The Scottish Government

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01 CHAPTER ONE INTRODUCTION

Context

01 There are some big questions that need to be asked in planning the future of Scotland's health care. This document poses these questions and provides a National Framework for the NHS in Scotland to ensure the development of a world class health service for the people of Scotland. It offers a long term vision for service change with clear recommendations on all aspects of the system.

02 The success or failure of any policy, set of changes or reforms is judged against the objectives they were trying to achieve. The objectives of public services like the NHS are complex and notoriously difficult to capture.

03 Difficult decisions often need to be made about the prioritisation of objectives, and problems can arise when one set of objectives falls seriously out of line with another. In the summer of 2004, several NHS Boards decided that the balance of evidence suggested limited centralisation of hospital services would give a sustainable service in terms of medical staffing, as well as offering better health outcomes from treatment, and that this was sufficient to justify any loss of access through increased travelling time for the public. Many people in local communities did not agree with this trade-off.

04 The Health Committee of the Scottish Parliament ( HCSP, 2005) said that in this instance, the NHS failed to understand what is important to:

• the public - maintaining local facilities and services (para 135),
• patients - too narrow a view of patient care, ignoring long and difficult journeys for care that can affect welfare (para 136).

05 Many commentators have suggested that Scotland urgently needs a debate about these issues. The debate must be about a core set of values that can be used as the basis for future judgements, both nationally and locally, on the way the NHS moves forward.

06 It was in anticipation of this debate that the Minister for Health and Community Care commissioned work to develop a National Framework for Service Change. The development of the framework would provide a vehicle for change, help to define the core values, and suggest what had to be done to deliver care that would meet them.

07 The Health Minister described how he saw the National Framework supporting the reform of NHS Scotland by providing a national context. The work was to draw on a set of values underpinning the modernisation of health services:

• providing services in a consistent and equitable manner across the whole of Scotland
• ensuring that patients are at the centre of change to ensure they get the treatment they require, when and where they need it
• removing barriers from the patient's pathway of care
• working in partnership with patients, staff and other stakeholders.

08 The terms of reference also provided a set of objectives underlying the exercise. These were to:

• provide a framework for work underway or about to get underway throughout the NHS on re-configuration and redesign as a means to ensure coherence across the service
• promote opportunities for local access to services and balance local delivery with the need to have centres of excellence providing high-quality, modern, specialist care
• identify exemplars and best practice that can help shape the future of health care in Scotland
• bring together proposals for re-configuration and redesign with current thinking on redefining the roles and responsibilities of the various players,
• facilitate re-configuration through alternative means of funding and resource allocation.

09 The nature of the terms of reference helps to explain further some of the context for the work. There is a recognition in the terms of reference that while NHS Scotland has made undoubted progress over recent years, the key improvements for patients are either too slow to emerge or, in a service as large and complex as NHS Scotland, not yet sufficiently visible at national level to show that real progress has been made.

10 The absence of a clearly-articulated narrative about how the health service was delivering timely access to services (locally where possible) was proving difficult to construct. The development of a National Framework would have to make sense of a considerable body of policy initiatives and pull them together into a coherent framework. It provides an opportunity to establish clarity and a shared view of what the NHS is trying to do and what each of the players in the system needs to do to help achieve the goals.

Vision and aims

11 We are helped in seeking to establish some clarity by the Health Minister's clear message about his vision for health care in Scotland. In setting out his plans to improve patient access to care, he said that: 'Our vision for the NHS is that it should deliver safe, high-quality services that are as local as possible and as specialised as necessary' ( SEHD, 2004).

12 Our purpose in describing a National Framework for Service Change is to provide a policy context within which that vision can be developed and delivered. We are offering a set of recommendations to the Minister that will enable care of a consistently high standard to be delivered close to home, where possible. We have had the needs of the patient at the forefront of our minds, and we believe that the achievement of the best possible outcomes for the patient should drive how, when and where we deliver health services.

13 The work to develop a National Framework has a long term planning horizon. We are looking at the challenges and opportunities ahead over the next 15 to 20 years. Our aim is to prepare the health service for those changes.

14 But the National Framework is not just a piece of 'blue-sky visioning'. It is a route map that describes what needs to be done to get us from where we are to where we need to be. It provides practical guidance for NHS Boards on the future of health care in Scotland to assist them, working collaboratively, to shape that service.

