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Health in Scotland 2004

CHAPTER 4: HEALTH SERVICES

Coronary Heart Disease and Stroke

Premature mortality for Coronary Heart Disease (CHD) and stroke continues to fall ( Figures 4.1 to 4.4). The success achieved to date in reducing mortality for CHD has led to the introduction of a more stringent target of 60% reduction in premature death in the under 75s by 2010.

The new structures introduced last year for CHD have been implemented and are working effectively. The National Advisory Committee and its sub-groups have covered a broad range of cardio-logical issues over the past year. The Committee has recently established two short-life working groups to consider pre-hospital thrombolysis and primary angioplasty, and the organisation and delivery of cardiological services. Both groups aim to report in the spring of 2005.

Managed Clinical Networks (MCNs) have taken the lead in prioritising bids for funding under the CHD and Stroke Strategy, which encompass the full spectrum of care. Substantial funding has already been committed to CHD and stroke and includes support for rapid-access chest pain clinics, heart failure and cardiac rehabilitation services and the development of Stroke Units. MCNs are working with Boards on developing primary and secondary prevention strategies which will draw on lessons learned from other projects including Have a Heart Paisley and the National Heart Health Learning Network.

Quality Assurance Frameworks are being developed in association with NHS Quality Improvement Scotland (NHS QIS). The Stroke Framework has been established and accreditation is currently underway. A quality assurance framework for CHD is under development and is expected to be completed early in 2005. The framework will be piloted prior to the formal launch and accreditation of all CHD MCNs.

Figure 4.1: Age specific mortality rates per 100,000 population: males dying from CHD.

Figure 4.2: Age specific mortality rates per 100,000 population: females dying from CHD.

Figure 4.3: Age specific mortality rates per 100,000 population: males dying from stroke.

Figure 4.4: Age specific mortality rates per 100,000 population: females dying from stroke.

Data and Information Technology (IT) systems are moving ahead and over the past year the IT sub-group has extended its remit to cover both CHD and stroke. The procurement of a new cardiac surgery system has been finalised and work will start on implementation in 2005. Audit facilitators have been checking the quality and completeness of revascularisation data as part of a broader Quality Assurance programme. One aim of the Strategy was to develop a comprehensive database system which captured data along the patient pathway. Good progress is being made. A minimum data set has been developed and piloted in three NHS Boards and information from the studies will help with the implementation and support for extension of the programme. Developments for stroke will draw on the work for CHD. An audit of all known stroke data systems will be undertaken before work commences on data definitions and the identification of core data items.

Activity levels continue to increase and, to ensure sufficient capacity, the Scottish Executive Health Department commissioned a review of capacity for revascularisation services. The Review reported in April 2004 and identified the need to increase capacity to accommodate the growth in percutaneous coronary interventions (PCI). Additional theatre facilities for coronary artery bypass graft (CABG) surgery were not required but there was a need to increase intensive care unit (ICU) capacity.

The National Advisory Committee on CHD continues to support a number of projects including the establishment of a national centre for the treatment of advanced heart failure, development of an adult congenital heart disease service and the development of a primary care collaborative based on the successful project in England.

Cardiac waiting times

The Health White Paper Fair to All, Personal to Each, published in December 2004, contained a number of new waiting time targets for specific conditions, including cardiac disease. The White Paper reinforced the commitment made in autumn 2004 that, from the end of 2007, no patient will wait more than 16 weeks for cardiac intervention. The target covers the period from GP referral through rapid access chest pain clinic, or equivalent, to cardiac intervention. This is the first time that a new target has included the period following GP referral and it will cover more heart treatments, including heart valve surgery. It is a reduction of 10 weeks on the current target and is significantly shorter than that available elsewhere in the UK.

In recognition of the fact that heart problems can manifest in ways other than chest pain, another target has also been put in place. From the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment. This is particularly relevant to patients who may need investigation of heart rhythm problems, requiring electrophysiological techniques.

Cancer

Survival from cancer

In 1999, the Scottish Executive committed to a 20% reduction in deaths from cancer in the under 75s by 2010. In 2003, there were 144.6 deaths from cancer per 100,000 of population, which is an improvement of 13.6% on the 1995 baseline.

Cancer Open Forum

The annual Cancer Open Forum was held in May at the Edinburgh International Conference Centre to review the first three years of Cancer in Scotland: Action for Change and build on its success. There are at least 300 more doctors, nurses, pharmacists and other professionals directly involved in cancer care and diagnosis, and treatment has improved with new and replacement equipment as a result of the additional £25m per annum put in place in 2001. At the May 2004 Conference, the next phase, Cancer in Scotland: Sustaining Change, was launched by the Minister for Health and Community Care. It can be found at www.cancerinscotland.scot.nhs.uk.

