational boundaries make sharing of data difficult and different lines of management accountability make improvement difficult.
50. Although there is some evidence of coproduction of targets and indicators with staff and the recipients of services for example the health and social care integration indicators, there is greater scope for coproduction. Some targets have been borrowed from other parts of the UK and many are based on good evidence that, if applied, should result in better outcomes. However, in many cases, no data is routinely collected to show outcome improvement.
51. There is no explicit acknowledgement of an overall aim for health and social care as the basis for the existence of indicators and targets. If a flourishing, healthy and long lived population is the aim, acknowledgement of this purpose would help engage staff and the wider population in delivery. The quadruple aim should be embraced across health and social care.
52. The reporting of performance should also be considered. At present, public debate tends to focus on specific parts of the system in isolation. The frequency of the publication of data is important in this respect with the indicators having weekly, monthly or quarterly publications receiving most attention and often in isolation of the bigger picture.
53. Accurate reporting requires appreciation of context. The social context in which some organisations have to deliver a target is significantly different from that in which other organisations have to deliver them. The social context of some groups such as disabled people or the elderly may require different indicators or different methods of analysis from those used in, for example, acute care.
54. The present approach has undoubtedly had many beneficial effects with waiting times for care being substantially reduced and other outcomes improved. Where countries report waiting times in A&E and for investigation and treatment, ours compare favourably with most international data. However, this review provides an opportunity for Scotland to move its performance to a new level by adopting a new approach which might encourage continuous progress in many areas.
55. The current groups of targets and indicators relate to several areas including work and employment, the environment, and communities. This wide range of topics reflects a highly strategic approach to societal development. In thinking through the relationships between the different dimensions of the NPF, it is clear that many of the drivers of sustainable economic growth have an impact on health and wellbeing. This review has focused on those of greatest relevance to health and social care. (See Appendix 1). However, the opportunity to consider a wider set of indicators which might include alternative measures of economic growth which are more relevant to population wellbeing might be considered at a future date.
56. To ensure people live longer, healthier lives, the health and social care system obviously requires to know it can act effectively to prevent, detect and treat illness. However, we know now that the decisions people take to maintain their health are significantly influenced by the social and economic conditions in which they live. To deliver longer, healthier lives, we need to have an effective health care system but we also need a supportive social and economic environment. In parts of Scotland, it is clear that the health benefit of improving the socioeconomic determinants of wellbeing is likely to bring greater improvements in healthy life expectancy than providing more health care. Action across the whole of society is required and the targets and indicators, if they are to be helpful, need to encourage joint working across all agencies and with all communities.
57. The NPF, Local Delivery Plan and Health and Social Care Integration indicators are intended to allow monitoring of progress and performance in delivering integrated services to people. These three sets of targets form the basis of this review and are defined in detail in Appendix 1. However, if the health and social care system is to make progress in improving outcomes, it needs to find an effective method for joint working to improve all determinants of wellbeing.