Value Based Health and Care action plan - measurement framework: technical report

3. Previously unpublished survey data

3.1 Value Based Health and Care survey

This section outlines the methodological approach used to design the Value Based Health and Care (VBH&C) survey and presents the frequency tables that summarise the survey findings which inform 42 monitoring metrics in the measurement framework.

Value Based Health and Care survey methodology

The VBH&C survey was designed to inform the content of metrics in the Measurement Framework and aimed at gathering the views and experiences of healthcare professionals regarding the delivery of the Value Based Health and Care Action Plan. The survey was developed by government research analysts from the Whole System Intelligence Analysis Division and informed by the Realistic Medicine Policy Unit within the Scottish Government, in collaboration with stakeholders directly involved in delivering the actions. The survey was available online for anonymous participation between Sep 30 – Nov 9, 2025.

The survey consisted of 21 closed-ended questions. Each of these questions is represented by a table in this Section of the report (Tables 1-21). Some questions required respondents to select a single response option, while others allowed multiple selections. Four questions included an “other” option, which enabled respondents to provide an alternative written answer.

A snowball sampling approach was used to distribute the survey. An invitation email from the Deputy Chief Medical Officer, which included the survey information, the survey link and the privacy notice, was sent to members of the Realistic Medicine Network^[13], who were asked to share it within their respective areas of work. Two reminder emails were circulated using the same approach. This method aimed to reach a cross section of healthcare professionals. Due to the sampling strategy, the total number of individuals who received the survey is unknown, and therefore a response rate cannot be calculated. The survey sample should not be taken to be representative of the wider health and care workforce.

Survey responses were anonymous and no personal identifiable information was requested. A total of 425 responses were received. Respondents were asked questions relating to their profession and area of work. Allied Health professionals accounted for 25% of respondents, followed by nurses (15%) and consultants (15%) (See Table 1). More than half of respondents (59%) worked in NHS Territorial Boards and almost a third (31%) worked in a Health and Social Care Partnership (see Table 2). Response were received from across all 14 NHS Territorial Boards (see Table 3).

Value Based Health and Care survey Interpretation of frequency Tables

Some tables in this section are derived from VBH&C survey questions which allowed respondents to “tick all that apply” meaning more than one response option could be selected. As such, percentages in the “%” column are likely to exceed 100%.

Furthermore, percentages presented in the Tables are shown to zero decimal places. Some of the descriptive text included alongside some Tables will refer to findings in a combined or banded way (eg very or fairly clear, agree or strongly agree, etc). Where banded findings are presented in the text the banded sum may not match the sum of the constituent figures presented in the table, and may vary by + or – 1 percentage point (eg 10% and 10% presented in a Table my sum to 19% or 21% when banded, given that the 10% presented may demote 9.5% - 10.49%).

Below is an explanation of further denotations used throughout the Tables in this Section:

• “*” denotes a response option which received fewer than 5 responses. Such data are omitted to mitigate disclosure risk.
• “0%” denotes a percentage which is <0.5%, presented to zero decimal places
• “-“ denotes a response option which received 0 responses.

Value Based Health and Care survey: frequency tables

The tables below present detailed frequency distributions of survey responses provided by Value Based Health and Care survey respondents, which align to 41 monitoring metrics included in the Measurement Framework. The tables display one or more monitoring metric organised in alignment with the survey questions from which they were derived.

Table 4 presents data relevant to monitoring metrics 1.3, 1.5, 1.7 and 10.1. Respondents were asked which of the listed tools they had used to support the care they provide. SIGN resources had the highest reported use (65%). Approximately one quarter of respondents reported using each of the following: the Realistic Medicine TURAS pages, the website, and the e‑learning modules ^[16] (26% each). Among other Realistic Medicine tools, the proportions reporting use were 10% for TURAS animations, 9% for TURAS Sways, 6% for the Realistic Medicine professionals’ app and 4% for the Realistic Medicine Finance Toolkit hosted on TURAS^[17]. Around a quarter of respondents (25%) had not used any of the listed tools.