Screening programmes

The extension of the breast screening programme to include women up to the age of 70, the introduction of liquid based cytology and the new IT system for call-recall for cervical screening continue to be phased in.

In April 2004 the Minister for Health and Community Care launched the Cancer in Scotland: Bowel Cancer Framework, which set out a variety of actions to support the co-ordinated development of symptomatic services and planning for a national screening programme. It is expected that the bowel cancer framework group will meet for the first time early in 2005.

Cancer waiting times

There are three national waiting times targets for cancer:

• by October 2001, the maximum wait from urgent referral to treatment for children's cancers and acute leukaemia will be one month
• by October 2001, women who have breast cancer and are referred for urgent treatment will begin that treatment within one month of diagnosis, where clinically appropriate
• by 2005, the maximum wait from urgent referral to treatment for all cancers will be two months.

Cancer in Scotland: Action for Change, confirmed that the children's cancers and leukaemia one month target was already being achieved (2001).

As far as the 2001 breast cancer target is concerned, the latest report (end September 2004) confirms that, where clinically appropriate, 80% of women are treated within the target time.

NHS Boards and regional cancer networks are reassessing their services to identify actions required to meet the 2005 target of a maximum two month wait from urgent referral to treatment for all cancers. To share challenges and solutions, a national workshop was held in November when a common understanding of the issues and actions required was clear. The support provided by the Scottish Executive's Cancer Service Improvement Programme is pivotal to streamlining care pathways.

Radiotherapy equipment planning

This exercise to identify the possible needs for radiotherapy and related equipment over the next 10 years is looking at:

• projected patterns of cancer incidence
• likely utilisation of radiotherapy
• patient access
• technical and clinical developments
• workforce.

The final report is expected to be submitted by February 2005.

Cancer networks development programme

Workshops for colorectal, urological and skin cancers attracted a wide range of staff from primary, secondary and tertiary care. Programmes focus on treatment protocols, audit, redesign, waiting times, patient information and patient involvement. Further workshops are planned for haematological, upper gastrointestinal, head and neck, breast and colorectal cancers.

Workshops were also held focusing on radiotherapy provision, lung chemotherapy modelling, patients' contributions to service improvements and Information Management and Technology (IM&T).

Mental Health

Scotland's mental health continues to be a priority for the Scottish Executive, in terms of improving services for people who are mentally ill and improving the mental health and well-being of individuals, families, communities, schools and workplaces.

The Mental Health (Care and Treatment) (Scotland) Act 2003 sets out some fundamental principles around ensuring access to services and support that help with employment, education, training and participation and access to arts, cultural and sporting activities. The Act is due to be implemented in 2005.

Efforts continue to break down the stigma and discrimination that still exist around mental illness. The anti-stigma campaign See Me... continues to help challenge and eliminate stigma all over Scotland. This is important for helping to create aware, informed and accepting communities, where local mental health care services are accepted as part of everyday life.

Progress continues in the establishment of the medium-secure psychiatric services necessary to ensure the provision of the right balance of care for some of the most vulnerable and damaged citizens. Their care, treatment and ultimately their recovery will rest to a large extent on the attitudes and behaviours of society.

Progress is also being made in primary care mental health. More than 30% of primary care consultations are for a mental health issue and over 80% of people's mental healthcare is delivered in primary care. With the introduction of Community Health Partnerships in 2005, there will be more evidence of primary care playing a greater part in mental health including promotion of good health, prevention of ill health, care and treatment.

This will be helped by the increasing emphasis on what communities, families and individuals can do as partners in care and support for people with mental illness. The Centre for Change and Innovation's programme Doing Well By People With Depression is an example of what can be done with guided self-help and improving access to a wider range of services and options that exist to complement medication.

The Scottish Executive hosted the first Four Nations debate on Public Mental Health in Edinburgh in October 2004, attended by over 120 of the leading UK experts in the field of public mental health, to discuss and plan for the future. The event underlined the importance of mental health being part of the mainstream work in other major public policy areas, in particular employment, education, community regeneration, housing and health inequalities.

It is important that policy development is informed by reliable, up to date research evidence. In SEHD, programmes of social research currently support the National Programme for Improving Mental Health and Well-Being and mental health law reform. Researchers also provide research advice and support across the broader mental health policy agenda.

