Designing and Implementing New Models of Care
Access to the right care at the right time not only depends on changes that need to be made in individual acute and secondary care services. We need to shift the balance of care from secondary/acute to primary/community care, not simply to improve waiting times but to ensure people get quicker and more effective support. Community and primary care services have an increasingly critical role in providing patients with more timely care closer to home. At the same time, designing some services at a regional level will lead to more effective, efficient and sustainable delivery for patients. The Improvement Plan will build on existing work in developing new models of care and ensure that this leads to significant improvements in access to care.
Community and primary care
Effective integrated community health and social care services are critical if we are to address waiting times and other secondary care demand issues. Through our approach to health and social care integration, NHS Boards and Integration Authorities are already working together to ensure sufficient focus and investment in care outside hospital to minimise avoidable inpatient care. The health and social care system needs to maintain its focus on improving public health and the development of preventative models of care (including self-management). If we want it to be financially sustainable, tackle persistent health inequalities, improve long-term outcomes and reduce pressure on the workforce, we cannot simply react to the management of patients with long-term conditions without taking long-term action across the health and care system as a whole.
It is essential that patients leave hospital when they no longer need to be cared for there, and that the savings made are appropriately reinvested so that a virtuous circle is created - increasing capacity in the community so that pressure is taken out of the system. To date, integration is starting to deliver success. Current projections indicate that local systems are on course to deliver a reduction of approximately 7% in avoidable bed-days by the end of this year. Integration Authorities are working towards the Health and Social Care Delivery Plan aim of reducing unscheduled inpatient care by up to 10% (or 400,000 occupied bed-days) by the end of 2018. Freeing up unscheduled occupied bed-days requires action and investment in communities to avoid unnecessary admission to hospital and to reduce delayed discharges where those are a concern.
Preventative and anticipatory care in communities, intermediate care, re-ablement and step-up/step-down care, along with best practice in relation to discharge procedures, all play an important part. All of these actions together will bring improvements in unscheduled care and the pressures on A&E within hospitals.
Alongside this Improvement Plan, we are taking renewed action to ensure these ambitions for integration are realised quickly and efficiently. In May 2018, we announced a review of progress by Integration Authorities, with the aim of understanding and addressing the challenges and opportunities integration brings. As part of the review, a joint statement between COSLA and the Scottish Government was issued in September, reaffirming the joint commitment to integration. Interim recommendations are expected later in the Autumn, and the review as a whole will conclude in early 2019.
At the same time, greater integration needs to be supported by a community and primary care workforce working together flexibly in support of patients. Given the role of the GP in deciding whether people require further assessment; investigation, treatment, referral and admission and ensuring that GPs have the time to undertake genuine shared decision-making is fundamental. Under the new GP contract, we are improving patient care by refocusing the GP role to Expert Medical Generalist, centred on complex care and clinical leadership of an expanded multi-disciplinary primary care team. GP practices will be part of clusters, benefiting from peer reviewing quality planning, improvement and assurance, including on issues like hospital referrals.
This work will build upon concerted, co-ordinated action at local level. Locally, agreed Primary Care Improvement Plans covering all 31 Integration Authority areas of Scotland have now been developed and agreed. The plans already show there has been a clear acceleration of both the pace and scale of the development of primary care multi-disciplinary teams of health and care professionals across all parts of Scotland, and a step-change in the nature of clinical leadership in the GP profession in co-designing reform. Over the next 12 months, the plans will be implemented to drive these changes further.
In addition, within particular community and primary care services, specific actions will also drive improvements. For example:
- Optometry. The up-skilling of the optometry profession has seen a dramatic fall in non-sight threatening conditions presenting to emergency eye departments, and more patients being monitored in the community before being referred onto the hospital. This was further strengthened from 1 October 2018 when changes to General Ophthalmic Services arrangements enabled the vast majority of post-operative cataract review appointments (c.42,000 per annum) to be carried out in the community instead of secondary care. Building on this, new action will: update and implement national clinical guidance for optometrists in primary care; improve patient pathways; implement Advice Pathways between optometry and Hospital Eye Services to speed up appropriate referral times; and share images and relevant information across primary/secondary care to prevent unnecessary referrals back to Hospital Eye Services and/or duplication of tests/images.
- Dentistry. The Oral Health Improvement Plan was published in January 2018. This is an ambitious programme to rebalance service provision from secondary to primary care where General Dental Practitioners with enhanced skills will have the opportunity to provide certain services that at present are delivered within a secondary care environment. Building on this, we are amending regulations to allow NHS Boards to list general dental practitioners with enhanced skills, and in our Fairer Scotland Action Plan, we have announced additional funding to support the expansion of Childsmile provision to support young children living in the poorest 20% of areas in Scotland.
- Pharmacotherapy. In our 2016-17 Programme for Government, we committed that by the end of this Parliament, all GP practices in Scotland will have access to pharmacists with advanced clinical skills. As part of the new GP contract agreement in Scotland, these pharmacists and technicians now form the foundation for the pharmacotherapy service, which will provide an important function in supporting patients with their medicines - not least those at higher risk of admission or readmission to hospital. Building on this, over the next three years the service will develop to support medication reviews for more complex cases, poly-pharmacy reviews for patients prescribed multiple medicines, monitoring those on high-risk medicines, post-hospital medicines reconciliation, taking action on hospital Immediate Discharge Letters, and authorising hospital outpatient medicine requests.
Regional and national collaboration
The Health and Social Care Delivery Plan reflected the need for NHS Boards to work more collaboratively and efficiently with each other and with local authority and other partners across disciplines and boundaries to plan and deliver services over the next 15-20 years, with a focus on improved patient outcomes and financial and workforce sustainability. Recognising that some of this work can only be achieved through cross-boundary collaboration, we commissioned regional delivery plans for each of three regions (North, East and West), focusing on the future shape of services, capital planning and workforce sustainability. The national Boards were commissioned to develop a plan to support the regional delivery plans.
The plans are continuing to be refined through local engagement. Over the next two years, the regional and national collaborations of NHS Boards, working with partners, will develop actions within the plans to drive service improvements, linking with the targeted specialty action plans wherever possible, including:
- Developing standardised referral criteria and pathways in the East region to reduce inappropriate referrals, so that people do not wait unnecessarily to see clinicians
- Extending the outpatient triage service in Aberdeen to the whole of the North region so referrals can be reviewed and alternatives to consultant outpatient attendances actively considered
- Extending the NHS Lanarkshire pilot on completing imaging before referral into secondary care to the whole of the West region to support early review of referrals by acute clinicians, so diagnostic image information will be used more quickly for the benefit of patients
- Developing a national Patient Reminder Service to reduce the number of people who did not attend or had delays in outpatient appointments
- Expanding the pilot work in new models of frontline primary care, including GP in-hours triage for same-day appointment requests and enhancing the role of paramedics to provide a greater range of treatment and interventions directly for patients at home
- Accelerate whole-system redesign of local patient pathways involving Integration Authorities, NHS Boards, and primary and secondary care clinicians (through 2019/20)
- Implement the General Medical Services contract to free up more GP time for appointments requiring longer discussions (through 2019/20)
- Build primary care multi-disciplinary teams to reduce unnecessary referrals by implementing the locally-agreed Primary Care Improvement Plans (through 2019/20)
- Take forward key actions to drive regional service reshaping where this will benefit patients through the regional delivery and national Boards' plans (through 2019/20)
Email: Philip Raines