Table 5 presents data relevant to monitoring metric 2.3. Two thirds (66%) of respondents reported a clear (very clear or fairly clear) understanding of the statement “By practising Realistic Medicine we can deliver Value Based Health and Care” and 11% reported an unclear (very unclear or fairly unclear) understanding. 9% were not familiar with one or both concepts.

Table 6 presents data relevant to monitoring metrics 3.3, 10.2 and 10.3. Respondents were asked which of the following tools and resources they had used to support the care they provide. Reported use of support tools was highest for NHS Inform (62%). Near Me (41%) and Right Decision Service tools for professionals (41%) were each used by around two‑fifths of respondents. Lower proportions reported using the Discovery Dashboard (14%), CfSD Best Practice Pathways (9%), Right Decision Service tools for citizens (4%), the Scottish Health Technologies Group website (4%) and Connect Me (3%). Around one-in-six respondents (16%) had not used any of the listed tools.

Table 7 presents data relevant to monitoring metric 3.5. Respondents were asked what barriers they had faced when using digital technology to support them to deliver VBH&C. The most frequently reported barrier was ‘lack of awareness of available digital technologies’ (62%). ‘Insufficient time to learn or integrate new technologies into practice’ (52%) and ‘insufficient training, confidence or knowledge’ (44%) were also commonly cited. Further barriers included ‘lack of leadership support for adopting digital solutions’ (29%), ‘technical challenges in using these tools effectively’ (28%), ‘lack of confidence in the quality or effectiveness of these technologies’ (17%), being ‘able to deliver Value‑Based Care without these tools ‘(14%), and ‘concerns about information security’ (12%).

Table 8 presents data relevant to monitoring metrics 4.1, 4.2, 4.3, 4.4, 4.5 and 5.1. Respondents were asked how often they use feedback from the following tools to inform their delivery of person-centred care. Patient experience surveys were the most commonly used source, with 62% reporting using it at least occasionally. Care Opinion was used at least occasionally by 42%. Around a quarter of respondents used Patient Reported Experience Measures (PREMs) (24%) and Patient Reported Outcome Measures (PROMs) (25%) at least occasionally. Shared decision‑making measurement tools were used at least occasional by 10%, as did the NEAR ME end‑of‑consultation survey.

Table 9 presents data relevant to monitoring metric 6.1. Among respondents, reported use of the Scottish Atlas of Healthcare Variation was limited: Almost four-fifths (79%) had never used it, 13% used it rarely, 6% occasionally and 3% often or very often.

Table 10 presents data relevant to monitoring metric 6.2. Respondents were asked what barriers they have faced when using the Scottish Atlas of Healthcare Variation to help them look for unwarranted variation. The most frequently cited barrier was lack of awareness about the Atlas (72%). Other reported barriers included insufficient training or knowledge (23%) and insufficient time to learn or integrate the Atlas into practice (20%).

Table 11 presents data relevant to monitoring metrics 8.1 and 8.2. Respondents were asked the extent to which they agreed with two statements. Just over half (51%) agreed or strongly agreed that the organisation they work for promotes a culture of prevention in health and care and around two-fifths (42%) agreed or strongly agreed that their organisation actively works to address racialised inequalities in health and care.

Table 12 presents data relevant to monitoring metrics 9.1, 9.2, 9.3 and 9.4. Respondents were asked how often they engage with RM and VBH&C networks and events. At least occasional engagement was reported by 17% for the Community of Practice, 33% for the Realistic Medicine Network, 37% for local Realistic Medicine teams, and 37% for local or national events related to Realistic Medicine. Around half (53%) were unaware of the Community of Practice, 31% for the Realistic Medicine Network, 30% for the local team, and 25% for local or national events.

