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03 CHAPTER THREE DRIVERS for CHANGE

01 This chapter examines the key factors driving change in Scotland's health care system. Much of the information is already in the public domain, but in this analysis, we attempt to examine the inter-dependency of the various drivers and seek to provide some clarity about what they mean for the future shape of the health service in Scotland. A full 'Drivers for Change' report is available on the National Framework website: www.show.scot.nhs.uk/sehd/nationalframework

02 The position is complex. Not all of the factors driving change point in the same direction. But the implications are obvious:

• change is inevitable
• given the complexity of the drivers, planning for change is essential
• 'more of the same' is not the solution - to meet the challenge of the drivers will require new ways of working, involving the whole healthcare system in the change process.

03 Healthcare service change needs to be part of a wider reform agenda. We start from a position where the health of Scotland's people compares unfavourably with most of Western Europe. That will require a continued focus on health improvement and on narrowing health inequalities. Changes in health care will have to be accompanied by complementary improvement in social care. Workforce redesign will be vital to secure service change. The inter-dependencies are considerable. But the focus of this work is on the changing healthcare environment. What are the factors that will impact on how we deliver care in Scotland, and what do those factors tell us about our future change agenda?

The changing population

04 Scotland is faced with a declining population and an ageing population. The population is projected to decline at an accelerating rate over the next forty years, from a current total of 5.05 million to around 4.5 million in 2042. While the existence and extent of the decline in Scotland's population is unusual, the ageing of Scotland's population is not. All industrial nations are experiencing an ageing of the population as a result of declining fertility and increasing life expectancy. It is the interaction between the ageing of the population and the overall decline that sets Scotland apart.

05 The long term shifts in Scotland's age structure can be seen in the age pyramids for 1911, 1951, 2001 and 2031, shown in Figure 3.1. What is most striking about the figures for 2031 is that the age groups 60 to 64 and 65 to 69 will be the largest five-year age groups in the population with, broadly speaking, younger age groups getting progressively smaller.

06 Most significant, perhaps, in terms of implications for health care is the growing population share of the older age groups, especially the oldest old. In 1911, 0.6% of the population was aged 80 and over; in 1951, the figure was 1.3%; in 2001, it was 3.8%; and by 2031, 8.2% of the population will be aged 80 and over.

Figure 3.1
Scotland's changing population structure

07 The pattern of demographic change is not consistent across Scotland. Lothian NHS Board area has by far the biggest projected growth in population through to 2018 (7%). The areas with the biggest projected falls are Orkney (10%) and the Western Isles (17%). Rural areas such as Dumfries and Galloway will show particularly marked shifts in the age structure of the population with growth in the number of older people and greater than average reductions in the number of younger adults.

08 What are the implications of this ageing population in terms of the burden of ill health and demands on the healthcare system? In general, the older a person is, the more likely he or she is to suffer ill health. He or she is also likely to have a higher incidence of chronic disease and, on average, a greater number of long term conditions.

09 We need to bear in mind, however, that the balance of evidence at international, UK and Scottish level is that age for age, older people have been getting healthier. So, while we can expect an increasing burden on health care from an ageing population, it is not as straightforward as assuming that a 20% increase in the number of older people means a 20% increase in the demand for health care.

10 A recent study exploited the fact that most healthcare expenditure takes place in the years immediately preceding death to forecast likely future increases in healthcare expenditure associated with an ageing population. It shows it is likely to increase at around half the rate which would be expected if age-specific rates of expenditure were to remain constant (Seshamani, 2004).

11 The ageing population will mean growing numbers of older people who are experiencing ill health with greater or lesser levels of dependency, but will also mean much higher numbers of healthy older people in the population. This increases not only the numbers of potentially dependent people, but also the numbers of older potential carers or care workers. The challenge will be to mobilise them in ways which will benefit the carers and the cared for.

The changing social context

12 The formal healthcare system is not the only provider of health care. The extent to which the growth in numbers of older people results in an increase in demands on the NHS will depend upon the living circumstances of older people and the availability of, for example, unpaid care provided by family members, friends and other members of the community.

13 The last half century has seen a major decline in older people living in the same household as their adult children or in other more complex types of household. The vast majority of older people now live alone or with only their partners.

14 There has been a particularly rapid rise in the number of older people living alone over the last ten years or so. Between 1991 and 2001, the numbers of people aged 85 and over who lived alone increased from 30,000 to 44,000 ( ISD Scotland, 2003) - a trend which is likely to continue.

