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THE NATURE OF THE CHALLENGE

Three factors in particular - and our response to them - will determine the shape of health care in Scotland for the next 15-20 years.

Population change and long term conditions

The next twenty years will see an ageing population, a continuing shift in the pattern of disease towards long term conditions (or chronic diseases as some people call them) and growing numbers of older people with multiple conditions and complex needs. These changes in themselves will make the current model of health care delivery unsustainable. We will no longer be able to afford a health care system which more often than not waits for a health crisis before providing care. This reactive approach often results in an unnecessary, damaging, expensive and prolonged hospital admission. We need a health care system with an emphasis on providing continuous preventative care for people with long term conditions to balance our ability to react quickly and safely to medical emergencies.

In 25 years' time, there will be more people in Scotland who are of retirement age than there will be children. The biggest growth is in the number of the 'oldest old' ( i.e. those over 80) the numbers of whom will double from around 200,000 at present to 400,000 over that time. Scotland is not alone in facing these changes and challenges. An ageing population and the growing burden of chronic disease are factors common to all advanced industrial societies.

What are the implications of this ageing population in terms of potential demands on the health care system? In general the older a person is, the more ill-health they will suffer. They will have a higher incidence of chronic disease and on average a greater number of long term conditions. However we need to bear in mind that the balance of evidence at an international, British and Scottish level is that age for age, older people have been getting healthier. So, while we can expect an increasing health care load from an ageing population it is not as straightforward as saying, for example, that a 20% increase in the number of older people means a 20% increase in the demand for health care. But there is no doubt that it increases the demands on the system.

We can demonstrate why that is the case. Figure 1 shows the cumulative distribution of use of NHS inpatient beds in Scotland. It can be seen that the 5% of patients who were the 'heaviest users' of inpatient beds in financial year 2003/4 accounted for 43% of all inpatient bed days. The 10% heaviest users accounted for 59% of inpatient bed days. 1% of patients accounted for no less than 16% of inpatient bed days.

Figure 1. Cummulative use of inpatient bed days.

Who are the heavy users of inpatient beds? Table 1 shows that they are disproportionately older people. People aged 80 and over are only 4% of the population, yet nearly half of the 1% of patients who account for most bed days are aged 80 and over and nearly 80% of the top 1% of patients are aged 65 and over.

Table 1. Age composition of bed days usage groups.

On the whole, the distribution of diagnoses among the heavy use groups is not dissimilar to the distribution of diagnoses for all inpatients. Therefore, it is not the nature of the diagnosis, disease or treatment that determines who is most often in our hospital beds. The principal determinant of being among the 'heavy usage' group of patients is age, for example someone aged 80 and over is around 40 times more likely to end up in the top 3% of hospital bed users than someone aged under 65.

We do not provide this analysis to suggest that older people are in any way responsible for putting pressure on the system. Rather, our argument is that in the absence of a sufficiently integrated and preventative health and social care system, hospitalisation is often the default response. We need to find alternatives to hospital admission for some of those frail older people. The number of multiple emergency admissions of older patients has been rising particularly rapidly over the last twenty years. In 1981 0.5% of the population aged 85 and over (242 patients) was admitted as an emergency three or more times in a single year. By 2001 this had risen to 2.6% of the population aged 85 and over (2321 patients). Identifying those patients at greatest risk, especially those suffering from more than one disease, and providing co-ordinated care based round their local general practice team would be a good start.

We predict that the traditional doctor-patient relationship will evolve over the next 20 years. Patients will be less deferential and less unquestioningly accepting of the treatment being offered to them. They will want to understand and be involved in the care which they are given. Via the internet they will have full access to a range of evidence on best-practice. For some, this level of patient involvement will be seen as a nuisance. It is the opposite. Patients and their carers will be the best resource we have for dealing with the growing burden of long term conditions. They will have the time and the motivation for becoming expert partners of NHS staff. In this context the role of health care professionals will increasingly be that of supporting and facilitating the management of long-term conditions by patients and carers.

Shifts in demography, epidemiology and attitudes tend to have their effects over a relatively long period of time. In contrast, many of the factors relating to the workforce are more immediate. They bring challenges but also opportunities for workforce development. They require well considered but quick responses - which may well have long-term implications.

Workforce issues

The NHS of the future will require a set of staff providing a different service, in different working environments and with different skills and roles. The size and the composition of the workforce is perhaps the most important determinant of the capacity of the NHS in Scotland.

A number of developments have brought workforce dynamics to the forefront of planning concerns. These challenges apply to all frontline staff, not just to doctors;

• fewer people of working age
• greater demand for flexible working patterns and part-time working to reflect the need for work-life balance
• increased demand for career breaks
• a reduction in the length of the working week in line with the European Working Time Directive ( EWTD)
• skills shortages in some areas
• difficulties with respect to recruitment and retention in remote and rural communities.

The impact of the European Working Time Directive, Modernising Medical Careers, new contractual arrangements for GPs and consultants, and the need to improve the standard of care available to patients are the main medical workforce factors placing a pressure for change on the system. Many of the pressures place limitations on the supply of medical or surgical input and when that is set alongside the potential for much increased demand, the case for change is obvious.