Highlights of the past year include:

• the commissioning of a major two-year evaluation of the first phase of Choose Life, the national strategy and action plan to prevent suicide in Scotland
• publication of a scoping study for a series of reviews that will co-ordinate the evidence base on suicide-related behaviour. Experts in the field of suicide-related research contributed to the study and recommendations were considered by a wide range of stakeholder groups
• publication of the second national Scottish survey of public attitudes to mental health, mental well-being and mental health problems. Findings indicate positive changes (since the first survey was carried out in 2002) in people's attitudes to those who experience mental health problems, particularly in relation to perceived dangerousness and issues of public protection
• the launch of an annual competition, designed to provide a flexible source of funding for small projects able to demonstrate a contribution to advancing the agenda of the National Programme in any of its main aims
• publication of a report of the analysis of responses to a major consultation process on the planned mental health law research programme.

Diabetes mellitus

The national diabetes strategy, the Scottish Diabetes Framework, and the national steering committee, the Scottish Diabetes Group, have helped to maintain the high profile of diabetes in Scotland and to direct and support action nationally and locally. Significant progress has been made during the year particularly in the establishment of Diabetes Managed Clinical Networks in all NHS Board areas, the extension of the SCI-DC clinical management system to almost 50% of the population of Scotland and the delivery of an improved system of screening for diabetic retinopathy.

Systematic review of services

In March 2004 NHS Quality Improvement Scotland published the findings of peer review visits which assessed the performance of diabetes services against the published standards. The NHS QIS National Overview Report concluded that: 'The care of people with diabetes in Scotland is generally of a very high quality'. However, NHS QIS also identified some issues requiring action, such as increasing the use of effective IT to enhance clinical care and to support service delivery and improving the co-ordination of care. Advances have been made in addressing these deficiencies.

Detection of diabetic retinopathy

Since the publication in July 2003 of HDL(2003)33 and the report Diabetic Retinopathy Screening Services in Scotland: Recommendation for Implementation, work has continued to provide diabetic retinopathy screening to all people with diabetes by March 2006. Digital images of the retina allow changes inside the back of the eye to be monitored and treated. Clinical standards for diabetic retinopathy screening were published by NHS QIS in March 2004. The retinal photograph in Figure 4.5 is abnormal and shows diabetic retinopathy encroaching on the macula.

Figure 4.5: Diabetic retinopathy.

Tackling the increase in type 2 diabetes

The most recent Scottish Diabetes Survey, which was undertaken in 2003 and published in 2004, estimated that over 161,000 people had been diagnosed as having diabetes, with over 80% likely to have type 2 diabetes. It has been estimated that at least half the cases of type 2 diabetes could be prevented if weight gain in adults could be avoided. Lifestyle changes, including eating a healthy diet and being physically active, are effective in delaying and, in many cases, preventing the onset of type 2 diabetes and in reducing the risk of developing complications in people with diabetes.

Patient focus

The work of the Patient Focus Implementation Group, led by people with diabetes, is developing information and educational resources for the benefit of people with diabetes across Scotland.

Figure 4.6: Blood glucose monitoring is an integral part of self-care for many patients with diabetes.

Diabetes in ethnic minorities

The three largest minority ethnic communities in Scotland (Pakistani, Indian and Chinese) are at significantly higher risk of developing type 2 diabetes than the majority white population. A report on the epidemiology of diabetes amongst black minority and ethnic groups in Scotland was published in April 2004 by the National Resource Centre for Ethnic Minority Health. A new subgroup has been established by the Scottish Diabetes Group to ensure that the recommendations of this report are put into effect.

Diabetes in Scotland: current challenges and future opportunities

The Scottish Diabetes Framework was launched in 2002 as the start of a 10-year programme to improve diabetes services in Scotland. Although significant progress has been made over
the last two years, there is still much to do. The review of the Framework presents an opportunity to take stock of progress, to clarify future directions and to maintain the momentum.
A consultation document to support the review was launched in November 2004.

Nursing, Midwifery and Allied Health Professions

Framework for Nursing in Schools

Work started in 2004 on developing a consistent framework for school health profiling and school health plans. The work, led by NHS Health Scotland in partnership with the Health Promoting Schools Unit, will result in a consistent national approach to gathering and collating information on the health needs of schools. Profiles will be used to inform school health plans, agreed by each school. Colleagues in both education and health are supporting the development, which should ultimately link into the performance improvement mechanisms for both NHS and schools.

