The Scottish Government

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EXECUTIVE SUMMARY

Our key messages

The NHS in Scotland needs to change. Not because it is in crisis as some would have us believe - it is not; but because Scotland's health care needs are changing rapidly and we need to act now to ensure we are ready to meet the future challenges. There could not be a more appropriate time to undertake a review of Scotland's NHS, and plan its future.

But just as the NHS needs to change, so too do the citizens of Scotland need to take a greater responsibility for their own health and for the overall effectiveness of the health system. As we set out in this report, in an area as dynamic as health care, change is inevitable. We have an extraordinary opportunity to improve our health and our health service, but that will not be done by complacent defence of the status quo. The NHS in Scotland and the public must work hand in hand if we are to deliver a health service that is fit for the future.

In developing this National Framework for Service Change, we provide a policy context as well as a plan of action. We make a number of detailed recommendations in the Report and these are underpinned by the following key messages. In planning the future of the NHS in Scotland we need to;

• ensure sustainable and safe local services; redesign where possible to meet local needs and expectations - specialise where required having regard to clinical benefit and to access.
• view the NHS as a service delivered predominantly in local communities rather than in hospitals; 90% of health care is delivered in primary care but we still focus the bulk of our attention on the other 10% - our current emphasis on hospitals does not provide the care that people are likely to need.
• preventative, anticipatory care rather than reactive management; the NHS should work with other public services and with patients and carers to provide continuous, anticipatory care to ensure that, as far as possible, health care crises are prevented from happening.
• galvanise the whole system; more fully integrate the NHS (including the contribution of hospitals, general practice teams, social care providers, patients and their carers) to meet the challenges.
• become a modern NHS; using new technology to improve the standard and the speed of care, connect clinicians, involve patients in their own care and support the research vital to future wellbeing.
• develop new skills to support local services; generalists as well as specialists, nurses and allied health professionals as well as doctors - all with the right skills for patients.
• develop options for change WITH people, not FOR them, starting from the patient experience and engaging the public early on to develop solutions rather than have them respond to pre-determined plans conceived by the professionals.

Our proposals

Our report is wide in scope and contains a large number of proposals that we are asking the Minister for Health to consider. Some of these build on initiatives already underway, some are based on international best practice and some are entirely new innovations. The top ten are as follows:

• All NHS Boards to put in place a systematic approach to caring for the most vulnerable (especially older people) with long term conditions with a view to managing their conditions at home or in the community and reducing the chance of hospitalisation.
• Targeted action in deprived areas to reach out with anticipatory care to prevent future ill-health and help reduce health inequality.
• Support for patients and their carers to manage their own health care needs and to help others with similar conditions.
• Implement urgently a national information and communications technology ( ICT) system, including an electronic patient record and the development of tele-medicine, as a means to improve access, quality, research and integration of the NHS.
• Empower multi-disciplinary teams in community casualty departments to provide the vast majority of hospital-based unscheduled care - networked by tele-medicine to consultant led emergency units.
• Shorten waiting times and inform patient choice by separating planned care from urgent cases, treating day surgery as the norm (rather than inpatient surgery), enabling better community based access to diagnostics, developing referral management services and introducing a delivery function that will draw on best practice across the world to further speed up patient access to services.
• Concentrate specialised or complex care on fewer sites to secure clinical benefit or manage clinical risk.
• Develop networks of rural hospitals to support our remote communities and establish a Clinical School for Rural Health Care to ensure workforce development.
• A step change in the development of regional planning to ensure that Health Boards make regionally based decisions about the shape of hospital based health services.
• Set a clear agenda for Community Health Partnerships to work across barriers between primary and secondary care and engage with partners in social care to shift the balance of care.

The nature of the challenge

"The most important policy issue facing European Governments over the next 50 years is how to cope with ageing populations...For Scotland the future is now... its population is ageing faster and dying quicker than any other industrialised nation"

The Scottish Report - Scotland the Grave? (2003)

The ageing of Scotland's population is a particular challenge for health care. In the next 25 years or so, the proportion of the population over 65 will increase to over one in four. One in twelve of us will be over 80. Older people are more likely to have a long term illness, more likely to have a combination of such illnesses, more likely to be admitted to hospital and more likely to stay there following admission.