15 The available evidence indicates strongly that the level of provision of unpaid care is, at best, not increasing. It is certainly not keeping pace with the growing need for care of an ageing population. There is evidence of an 'intensification' of unpaid care towards greater input by close family members (particularly partners) (Hirst, 2001; Pickard, 2002). The system of unpaid care is fragile and needs support if its breakdown is not to result in even greater demands on the NHS.

16 Many of the care needs of frail older people are social, rather than medical. As will be seen below in the context of rising emergency admissions, the lack of integrated and preventive care can lead to a crisis for an older person that results in an emergency inpatient admission. Our response to such issues requires a 'whole-system' approach involving clinical input by a range of skilled people, excellent links with social care, and greater patient involvement.

17 In the light of these demographic and social trends, it is clear that we need to find new and better ways of delivering health care. 'More of the same' will not be sustainable.

Patterns of ill-health

18 Scotland's changing pattern of mortality and disease over the last two centuries is broadly similar to that of other industrial nations. Scotland has experienced its own version of what is commonly called the 'epidemiological transition'.

19 The late 19th Century and the first half of the 20th Century saw a pattern of disease associated with rapid industrialisation and urbanisation, with high levels of childhood mortality and a high prevalence of infectious disease. As these scourges were conquered in the first half of the 20th Century, and as the population has become older, the major burden of ill health facing the health service is increasingly that of chronic disease. Again, this reflects a global pattern.

20 Scotland's pattern of ill-health and mortality does have its own distinct features, however. Scotland tends to lie at the bottom end of European league tables of mortality and morbidity. Recent estimates of comparative life expectancy at birth put Scotland at (women) or close to (men) the bottom of the list of Western European countries. This is a recent phenomenon. In 1950, Scotland was in the top half of seventeen European countries in terms of mortality.

21 Mortality rates among children and young people in Scotland are around the European norm. Only by the time they reach their thirties and forties do Scottish adults start to show higher mortality rates.

22 But Scotland's health isn't poor in all respects. Scotland has the worst death rates in Europe for cardiovascular diseases and lung cancer, but performs relatively well in terms of external causes of death such as injuries and violence (such as road accidents), Scotland's infant mortality is around the European average.

23 Why is Scotland's health in general so poor - and why, in particular, does Scotland have higher levels of mortality than the rest of the United Kingdom? Part - but not all - of the answer lies in Scotland's higher levels of deprivation. Recent analysis showed that in 1991 around 40% of Scotland's excess mortality was accounted for by deprivation ( PHIS/ ISD Scotland, 2001).

24 Apart from the role of deprivation, it has proved difficult to explain Scotland's poor relative health. Factors such as smoking, alcohol abuse and diet may all play a part. These may be among the surface symptoms of a deeper set of causes related to the decline of Scotland's heavy industrial base.

'Historically, acute and immediately life-threatening problems were the principal concern for healthcare systems. Advances in biomedical science and public health measures over the past century have changed this dramatically. However, most healthcare systems have not kept pace with the decline in acute health problems and the increase in chronic conditions. Although there are notable exceptions, such as experiences with community-oriented primary care, most health care today is still trying to manage chronic problems using acute care mentality, methods and systems.'
(Epping-Jordan et al., 2003).

25 It has been suggested that until 1950, the major focus of health care was infectious disease. During the second half of the 20th Century, health services were oriented towards the provision of episodic care for acute conditions. In the 21st Century, chronic disease will be the major challenge for health care (Anderson, 2004).

26 If we accept the broad terms of this analysis, our NHS was introduced at the tail end of the era in which the main challenge was infectious disease and has largely been geared to dealing with acute conditions on an episodic basis.

27 The most direct evidence of the prevalence of long-term conditions in Scotland comes from the Scottish Health Survey. Even for age groups 45 to 54, 'early middle age', 45% of the population reported at least one long-standing illness. In the age group 65 to 74, 62% reported at least one long-standing illness (Figure 3.2). 29% of those aged 65 to 74 reported more than one long-term condition, while international evidence suggests that older age groups will have an even higher prevalence of multiple chronic conditions.

28 People with chronic illnesses generate substantial demands on health services. It has been estimated that 75% of all US healthcare expenditures are related to the treatment of chronic conditions (Hoffman et al., 1995). In the UK, patients with a chronic condition account for 80% of all GP consultations and are twice as likely to be admitted to hospital and experience longer stays when they are admitted (Department of Health, 2004).