Framework for Nursing in General Practice

The Scottish Framework for Nursing in General Practice was launched by the Minister for Health and Community Care in September 2004. The framework seeks to support the development of nursing alongside the implementation of the new General Medical Services contract supporting greater diversity of roles and delegation of duties to other team members. Workshops to be held with each prospective CHP early in 2005 will provide an opportunity to discuss the framework, agree local actions and consider the need for a national practice nursing network to support the ongoing development of the discipline.

Family Health Nurse Project

Scotland continues to lead the work on the WHO Europe Multi-National Family Health Nurse (FHN) project. The project has now been extended to include the testing of the model in the urban setting of NHS Greater Glasgow. Involvement in the study demonstrates commitment to supporting, in particular, countries from Central and Eastern Europe at a policy, education and practice level.

Scottish Multiprofessional Maternity Development Programme

The Scottish Multiprofessional Maternity Development Group (SMMDG) and its programme of educational activity are examples of clinically focused, multiprofessional working and education. The Group, supported by SEHD, takes responsibility for strategic decisions and the quality aspects of the programme and decides on the development of new courses. Courses becoming available across Scotland include Neonatal Resuscitation, Routine Examination of the Newborn and the Generic Instructor Training Course. The Scottish Normal Labour and Birth Course is about to be piloted and is due to begin in 2005. The curriculum for the Scottish Core Obstetric Teaching Training in Emergencies has been developed and the package will be submitted to
NES for validation. Information about these courses is available on the dedicated website www.scottishmaternity.org

Facing the Future

Facing the Future continues to address recruitment and retention issues in nursing and midwifery. The second Facing the Future Convention was held in September 2004 focusing on the successes and the need to concentrate on retaining staff. At that convention, A Framework for New Nursing Roles was issued for consultation. It provides clear guidelines on how new and existing roles should be developed. This is especially pertinent with all the current service modernisation and redesign work in NHSScotland.

Research and Development in Nursing, Midwifery and Allied Health Professions

In 2004 the Minister for Health and Community Care launched an £8m research capacity and capability scheme for nursing, midwifery and allied health professions. While there is growing recognition of the contribution that nurses, midwives and allied health professionals make to healthcare research, concerns remain about the relative lack of knowledge and experience to lead and implement research relevant to the needs of these professions and their patients. The objective of this funding is to create a new culture which will embed research within practice so that all people in Scotland can be assured that their care is based on high quality research evidence.

Nurse/Midwife Consultants

The development of strategic clinical leadership and the consultant role are not exclusively related to nursing: they apply just as appropriately to allied health professions and other groups. The initiative is about identifying the most appropriate leader from the patient's perspective. Developing nurse/midwife consultant roles presents an opportunity to:

• look afresh at service provision
• challenge traditional practice, attitudes, and culture
• develop new approaches to the delivery of care
• strengthen the clinical nursing and midwifery voice in strategic planning of services
• influence health and healthcare within clinical areas.

Nurse prescribing

There are currently 600 trained, extended, and supplementary nurse prescribers in Scotland. Nurses working in partnership with medical staff and others as independent and supplementary prescribers have enhanced patient care and improved access to treatment, particularly in minor injury and minor ailment services, health promotion activities and palliative care.

Allied Health Professions

Several initiatives have been taken forward under the AHP strategy Building on Success: Future Directions for the Allied Health Professions in Scotland, including the establishment of eight specialist practitioner posts in health priority areas. The first AHP Consultant in Scotland, a Consultant Dietician in public health nutrition in NHS Tayside, was appointed in 2004. The development of AHP Consultant posts is intended to provide better outcomes for patients and there is a commitment to the development of more AHP consultant posts across a range of professions and care groups.

The partnership approach adopted in extending research capacity and capability in nursing, midwifery and allied health professions has led to joint working in developing the research base in promoting excellence in healthcare. An AHP Action Plan for research and development was launched in May 2004.

The first national consultation on role development of AHPs was carried out in 2004 and a framework for this has been agreed with nursing and midwifery. This piece of work will continue to support the redesign of services and roles within healthcare teams. It will enable patients to have more direct access to services, for example, in NHS Greater Glasgow to physiotherapy and podiatry services, and to benefit from new roles in radiography that support sustainable services.

Quality and Safety

Improving patient safety

Improving patient safety is a priority for NHSScotland. NHS Quality Improvement Scotland is involved in a number of initiatives that are helping to ensure that services provide safe, high quality care.

The main areas of work are to:

• improve the understanding and management of risk
• identify better ways of working
• introduce more standardised and safer systems
• spread good practice throughout NHSScotland.

An action plan makes specific recommendations on how this can be achieved. It is based on the effective use of robust risk management systems to assess and manage potential problems and the promotion of a strong safety culture throughout NHSScotland. This will contribute to continuous improvement across the service that will improve standards of care for patients.