We also expect an increased incidence and burden of long term conditions (chronic diseases such as diabetes, arthritis, rheumatism, high blood pressure etc) - and we know that patients with long term conditions are twice as likely to be admitted to hospital.

A major locus of pressure on the NHS over the last twenty years (and potentially into the future, unless we address the issue) has been the rise in emergency hospital admission. The increasing burden of ill-health associated with an ageing population only explains a proportion of this increase in emergency admissions. Perhaps the most fundamental strand of explanation for the rise in emergency admissions lies in the mismatch between the needs of the population for proactive, integrated and preventive care for chronic conditions and a healthcare system where the balance of resources is aimed at specialised, episodic care for acute conditions.

This suggests that there are a number of future challenges and pressures on the system that require an increased focus on the delivery of proactive, locally responsive care.

In responding to the challenge, we have been guided by a number of factors;

(a) Patient expectation and public trust

Patients and the general public told us at our open meetings that they wanted services delivered locally wherever possible; they were willing to travel for highly specialised surgery but wanted as many "core" services as possible close to home. They have lost a certain amount of confidence in the NHS due to what they perceive as unnecessary "creeping" centralisation driven by what is convenient rather than what patients need. Patients want access as quickly as possible to consistently high quality services delivered by a suitably trained professional, whilst realising that we could not provide a hospital at the end of every street.

(b) Rural issues

One fifth of the Scottish population lives in a rural area. Rural communities face particular challenges in terms of transport, access to services and the sustainability of local communities. We need to recognise those differences and describe models of care to meet rural needs.

(c) Inequalities

Although the health of Scots is improving, the differences within Scotland in life expectancy and mortality are significant and widening. In a deprived area, you are more than twice as likely to have a long term illness than if you live in an affluent area and it has been calculated that the deprived lose fifteen years of life compared to the affluent.

(d) Standards

The public should feel that national standards can ensure local excellence. The Scottish Executive needs to take a lead role in building the evidence base for change monitoring practice and intervening if services are seen to be failing.

(e) Staffing issues

The size and composition of the workforce is a key determinant of the capacity of NHS Scotland. The workforce is increasing. And while we must all welcome the much needed reduction in working hours, at the same time, the impact on doctors' hours is substantial, there are recruitment and retention challenges and new contracts require different approaches to providing care "out of hours". We have an opportunity to match service change with workforce change. This will require a re-profiling of the workforce and an investment in training and education across the clinical professions. In particular, new approaches are required to staff the "hospital at night".

(f) Affordability

By 2007-08 we will be spending twice as much per head of population than we were in 1999-2000 and the total budget will be £10 billion. Whatever we do needs to be affordable within that budget and to get the best possible value for every public pound spent.

Our values

The basic ethos of the NHS in Scotland - free comprehensive care available to all - still commands universal public support. The future of our health services needs to be built from that base. Our work with the public also tells us that they are looking for health services that are better, quicker, closer and safer; health care that meets the needs of all Scotland, old and young, rich and poor, urban and rural. They are looking for health care that is local wherever possible, specialised where it has to be but delivered to national standards, providing a level of certainty about what people can expect. That suggests to us a set of values to underpin our work as follows:

Fair to all

Equity of access, based on clinical need, to services of the right quality

Personal to each of us

Care designed for each individual, ensuring the patient is at the heart of what we do.

A new way of delivering care

We believe that to meet the challenges and to deliver on the key requirements described above will require a shift in the way we deliver health care in Scotland. This will require new ways of working, new skills, new thinking and a new culture in the NHS - one of shared responsibility and engagement of front-line staff in service improvement.

In effect, this new approach is about getting the NHS in Scotland to work as a single, whole system. We need all of the partners in the system to realise that they are inter-dependant. Action in one part of the system has an impact elsewhere. And we need the partners to understand that we all need to change. For example, in order to meet the challenges of caring for people with long term conditions we need much better integration of primary, secondary and social care. The nature of the change required is summarised in the box below.

Implementation

Of course, this will not be easy. The health system is complex and it will take time to set a new direction. We have referred already to the workforce constraints and the need for the NHS to be affordable. It will require improved leadership throughout the NHS, from clinicians and from managers, and a willingness from patients and the public to look beyond the bricks and mortar of their local hospital.

