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Partnership for Care: Scotland's Health White Paper
CHAPTER
FOUR QUALITY, NATIONAL STANDARDS AND INSPECTION
A new guarantee of service within national waiting time targets
New clinical targets and local targets for waiting times to drive service improvement
Patients and public involved in developing standards
NHS Quality Improvement Scotland inspecting performance against standards
Clear arrangements for intervention, with statutory powers to tackle service failure
1. The starting point for improving quality must be the experience of every patient who passes through the healthcare system. But more is required. Patients and the public expect the NHS to provide safe, high quality care and treatment - and they expect this to be available consistently across Scotland. Safety and clinical quality are fundamental aspects of the way clinicians plan and give care. Improvements in quality are constantly being made through improvements in technology, knowledge and experience and patient feedback is an essential part of the process. We will continue to support this work, ensuring that quality assurance systems are in place, and that frontline staff are helped to deliver high quality care. We will ensure rigorous and independent monitoring and inspection, with robust arrangements to investigate and tackle serious service failure.
2. We want the public to feel confident that health services are as safe and effective as possible, and to know where this assurance comes from and who gives it. That is why in January we set up a new body - NHS Quality Improvement Scotland - to focus on improving the quality of clinical care. This new organisation will link more closely the work programmes of all of the partners in this important field including the
Scottish Inter-Collegiate Guidelines Network.
3. NHS Quality Improvement Scotland will provide clear, authoritative advice on effective clinical practice, set national standards and inspect and publish reports on performance. NHS Quality Improvement Scotland inspections will be entirely independent of government and of NHSScotland. It has the skills, access, resources and power necessary to identify areas of weakness and ensure that NHSScotland is improving quality where that is necessary. It also has a tough new remit to investigate serious service failures and make clear recommendations for remedial action. Ministers will request NHS Quality Improvement Scotland to investigate hospital or other services where they consider that is necessary. NHS Quality Improvement Scotland may also intervene itself, for example in response to public concern.
4. The Executive will intervene where necessary to correct significant service failures. If there are serious concerns about patient safety and service quality or persistent failure to deliver against national targets, including waiting times, then we will require NHS Boards to make immediate changes to remedy these, working with Boards to provide support, strengthen management and make other necessary changes. The Executive has arrangements for escalating intervention to address service failures within the NHS. We will review our powers of intervention and bring forward legislation, if necessary, to ensure that we have in place effective mechanisms for the delivery of national standards and priorities.
5. Audit Scotland has an important role in relation to the efficiency and effectiveness of NHS organisations, independently of NHSScotland and government. Its financial audit of NHS organisations is complemented by its performance audits of aspects of the service provided by NHSScotland. Efficiency and effectiveness are vital to make sure that the extra resources flowing into the NHS achieve improved services for patients. There is a close working relationship between Audit Scotland and NHS Quality Improvement Scotland to achieve rigorous standards of inspection and monitoring. This will help to ensure patient confidence in the quality and safety of healthcare provision.
6. NHS Quality Improvement Scotland will also work alongside the
Scottish Commission for the Regulation of Care which will modernise and standardise the regulation of care services. National Care Standards have been developed to provide a benchmark for this regulation.
7. Patients have a central role in every aspect of the work of NHS Quality Improvement Scotland including the development of standards and the monitoring and review of compliance. The NHS will have to persuade patients' representatives that their services are up to standard. In particular, we propose that the new Scottish Health Council - which will provide a new, far sharper focus for patient and public involvement in NHSScotland - will be an integral part of NHS Quality Improvement Scotland. This will ensure the patient's viewpoint is right at the heart of determining standards of healthcare and service, and of inspecting performance.
8. To support our overall approach to improving clinical quality we will continue to invest in research to underpin health improvement and better health services, within a
new research strategy focused on the clinical priorities of cancer, cardiovascular disease, mental health and public health. Through this investment we will strengthen the evidence base for tackling Scotland's major health problems and health inequalities.
Clean Hospitals
9. The public expects Scottish hospitals to be clean and that patients will be protected from acquiring infections in hospital. We asked the Clinical Standards Board for Scotland - a predecessor body of NHS Quality in Scotland - to produce service standards for hospital cleaning and infection control. Hard-hitting reports have recently been published showing that although progress is being made, much more needs to be done in individual hospitals. NHS Quality Improvement Scotland and the Health Department will ensure that individual action plans are implemented and the necessary changes made.
10. To help achieve the standards the public expects, NHS Quality Improvement Scotland has set national standards on infection control and we are, for example, developing a new educational programme for 3500 infection control link nurses to help encourage the development of skills and expertise within the NHS. A task force headed by the Chief Medical Officer is implementing our Healthcare Associated Infection action plan, including the key conclusions from
The Watt Group Report, but all hospital staff, including managers, clinicians, and domestic services and catering staff are responsible for ensuring standards are met.
Service Standards and Waiting Times
11. Patients expect to wait less as a result of the extra money going into the NHS. We agree. We will ensure that the Service makes a substantial and sustained improvement in waiting times for outpatient appointments and hospital treatment. For too long the service has suffered from bursts of clinical activity to respond to waiting time pressures, which have not resulted in sustained service improvements and have sometimes distorted clinical priorities. Patients need to be confident that their diagnosis and treatment is well-planned, reliable and available within reasonable timescales. Equally clinicians want to offer patients the fastest and most reliable service appropriate to their individual clinical need.