The potential risks for patients are higher in some areas of healthcare than others. Four priority areas that have been identified for attention by NHS QIS are healthcare associated infection (HAI), blood transfusion, the prescription and administration of medications, and surgery. It has produced national standards for the control of HAI and is reviewing the performance of services against these standards. A report has been drawn up on the safe, effective and efficient use of blood products and another group is exploring how better use can be made of existing data on surgical performance. Audit Scotland are currently reviewing arrangements in place for the prescribing and administration of medications and NHS QIS will review their recommendations and consider how to contribute to this important area.

NHS QIS is closely involved in monitoring healthcare governance standards across Scotland. Healthcare governance is the mechanism for assuring that people receive the highest quality
of care possible. Services that fail to achieve high standards may pose a potentially greater risk to patients.

Improving the quality of care

NHS QIS was established in 2003 to work with staff, patients and the public in Scotland to improve the outcomes and experiences of patients. In 2004, NHS QIS produced reports on a wide range of topics including:

• ultrasound screening for pregnant women
• the acute care of older people
• action to improve diabetic care
• a review of specialist palliative care services
• a review of the care of people with schizophrenia
• a follow-up report on healthcare associated infection.

Standards have been finalised on learning disabilities, stroke services, diabetic retinopathy screening and out-of-hours primary medical services. During the year draft standards on healthcare governance (bringing together the components of safe, effective and patient-focused care) were issued for consultation. While these are being finalised, an interim review of clinical governance and risk management is being undertaken.

Improvements are already being made across NHSScotland as a result of the work of NHS QIS. For example, a review of the treatment of patients who had a heart attack found that not all hospitals in Scotland met an important standard about giving thrombolytic ('clot-busting') drugs promptly. Since then, all hospitals have reviewed their services and now meet the target. The national screening programme which is being introduced across Scotland to detect diabetic retinopathy followed a health technology assessment on how such a programme could be organised.

Other examples of how NHS QIS helps to raise standards in NHSScotland are contained its report Improving Patient Care: A Strategic Framework, published in April 2004. It sets out the organisation's aims for the next few years and how it intends to achieve them and has been used to guide the development of NHS QIS's first corporate and business plans. NHS QIS aims to ensure that continuous quality improvement is at the heart of the NHS. It wants patients and carers involved in decisions about their own care and NHS staff empowered and enabled to bring about the improvements that are required.

Community Health Partnerships

The NHS Reform (Scotland) Act 2004 came into effect in June 2004. It provided the legislative basis for the establishment of Community Health Partnerships (CHPs) which will be vital for the modernisation and redesign of NHSScotland and of joint services with Local Authorities. Statutory guidance was issued in October 2004 to inform CHP schemes of establishment which must be approved by the Scottish Ministers before being established across Scotland by April 2005.

CHPs provide a unique opportunity for professionals and staff to work in new ways with local people to design primary and community-based services to fit local needs. Working in partnership with statutory bodies and the voluntary sector, they will have a central and enhanced role in strategic service planning, working as part of decentralised but integrated health and social care systems. In particular, CHPs will seek to:

• close the health gap
• reduce health inequalities within and across local communities
• improve the quality of local health and social care services
• deliver specific service improvements, particularly in the management of chronic diseases.

CHPs are being created to improve outcomes for local people - patients, carers and service users - because practitioners and staff will have devolved responsibility and resources to deliver a wide range of services. Working jointly, all professionals (particularly community clinicians and those providing acute or specialist care) and their partners should be in a position to:

• reduce waiting times for assessment, diagnosis, treatment and care in a systematic way across a range of services
• provide a wider range of services in community settings, including appropriate alternatives to hospital admission such as rapid response services and integrated out of hours arrangements
• manage waiting times for inpatient and outpatient services more effectively by using their understanding of local demand to influence and adjust the supply and/or design of services
• decrease the number of inappropriate hospital visits by improving the quality of referrals to consultants and increasing the skills of community practitioners
• increase the number of single points of access for all community-based services
• reduce the number of people admitted to hospital as an emergency by improving the level and quality of chronic disease management and increasing community-based support (e.g. mental health teams)
• reduce the number of delayed discharges from hospital through increased provision of rehabilitation services and rapid response services.

The Scottish Executive will continue to support the development of CHPs during 2005. In particular, NHS Boards will be expected to implement their local Development Plans for CHPs to ensure there is sufficient workforce capacity and capability working in community-based services and that there is leadership and management support for their staff.

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