Much has been said and written about the future of the traditional District General Hospital. People want to retain local services and that is understandable. But for some of the care that we will provide in the future, it is also unambitious. When we talk about local care, particularly in our work on the care of older people and on the care of people with long term conditions, one of our key aims is to keep the patient out of hospital by providing the necessary support and treatment in or close to home.

That will not always be possible. There is a range of care that needs a critical mass of patients in order for it to be provided. We have in mind here, diagnostic testing, routine procedures including some surgery (much of which can be done as a day case), and treatments such as dialysis, chemotherapy, rehabilitation etc. Because this kind of care requires investment in equipment and expertise, we cannot deliver it in every GP surgery, but we could do some of it in a Community health centre if we could get GP practices to band together, we could do most of it in Community Hospitals and we can do potentially all of it in every District General Hospital ( DGH).

Largely as a result of the much needed reduction in doctors' hours, it has become much more difficult to deal with emergency care in all local hospitals. But, even here, there is much that can be done. It will require redesign of services, advanced roles for nurses and paramedics and GPs working in teams with other professionals to provide out of hours care. The range of hospitals that we currently badge as District General Hospitals will be able to provide, as a minimum, a twenty four hour "community casualty" service - as will a number of Community Hospitals. But in some cases it will not have consultant cover on site and if a patient is likely to require emergency surgical or medical interventions, they may be transferred (or taken immediately) to a bigger hospital - using clinical guidelines which have been written and approved by both hospitals in partnership. The sense of linkage, interdependence and networking in a key cultural challenge which needs to be met at many levels of the NHS.

For highly specialised care, we point to clear evidence of better outcomes related to higher volume. We identify a range of such complex conditions and provide the evidence (not shroud waving) that will convince the public that centralisation of certain services leads to much better outcomes.

So what does this tell us about the shape of our future NHS? What should it look like if we are to be best placed to meet the challenges? The large majority of care should be provided in the community. Much of it should be delivered in or close to home. We should extend the scope of what we currently know as primary care to include routine diagnostic tests, providing alternatives to hospitalisation ( e.g.GPs with special interests) and doing the follow up from acute care. To maximise the opportunities for this, we need to fully utilise the potential of the community hospitals, we need to import to urban Scotland the model of the Community Hospital as a local hub (perhaps by bringing together a number of GP practices on to a single site where they can share access to diagnostic and other facilities) and that will require a shift in resources to achieve a shift in the balance of care.

By shifting care from the traditional District General Hospital to multi-disciplinary, community based teams, we have the opportunity to use the DGH in a number of different ways. Some will focus on planned surgery to enable quicker access to care. These units may have "community casualty departments" attached but they will not admit patients who need emergency surgery. Other DGHs will continue to do both planned and emergency work but they will stream these procedures as far as possible. This will mean that, over time, the shape of our hospital provision will change. We cannot staff every hospital to do everything and the evidence shows that there is a massive downturn in activity during the night that can be safely dealt with by local nurse led teams, transfer of high risk patients to designated partner hospitals and networked emergency centres. In the central belt, we are confident that the stabilisation and transfer of seriously ill patients is the optimal means to manage risk within the limit of the available resource. In rural communities, transport becomes more problematic and our Rural General Hospital model offers a variation to take account of this.

It is not the function of a National Framework to say precisely what every DGH in Scotland should do. Our aim has been to make the decision making process more evidence based, transparent and therefore easier to make Boards more accountable to Government and the public alike.

One of the key messages for us in doing this work has been that we need to invest in the whole system. A good example is delayed discharges. We know that a number of patients stay in an NHS bed longer than they have to because there has been a delay in providing them with the support they need when they return to the community. What is less well known is that the vast majority of delayed discharges are from patients admitted on an emergency basis. If we prevent the admission, we could resolve the delayed discharge. We need to treat the cause of the problem rather than the symptom.

The keys to whole system improvement are as follows;

• a clearer understanding of what we are trying to achieve (summarised in the key messages set out earlier in the Report);
• integrated, collaborative and co-ordinated working by the NHS and its partners across the professions, across the traditional boundaries and across Scotland - Regional Planning Groups, Community Health Partnerships and Managed Clinical Networks will have a key
  role here;
• excellent management to ensure performance is aligned with the vision and that the NHS rewards those contributing to the whole system;
• resource flows that channel additional investment to support service change;
• an empowered workforce able to lead the clinical change necessary to make this work.

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