The Scottish Improvement Journey: a nationwide approach to improvement

This paper shares the story of the Scottish Improvement Journey encompassing 50 years of clinical audit and improvement programmes.

2. The Scottish context

Scotland is a small country of approximately 5.4 million people spread across diverse areas from the urban cities of Glasgow and Edinburgh to extremely rural regions and islands (Table 1).

Table 1: Characteristics of Scotland (National Records of Scotland, 2017)


5.37 million (2015)



Largest city



Northern 1/3 of the island of Great Britain as well as 790 surrounding islands


Devolved parliamentary legislature within the UK constitutional monarchy

The population of Scotland is projected to increase by 7% to 5.7 million by 2039 (National Records of Scotland, 2015) with a strong upward trend in ageing population being observed (Figure 1). A 28% increase in the number of people of pensionable age or over and an 85% increase in those 75+ are projected by 2039. Meanwhile the working age population is set to increase by only 1% (National Records of Scotland, 2015). This trend will significantly impact public services through the demand for health and social care services, particularly given the expected rise in long-term health conditions.

Figure 1: The projected percentage change in Scotland’s population by age group, 2014-2039 (National Records of Scotland, 2015, p.14)

Figure 1: The projected percentage change in Scotland’s population by age group, 2014-2039 (National Records of Scotland, 2015, p.14)

Additionally, Scotland has been facing economic pressures through funding cuts across public services - Christie Commission (2011) reports a shortfall of approximately £39 billion across the years of 2010 – 2026. In this era of funding constraints, flexible resourcing and new and different ways of working are sought after to meet the needs of the people and communities the services seek to support. For example, in the past, significant public spending (about 40%) was devoted to interventions that could have been avoided by earlier preventative measures (Christie Commission, 2011). However, since the Public Services Reform Scotland Act (2010), the focus has shifted to targeting the causes of social problems in addition to the consequences.

In spite of the constraints on public spending, the rising demands due to social and demographic changes or the economic downturn, Scotland strives to reduce social and economic inequalities in the country (Christie Commission, 2011). The political and governmental leadership puts significant pressures on, and efforts towards, the development, improvement and defragmentation of public services. While the generally stable political climate in Scotland may currently be facing some uncertainty due to the country’s vulnerability to changes in the UK policy and UK-wide decisions, the country’s leadership emits full support and commitment to the improvement of public services.

2.1 Scottish healthcare

Given that the early improvement work in Scotland emerged within the healthcare sector as outlined below and throughout the paper, it is important to set the context of Scottish health care in particular. While originally created in 1948, the National Health Service Scotland (NHSScotland) became independent from the other three UK National Health Service systems – England, Wales, and Northern Ireland – in 1999 following the creation of the devolved Scottish Government. The NHSScotland is the national health care provider in the country and comprises of 14 Territorial NHS boards as well as seven Special NHS boards ( NHS Education for Scotland, NHS Health Scotland, NHS National Waiting Times Centre, NHS24, Scottish Ambulance Service, The State Hospitals Board for Scotland, and NHS National Services Scotland) and one public - body (Healthcare Improvement Scotland). NHSScotland employs over 160,000 staff – or 139,000 after adjusting for part-time working, including over 59,700 nurses and midwives, and 23,000 doctors, GPs and allied health professionals, including pharmacists and dentists (Information Services Division, 2017).

Table 2: NHSScotland Workforce Composition (Information Services Division, 2017, p.5)

Staff group

Headcount (after adjusting for part-time working)

All NHSScotland Staff


Nursing and midwifery






Medical and dental support


Allied health professions


Other therapeutic services


Personal and social care


Healthcare science


Ambulance services


Administrative services


Support services


Unallocated/ not known


Within the healthcare context, it is important to highlight the Scottish health record and its challenges. Over the last 20-30 years, alcohol has become the problem that Scotland has always been stereotypically associated. In the early 2000s, alcohol related mortality rates in Scotland were approximately twice those of the rest of the UK. However, Scotland has also seen a rapid decrease in its rates since the peak (Office for National Statistics, 2016). Additionally, Scotland is facing increasing levels of health inequality suggesting that people living in the most deprived areas develop multimorbidity 10-15 years earlier than those living in the most affluent areas particularly due to socio-economic deprivation (Barnett et al., 2012).

On 1 st April 2016, the Health and Social Care Integration Act came into force. This reform brings together local council care services and the NHS under one partnership in each area in order to improve quality and consistency of care for people of all ages. This new joint responsibility aims to ensure better and more coordinated patient journeys between health and care settings enabling people to safely stay at home or in a homely setting (The Scottish Government, 2016). The resulting system re-design has patient benefits at heart and helps Scotland to move from reactive interventions to preventative care. Simplifying the landscape of those engaged in different improvement works in this space, the Improvement hub (ihub) was created by combining some of the previously established improvement-focused organisations – the Improvement Directorate at Healthcare Improvement Scotland, the Joint Improvement Team, and the Quality & Efficiency Support Team within Scottish Government.

1.1.1 Key national organisations currently working on improvement with NHSScotland

Many organisations and people within NHSScotland, the Scottish Government and beyond are involved in and committed to improvement work in Scotland. The following list of organisations, while not exhaustive, provides an overview of the key sources of, and resources for, current improvement work in Scotland:

Healthcare Improvement Scotland ( HIS) – a public body of NHSScotland, previously known as NHS Quality Improvement Scotland, the lead of the Scottish Patient Safety Programme ( SPSP). Includes the ihub – a new improvement hub run by HIS to support improvements in health and social care service delivery and the development of improvement culture and infrastructures – a merger of the former Joint Improvement Team ( JIT), the Quality and Efficiency Support Team ( QuEST), and the Improvement Directorate at HIS – established 1 st April 2016;

Leading Improvement Team ( LIT) in the Scottish Government ( SG) – enabling SG and Scottish public services achieve better outcomes for Scotland through the application of an improvement approach;

NHS Education for Scotland ( NES) – a special NHS board responsible for developing and delivering training and education for the Scottish healthcare workforce;

Improvement Service– the national improvement service for local government in Scotland. Its purpose is to help councils and their partners to improve the health, quality of life and opportunities of all people in Scotland.

Quality Scotland – a charitable, member-based organisation working across Scotland in the private, public and third sectors providing expertise and resources to deliver continuous performance improvement.

Institute for Healthcare Improvement ( IHI) – Scottish Government’s quality improvement Strategic Partner, an independent non-profit organisation based in the USA.


Back to top