29 In Scotland, ISD Scotland Practice Team Information shows that even using a relatively narrow definition of chronic disease, 57% of 65 to 74 year olds had a primary care contact for at least one condition and 18% were seeing the primary care team for two or more. In the 75 to 84 age group, 61% had a contact for at least one condition and 22% for two or more.

Figure 3.2
Number of longstanding illnesses by age. Both Sexes. Scottish Health Survey 1998

30 The incidence of certain conditions will increase largely as a reflection of the ageing population. For example, unless there are major advances in prevention, there will be a doubling in the number of people with dementia in the next forty years and a trebling in the number of people aged 85 and over with dementia.

31NHS Scotland is only beginning to come to terms with the implications of these major shifts in the pattern of ill-health. It will need a paradigm shift in the way services are delivered to deal with the growing dominance of long-term conditions.

The health service response: patterns of patient activity

32 Trends in patient activity reflect the numbers of patients treated by the health service and changes in the way they are treated - for example, the move from inpatient to day-case settings for many types of surgical procedure, or the increasing role of members of the practice team other than the GP in primary care.

33 These trends are not in themselves sources of pressure or independent drivers of change in the NHS. Long-term trends in patient activity can, however, help us understand how the service has responded to changing patterns of demand in the past and may continue to respond in the future if the model of service delivery does not change.

34 Trends in the emergency admission of older people are particularly important in this respect. Such admissions represent perhaps the greatest source of pressure on the NHS and help us to understand how the whole system of care has responded to the demographic and epidemiological pressures we have outlined. The entire increase in hospital beds occupied by emergency inpatients over the last 20 years has been contributed by patients aged 80 and over (Figure 3.3).

Figure 3.3
Bed days by emergency inpatients by broad age group. 1981 to 2002.

Source: ISD Scotland

35 The impact, however, is more than simply the use of beds. There is increasing concern that unnecessary days spent in hospital may have deleterious consequences for older patients. Over 85% of delayed discharges occur after emergency admission. In addition, winter bed crises, with their serious
knock-on effects throughout the system, are overwhelmingly the product of surges in the emergency admission of older people. Emergency pressures make it difficult to bring down waiting times as emergency admissions cut into the resources (beds, staff, theatre time) needed for elective care.

36 The number of multiple emergency admissions of older patients has been rising particularly rapidly over the last 20 years. In 1981, 0.5% of the population aged 85 and over (242 patients) were admitted as an emergency three or more times in a single year; by 2001, this had risen to 2.6% (2321 patients).

37 Increasing emergency admissions among older people have occurred across most types of diagnosis, but the most rapid rise has been in 'signs and symptoms' - conditions such as chest pain or 'aff yer legs', for which a definitive diagnosis has not been achieved.

38 What lies behind these trends? It might be felt that the finding of rapidly-rising numbers of emergency admissions among older people should come as no surprise, given the growing numbers of older people in the population. In fact, population change accounts for only a small proportion - perhaps a quarter - of the increase. The exact proportion depends upon the period of time and the age group considered.

39 Over the last 20 years, older people of a given age have been getting healthier, not less healthy. Only a small proportion of the rapid increase in emergency inpatient admissions in the 1980s and 1990s was attributable to a greater 'burden of ill health' in the older population.

40 The conclusion has to be that the increase in emergency admissions (and multiple emergency admissions) among older people has not primarily been a direct reflection of increased morbidity or ill health in the older population, but has in the main been a reflection of the way in which the whole system of care has tended to respond to the healthcare needs of older people.

41 The role of primary care is key. GPs are still the main gatekeepers to acute care. Around 70% of emergency inpatient admissions are the result of a GP referral. It takes only tiny changes in GP referral behaviour to have a major impact on emergency admissions.

42GPs refer approximately 1 in 50 of the patients they see. For every 1000 patients seen by a GP, therefore, 20 will be referred for emergency inpatient admission. If GPs were to refer one extra patient per 1000, this would result in an increase in inpatient referrals from 20 to 21 per 1000, or an increase of 5% in the number of referred emergency admissions.

43 As a very rough order of magnitude, a full-time GP will have around 4000 patient contacts per year, or 1000 per quarter. Each GP has only to refer one extra patient per quarter to produce a 5% rise in emergency inpatient referrals.