12. This requires actions at a number of levels and over different timescales - waiting times will not be solved overnight. We must take actions that tackle the roots of the problems as well as alleviate the symptoms.
13. To address the root causes of delays each NHS Board must take a 'whole system' approach to service redesign to reduce waiting times. This will ensure that patient expectations are taken fully into account and that the reasons for bottlenecks and duplication of activity are removed. In designing better healthcare, health professionals will be increasingly aligned to a particular service and less to a particular institution, as they harness the benefits from working more consciously as part of a clinical network, sharing expertise and good practice to reduce waiting for patients.
14. Reducing waiting times also requires much quicker access to clinical information, which can speed up decision-making. New arrangements such as the introduction of contact centres for each hospital, and the introduction of new hospital appointment systems, will make it easier for patients and healthcare professionals to book appointments for consultations.
15. There will be increased national support to the health service from the Health Department which will promote understanding of the issues that lead to delays in assessment and treatment, and support the spread of service improvement approaches. It will do this by:
sharing examples of good practice with hospitals and NHS Boards;
supporting staff in redesigning services to reduce delays and waiting times for treatment;
launching a new national programme of service improvement and redesign;
providing leadership from the National Waiting Times Unit for capacity planning;
expanding the waiting times database to ensure that patients and clinicians are given maximum flexibility in deciding how, where and when to access healthcare;
ensuring that the Golden Jubilee National Hospital acts as a support to NHS Boards by contributing appropriately to reducing waiting for outpatient, in-patient and diagnostic services; and
booking spare capacity in the private sector to reduce the misery for those waiting longest. We will continue to do this where this will complement and not detract from NHS Boards' corporate responsibility to develop sustainable local solutions to long waits.
16. Because of these actions, we will be able to make progress in relation to targets and guarantees and will hold Boards accountable for their performance by:
first, setting National Guarantees. We will give patients a guarantee that our national targets will be met. These will be monitored to ensure that patients have prompt access to services. If a patient is not treated by their local NHS within the National Guarantee, we will give them the right to be treated elsewhere. This may be in the National Golden Jubilee Hospital, elsewhere in the NHS, in the private sector, or in exceptional circumstances elsewhere in Europe;
second, setting condition-specific waiting targets which cover the most urgent clinical conditions will continue to be set by NHS Quality Improvement Scotland. These will build on the existing Coronary Heart Disease and Cancer targets; and
third, requiring each NHS Board to set challenging local targets for their inpatient, daycare, and outpatient services. They will demonstrate the progress which each Board is expected to make in reaching and then exceeding our National Guarantees.
17. We will move faster to deliver improvements in outpatient waiting. The current target of 26 weeks maximum wait by 2006 will be brought forward by a year so that it is achieved in 2005. We will improve the management of outpatient waiting times by recording for the first time the number of referrals received for a service, and the waiting time for patients who have not been seen at a clinic. This will enable hospitals to plan services that have the capacity to provide outpatient appointments within agreed targets and within clinical priorities.
18. We are also determined to end delayed discharge. This 'bed blocking' happens where patients, mostly elderly, have to stay on in hospital simply because more appropriate care is not available in the community. We are investing an extra 30 million a year to enable Local Authority and NHS partnerships to tackle delayed discharges. Partnerships must deliver on their targets to receive additional resources. If they fail, support teams will help ensure patients receive the care they need.
19. NHS Boards and Local Authorities are keen to learn from each other's experiences of tackling delayed discharge. The Executive is supporting this through a Good Practice Resource and National Learning and Sharing Network which provides partners in health, social work and housing with information on what works and what does not.
Incentives for Good Performance
20. We have described how the Health Department and NHS Quality Improvement Scotland will intervene where performance becomes unsatisfactory, and how waiting times guarantees for patients will provide strong incentives for NHS Boards to deliver maximum waits for treatment. We will also provide incentives for good and improving performance. NHS staff are strongly motivated to provide clinically excellent services which respond to patients' needs. However, we need to focus the efforts of everyone in the NHS - Boards, clinical staff and managers - on achieving progress on key priorities which mean most to patients and the public. The Scottish Executive Health Department set 12 priorities for the NHS for 2003-04 - far fewer than before. The Service is focusing on these. But we need to bring other parts of the performance and incentive framework into line.
21. The Performance Assessment Framework (PAF) includes 60 quantitative measures of NHS performance and a further 30 qualitative measures to provide a set of published indicators on which the public can judge performance. The Framework provides valuable, high quality broad-based information which provides an important basis for the Executive's system of escalating intervention. This system builds on the annual Accountability Review meetings, which are crucial to improving NHS Boards' performance. We will also work with Boards to develop a new Performance Incentive Framework in 2003 that will help provide incentives for good or improving performance.
22. Against that background, we will:
keep NHSScotland focused on no more than 12 priorities each year;
publish a core set of key performance indicators relating to the NHS priorities and drawn from the PAF;
develop a new Performance Incentive Framework;
agree with NHS Board Chairs how senior managers' pay progression and bonuses can best be linked to performance on the NHS priorities as part of their annual appraisal in a way that is felt to be fair and reinforces motivation.
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