Table 13 presents data relevant to monitoring metrics 11.1, 11.2 and 11.3. It reports responses from Consultants and Resident Doctors only (n=70) who participated in the VBH&C survey. The extent to which respondents in this cohort felt each tool has supported them to reduce or stop lower‑value interventions varied by tool. Discharge PIR (Patient‑Initiated Review) was reported to provide at least limited support by 40%. Active Clinical Referral Triage (ACRT) provided at least limited support for 31% while Effective Quality Interventions Pathways (Opt‑In Pathways) were reported to provide at least limited support by 19%. The most common response for each tool was “I am not aware of this”, (43% for ACRT, 47% for Opt-In Pathways and 30% for Discharge PIR), followed by “I have not used this” (24% for ACRT, 31% for Opt-In Pathways and 29% for Discharge PIR).

Table 14 presents data relevant to monitoring metrics 11.4 and 11.5. Respondents were asked to what extent Centre for Sustainable Delivery (CfSD) Clinical Pathways, NHS Scotland Discovery data and the National Green Theatres Programme have supported them to reduce or stop lower‑value interventions and care. At least limited support was reported by 15% for CfSD Clinical Pathways and 18% for NHS Scotland Discovery data. For the National Green Theatres Programme, 10% of respondents reported at least limited support. Being unaware of these resources was reported by 59% for CfSD Clinical Pathways, 60% for NHS Scotland Discovery data, and 61% for the National Green Theatres Programme. Additionally, 25%, 19%, and 27% of respondents respectively reported that they had not used these resources.

Tables 15, 16 and 17 present data relevant to monitoring metrics 12.1, 12.2, 12.3, 12.4, 12.5 and 12.6. The corresponding VBH&C survey questions, used to derive the findings set out in Tables 15, 16 and 17 included the response option “my role does not involve prescribing”. Respondents who selected this option (n=192) are omitted from these findings, and percentages presented are based on the remaining respondents, referred to as “Total with role which involves prescribing” or “respondents with prescribing responsibilities”.

Respondents with prescribing responsibilities were asked to what extent selected initiatives have supported them to reduce the use of medicines of low and limited clinical value (see Table 15). The highest proportions reporting some or significant reduction were for polypharmacy prescribing guidance and implementation toolkits (44%) and 7‑step person‑centred reviews (41%). Some or significant reduction was also reported for the National Therapeutic Indicators (31%), clinical decision support software (23%), and the Scottish Therapeutics Utility (25%). The most common response for each initiative was “I am unaware of this initiative”, followed by “I have not used this”.

Respondents with prescribing responsibilities were asked what impact selected initiatives and resources had on their ability to deliver safer, more effective and person-centred care (see table 16). The highest proportions reporting significant or some positive impact were for 7‑step person‑centred reviews (35%) and polypharmacy prescribing guidance and implementation toolkits (34%). 24% reported some or significant positive impact for National Therapeutic Indicators, 20% for the Scottish Therapeutics Utility, 18% for Scottish Government Quality Prescribing Resources and 16% for clinical decision support software. The most common response for each initiative was “I am unaware of this initiative”, followed by “I have not used this”.

Table 17 presents responses from Respondents with prescribing responsibilities, when asked about the impact of the National Therapeutic Indicators and the Scottish Therapeutics Utility on their ability to identify unwarranted variation in prescribing practices. Around a quarter indicated that these tools had a significant or moderate impact (26% for the National Therapeutic Indicators and 25% for the Scottish Therapeutics Utility). The most common response for both resources was “I am unaware of this initiative” (44% for the National Therapeutic Indicators and 48% for the Scottish Therapeutics Utility), followed by “I have not used this” (24% for the National Therapeutic Indicators and 21% for the Scottish Therapeutics Utility).

Table 18 presents data relevant to monitoring metric 13.1. Respondents were asked the extent to which their organisation promotes the “It’s Ok to Ask campaign”. Nearly half (46%) reported being unaware of the campaign. Among those who were aware of the campaign, 19% reported moderate promotion, 19% reported limited promotion and a further 9% indicated significant promotion.