15 In the report, we examine the range of factors that will influence the demands, challenges and opportunities faced by government, healthcare organisations, clinicians and patients over the next 20 years or so. We set out what our work in identifying these drivers for change and informed judgement from other sources tells us about the future planning horizon.

16 We examine the scope for doing things differently. There are new opportunities to deliver more care in local settings. We have to find ways to speed access to planned care and to ensure that if people have an unplanned or unscheduled need for care, they can get it quickly from the most appropriate source. And we look at specialisation and the evidence for it - including the relationship between volume of activity and outcomes.

17 In all of this work, we have had in mind a number of guiding principles. We want to see health care in Scotland that is better, quicker, closer and safer. That is not to say that the National Health Service ( NHS) is deficient in any of these areas. Indeed there is evidence from surveys and from patient feedback that the NHS is delivering care that is good (and sometimes excellent), accessible and safe. But what we have to recognise is that there is still variation in quality. There is always scope to improve. Carrying on doing the same will no longer meet the needs of the people of Scotland.

18 We have also put a considerable store on ensuring that future services are sustainable. In some ways, the word 'sustainability' both illuminates and obscures the debate. It is a word that is immediately understandable, yet is open to multiple interpretations and misinterpretations and, occasionally, rouses suspicions.

19 Some members of the public, or their representatives, see 'sustainablilty' as an excuse to reduce or remove services. Others see it as only about costs. That is not how we have approached it at all.

20 The dictionary definition of sustainability is to support, to prolong or to keep going. That is how we have looked at the issue. It is about recognising that services need to be maintained, supported and sustained, but also recognising that in order to be sustained, they may have to change. Our focus is on the service, on what the patient needs. It is not on the bricks and mortar.

21 Sustainability is not a uniquely Scottish issue. Healthcare systems across the world are grappling with it. In November 2002, for example, the Commission on the Future of Health Care in Canada made recommendations 'to ensure the long term sustainability of a universally accessible, publicly-funded health system' (Health Canada, 2002). As can be seen from Box 1.1, the Commission saw three essential aspects, the balance of which enabled sustainable care.

22 The Commission's definition of sustainability as a balance between the three factors seems equally appropriate in a Scottish context. We also agree with the Commission that there is no 'invisible hand' that silently and unobtrusively keeps these elements in balance. Ultimately, the question of whether and how the system is sustained comes down to choices by those involved in the system - by government, by providers, by clinicians and by patients.

23 The framework also talks about a new partnership with patients and with the public more generally. It recognises the need to get the public involved in planning health care, to get patients involved in providing health care, and to get each of us taking responsibility for ensuring that we are as healthy as we can be. The government and the clinicians can only do so much - some of the responsibility for making Scotland's health care fit for the future lies with the Scottish people.

24 In a country the size of Scotland, we have a number of advantages and opportunities. We have the opportunity to have a genuinely national health service, a service that meets the needs of all of Scotland: for example, the 20% of people who stay in rural Scotland or the 8% who will be aged 80 or more in 20 years' time. We recognise that the needs of these people are quite substantially different from the affluent young person living in the central belt, and the framework applies equally to all.

25 The Minister's vision in 'Fair to all...' reinforces the two fundamental founding principles of

the NHS. The first is that there should be equal access to treatment for all, based on clinical need and regardless of the person's ability to pay. The second is that collective funding of the NHS (through the taxation system) is the most effective way to ensure that quality care is available to all.

26 These two principles appear to remain central to the vision and were not challenged to any extent in our engagement with patients, the public and staff. In thinking through our advice to Ministers, our assumption has been that these principles remain valid today and for the foreseeable future.

27 In the report, we cover the wide range of issues referred to above. At the heart of our work is service change and improvement - services that are better, quicker, closer and safer. Change has to be sustainable, ensuring we are able to deliver the right services to meet evolving needs. It also needs to be built on a partnership with patients, taking their requirements fully on board - taking the time and effort to engage patients before decisions are taken. Finally, we are about building on the founding principles - equitable access according to need.

Are we aiming at the right targets?

28 Scotland should have a health system that we can be proud of. In many ways, that involves building on what we have got. There are many examples of excellence in the Scottish NHS. If we could make that excellence the norm and raise the standards of all to those of the best, we would be well-placed to meet the challenges of the future.

29 But in planning for the future, we should take into account what others say about the essential features of high-quality health care. What is it that characterises effective healthcare systems? There are many ideas about this, but a number of common themes emerge.