The scope for an effective response to these issues extends to 3 broad areas;

• rota redesign - e.g. fewer tiers of cover, introducing cross cover between specialties or designing rotas including professionals other than doctors;
• new or extended roles - nurses, allied health professionals etc;
• service redesign - new ways of delivering out of hours care, exploiting new technologies etc.

In Scotland, we need to do all three. We must be clear about this. If we are to secure our aim to deliver local services where it is safe and sustainable to do so, these changes will be required. More often, patient care will be managed and delivered by a health care professional who is not a doctor. We spoke about this concept at all of our public meetings. The overwhelming view of those who attended was that they were happy to see a trained nurse, allied health professional or other skilled health care provider so long as that person was trained and competent. The bottom line here is that local services can be made sustainable but it will require creative redesign and may not extend to the full range of emergency services available out of hours.

Work on national workforce planning (including education) is underway. It will be essential to link service planning to workforce planning at every level (local, regional and national). We need to ask some fundamental questions about the recruitment and training of medical and nursing staff in Scotland. We also need to be sure that we make the best and the most appropriate use of our staff. Given the population trends, recruitment may be more competitive in the future. If we are to successfully attract, train and retain high quality staff, then we need to offer careers in a modern, attractive environment. We also need to ensure that the roles of staff meet the changing demands of the service. If we are right about the future trends in service provision, then we will need clinical generalists working in local environments but a significant degree of specialisation in the units delivering far more complex care. We need to plan too for the particular issues faced in our rural communities. Given the time lag in training new clinical staff, we need to be planning now for these future scenarios.

Recent years have seen a range of initiatives to enhance and broaden the roles of health care professionals throughout the NHS. These developments need to be accelerated in order to deliver better service in the face of new and increasing demands and in order to make NHS careers all the more fulfilling and attractive.

Information and Communications Technology

Technology is not a panacea. However information and communication technology ( ICT) has the potential, in combination with organisational modernisation, to revolutionise the way health care is delivered. It is simply not acceptable any longer to turn a blind eye to the cancellation of operations because the medical records have been mislaid or not sent, to shrug our shoulders as patients get the same test over again because we cannot find the previous results, to bemoan the lack of decision support tools that would enable care providers to respond safely and effectively on the basis of evidence based guidelines. We need to take action now.

Many of the interactions between patients and the health service will be conducted electronically in the future. At the end of 2002, 40% of Scottish households had access to the internet and that figure is increasing rapidly. It is easy to envisage a future where patients could access officially recognised websites run by the NHS. The aim of increasing patient involvement would also be much enhanced if patients were able to access and update their individual Electronic Health Record. We might expect that within the next 10 to 15 years patients will be able to carry a credit-card sized copy of their medical record.

An Electronic Health Record will be perhaps the single most important development in ICT aimed at supporting a new model of health care delivery. Patients will increasingly have a complex mix of medical and social problems requiring input from several different services. Co-ordination of care can best be built on the basis of a comprehensive electronic patient record. If care is to become preventive and anticipatory, patients must be constantly monitored for signs of incipient crises ('kept on the radar'). Again a comprehensive real-time record is a necessary foundation for such care.

Diagnosis will be fundamentally different too. The use of advanced information and communication technologies will permit tele-diagnosis and the centralisation of complex and expensive diagnostic services. At the same time, engineering advances will lead to lower-cost imaging and other diagnostic methods that can be used in the community and in the home.

The effect of technological change in general may well be to further accelerate some of the changes we are seeing already. It should be possible to do much more monitoring, diagnosis and treatment locally (including in the home) but there will be even more complex, specialised and expensive treatments available that we will be able to provide in only a few locations in a country the size of Scotland. In any event, we are sure that we need a national information technology system for our National Health Service. We set out later in the report what we
think it should do.

The pace of change is likely to quicken and it will be important to plan for some of these changes. Integrated planning of service configuration, service design and workforce requirements will be necessary. The provision of a modern health service in Scotland will require new infrastructure (particularly information technology where the current position across the NHS in Scotland seems a long way short of best practice in other sectors), new thinking, new skills and the support structures needed to train clinical leaders. The future of healthcare will not be more of the same.

In recommending change, we need to have some degree of certainty that it will be sustainable and affordable. We believe that what we propose meets both criteria. Of course, as with any change programme, there is uncertainty and an absence of fully costed data. We are recommending new ways of delivering services and accordingly there are only limited data about cost effectiveness.

We asked Dr Andrew Walker, from Glasgow University's Centre for Biostatistics, to provide a commentary for us on the economics of our proposals. Dr Walker sounded a note of caution in suggesting that there was limited evidence of costs and benefits for changes of this magnitude and he pointed out that the studies which do exist might not generalise to other settings. He noted for example that the evidence on changes to the emergency care network was patchy.

But, on the other hand, he concludes that the shift away from acute care and towards preventative services and management of chronic diseases (which is central to our proposals), can improve the long term health of the population without additional spending, so long as the services involved are carefully selected. And he points out that chronic disease management can be cost effective but is unlikely to be cost saving.

Taken in the round, and notwithstanding the shortage of hard data, we expect the changes outlined in this report to be cost neutral for the whole NHS but that they will require more weight to be given to providing care in local communities in allocating the future increases in the health budget.

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