Tables 19, 20 and 21 present data relevant to monitoring metrics 13.2, 13.3, 13.4, 14.4, 14.5 and 14.6. The corresponding VBH&C survey questions, used to derive the findings set out in Tables 19 included the response option “My role is not patient facing”. Respondents who selected this option (n=65) are omitted from findings included in Tables 19, 20 and 21, and percentages presented are based on the remaining respondents, referred to as “Total with a patient facing role” or “respondents with a patient facing role”.

Respondents with a patient‑facing role were asked how often they use the BRAN questions to support people in making decisions about their treatment and care (see Table 19). Around half (51%) reported using the BRAN questions at least occasionally, while over a third (34%) indicated that they were not familiar with BRAN questions.

Respondents with a patient‑facing role, and who had not responded “I am not familiar with the BRAN questions” at the previous question, were asked the extent to which they agreed or disagreed with two statements (see Table 20). Around four-in-five (81%) agreed or strongly agreed with the statement that ‘BRAN questions are effective in helping people make an informed choice about their treatment and care’ and around half (52%) agreed or strongly agreed that ‘My organisation supports me in promoting and using the BRAN questions’.

Respondents with a patient‑facing role were asked the extent to which they agreed or disagreed with three statements (see Table 21). Over two‑thirds (69%) agreed or strongly agreed with the statement ‘I am able to take the time to get to know the people I care for and what is important to them’. A large majority (86%) agreed or strongly agreed with ‘I am able to involve the people I care for in decisions about their care’, and a similar proportion (87%) agreed or strongly agreed with ‘I am able to listen to the people I care for and understand the outcomes that matter to them’.

3.2 Health and Care Experience Survey 2023/24: Secondary Analysis

The Scottish Health and Care Experience Survey (HACE) is a national survey that gathers feedback on people’s experiences of GP services, out‑of‑hours care and social care. It is an online and postal survey sent to a random sample of people who were registered with a General Practice in Scotland, lived in Scotland, and were aged 17 and over on 25 September 2023. The survey has been run every two years since 2009. The 23/24 survey included closed and open‑ended questions and received 107,538 responses (equating to an overall response rate of 20%), including 43,803 free‑text comments about experiences of General Practice and out‑of‑hours care. Questionnaires were sent out in October and November 2023 asking about peoples’ experiences during the previous 12 months.

The free-text comments were collected through two open-ended questions in the HACE survey^[18]: Question 18, which focused on people’s experiences of General Practice, and Question 26, which focused on out of hours healthcare. Secondary analysis of these free text comments in the Health and Care Experience Survey 2023/24 was carried out by government research analysts to inform the Value Based Health and Care Measurement Framework, specifically the monitoring metric 14.7. Responses to both open-ended questions were combined and analysed together. Appropriate ethical procedures were followed to access the free-text responses to both questions of the HACE survey. These procedures primarily involved submitting a formal access request, adhering to data protection standards, and ensuring all data was handled securely.

Due to the large volume of free-text responses, a list of keywords was developed and used to filter and identify relevant comments containing terms related to the Value Based Health and Care.^[19] Responses containing at least two specified keywords were initially selected (n=3,161). Following this, a shorter list of primary keywords was identified and used to undertake a further round of screening, which resulted in 1,081 responses. A final manual review excluded comments that were unclear, lacked sufficient detail, or fell outside the scope of the analysis. This resulted in a total number of 426 responses included for the secondary analysis. These were examined using thematic analysis, independent of the closed‑ended survey questions.

The free-text responses were analysed independently from the closed-ended questions. Respondents’ comments generally reflected a balance between positive and negative experiences; however, some discrepancies were observed, with slightly more negative experiences reported. While the findings from the closed-ended questions highlighted mostly positive experiences of care, the slightly higher proportion of negative free-text comments may indicate that respondents with negative experiences were more inclined to share their views.