30 In the United States, the Committee on the Quality of Health Care in America proposes six aims for 21st Century healthcare systems (Box 1.2). The nature of the US system is markedly different from the NHS but it is interesting to note the degree of commonality around the aims even if the means of delivery differs.

31 We can take some comfort from the similarities in approach, and we should learn from the work already done by these high-profile, respected organisations. But having confidence about what we need to aim for is only part of the answer.

32 If the National Framework is to be a practical tool for guiding service change, it needs to be clear about what action is necessary to achieve change and what levers we can put in to ensure that the whole system pulls in the same direction.

Responding to the challenges

33 In the chapters that follow, the report sets out a plan for action at national, regional and local levels that will meet the aspirations of patients, staff and the wider communities which depend heavily on the input of the NHS.

34 The report focuses on how NHS Scotland needs to change to meet the challenges in a way that is consistent with the vision and the principles set out above and that accords with the patient expectations (see Chapter 2).

35 We are faced with a set of complex issues, and they are likely to require a range of actions. We need to ensure that the decisions we take and the direction we follow are co-ordinated and that we attend to the whole system of care - not just to the issues of waiting times for hospital procedures that seem to attract so much political and media attention, but to the whole continuum of care. Our aim is to deliver whole-system benefits.

36 The report chapters are shaped around a number of key themes.

Shifting the balance of care

This chapter is based on a recognition that the challenges of an ageing population and growth in chronic disease will require a shift from a system geared towards providing episodic care with an emphasis on acute hospitals towards preventative and continuous care delivered locally where possible. The chapter includes consideration of:

• care in local settings
• long term conditions
• care for older people.

Self-care, carers, volunteering and the voluntary sector: towards a more collaborative approach

The NHS needs to recognise and support the contribution of other partners in the wider system of health. In particular, the development of self-management of long term conditions will be increasingly important.

Tackling health inequalities

The NHS needs to take a more proactive approach to the identification and treatment of those individuals in deprived areas whom the NHS is failing to reach.

Access to the right level of unscheduled care as locally as possible

This will require matching care to need, helping patients to get quickly to the right member of the clinical team when they need it (including in an emergency) and making the best use of resources to meet those needs.

Managing access to quicker planned care

Developing new approaches to delivering planned care that will cut waiting times, including elective care and diagnostics.

Care designed to deliver best outcomes

A focus on what is best and safest for the patient, rather than on the bricks and mortar of the local hospital, and an evidence-based approach that puts patient outcomes and quality of care first. The chapter includes consideration of specialised care and volume and outcomes.

New ways of delivering rural health care

The chapter presents the case for integrated care, new roles for community hospitals, and models for the Rural General Hospital.

A Health Service fit for Children

A detailed framework for the planning and delivery of health care services for children with a particular focus on paediatric critical and intensive care. In addition the chapter includes an update on the recommendations of the Expert Group on Acute Maternity Services.

Care based on collaboration and integration

The vision is of the whole system working together to put patient needs at the centre.

e-health

This is about integration enabled through a single national IT system - the 'glue' that binds the system. It looks at delivering local care and quicker access to care through e-health strategies, linking specialists to health centres and local hospitals throughout Scotland.

37 In the chapters that follow, we explore each of these themes in turn. It is important to note, however, that we do not see any of these themes as having primacy over the others. If we are to meet the future challenges, we need to take action under all of these headings, with a view to taking a whole-system approach.

38 We begin, however, by focusing on two crucial issues that impact on the shape of NHS Scotland. These are:

• What do patients expect from services?
• Drivers for change.

In summary:

• the National Framework sets out a plan to develop health care in Scotland that is about delivering the best available care as close to the patient as is possible
• care must be delivered quickly by staff who are appropriately skilled
• the service should anticipate need where possible, rather than respond to it
• the NHS needs to be robust and adaptable
• the NHS needs to work in partnership with a range of partners, including social care providers, the voluntary sector and with patients and the general public
• the NHS needs to meet the needs of all.

References

Commission on the Future of Health Care in Canada (2002) Building on Values Ottawa:
Health Canada.

Health Committee of the Scottish Parliament (2005) Reshaping the NHS? Workforce Planning in the NHS in Scotland. The Scottish Parliament.

Scottish Executive Health Department (2004) Fair to All, Personal to Each. Edinburgh: SEHD.

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