44 In making a decision about whether to refer a patient for emergency inpatient admission, a GP will make a rational assessment of the options for care available and make a decision in the best interests of the patient. Whether emergency inpatient referral is seen as the best option will depend crucially on the availability of resources and systems - such as integrated care teams or other forms of flexible support for patients at home - which could provide alternatives to inpatient admission. It is also affected by the extent to which the GP sees these systems as safe, accessible and credible.

45 Despite the availability of these services, emergency inpatient admission will often be seen as the simplest and most effective way of ensuring a patient gets immediate and appropriate attention. The hospital is the one part of the system which hardly ever says 'No'.

46 Some of the dominant patterns of change in primary care over the last 20 years may have worked to push up the referral rate. These would include a shift away from personal continuity of care (larger practices and out-of-hours services, for instance), an increase in defensive medicine and an increase in other demands on GPs. But even if none of these changes were occurring, the overall increase in the demand for care directed at a primary care system, which is often under pressure and working close to capacity, may itself produce higher referral rates and, consequently, a disproportionate increase in emergency admissions. Such considerations may be particularly applicable to frail older people ( ISD Scotland, 2003).

47 But the powerful amplifiers involved here could be turned the other way. If alternatives were provided to help GPs refer fewer patients, disproportionate downward impacts on emergency admission could be produced.

48GP referral patterns are just one example of how the system can work to push up emergency admissions of older people. Other factors include a relative lack of investment in social care and more beds being made available by the shift of elective surgery from an inpatient to a day-case basis.

49 Perhaps the most fundamental explanation for the rise in emergency admissions, however, lies in the mismatch between the needs of the population for proactive, integrated and preventive care for chronic conditions, and a health care system that is still organised primarily to provide specialised, episodic care for acute conditions.

50 In this sense, Scotland's experience reflects a more general situation outlined by the World Health Organisation's chronic conditions team:

'Effective prevention and management of chronic conditions requires an evolution of health care, away from a model that is focused on acute symptoms towards a co-ordinated, comprehensive system of ongoing care. Without this type of change, healthcare systems will grow increasingly inefficient and ineffective as the prevalence of chronic conditions rises. Health care expenditure will continue to escalate but improvements in population health status will not.'
(Epping-Jordan et al., 2003).

51 Future patterns of patient activity, in particular the numbers of emergency admissions among older people, will depend on the extent to which services continue to be delivered according to the old model.

Remoteness and rurality

52 One fifth of the Scottish population lives in a rural area (Scottish Executive, 2004). Of these people, a significant number live in very remote areas that require different healthcare arrangements to cope with times of enforced self reliance due, principally, to weather and transport difficulties.

53 Healthcare arrangements for remote and rural areas are currently facing a set of distinct and complex challenges. The various drivers for change outlined elsewhere in this section (such as deprivation, demography, workforce developments and technology) will impact on rural and remote areas in ways which often differ significantly from their impact on less remote and more urbanised localities.

54 There is therefore a need for a nuanced and specific response to the healthcare issues of remote and rural areas. There must be an alternative to the dominant model of healthcare thinking in Scotland, which has been distinctly urban based.

Demography

55 Population sparsity introduces difficulties in the economic delivery of services (Deauville, 2001; Skills for Health, 2004). Low absolute numbers lead to difficulties in sustainable service provision and the retention of clinical skills.

56 Rural areas are projected to show especially strong shifts in the balance of the population towards older age groups and a decline in younger economically-active age groups. This has implications for increased demand for health care for older people and the recruitment of staff to provide care.

Deprivation

57 Deprivation in rural areas has tended to be hidden, in part because of inadequate and inappropriate definitions and measures (Barnett et al., 2001), masking unmet need (Stark et al., 2004). The healthcare effects of deprivation in remote and rural areas are amplified by problems of access and the disproportionate cost of travelling to services.

Access

58 Transport infrastructures are not always optimally configured to allow access to services for people in remote and rural Scotland. Long distances and the lack of a transport infrastructure increase the inaccessibility of services (Scottish Executive, 2004). The disproportionate cost of travel and infrequent scheduling of services make it extremely difficult for families to visit and provide support for patients in hospital. This will increase the emotional cost and physical toll of supporting relatives away from home. Longer recovery times may result.

Education and training drivers

59 Distance from major centres means that clinical staff often have to extend their skills beyond their core areas (Swan et al., 2004). The breadth of work delivered by clinical staff in remote and rural settings may make it difficult to maintain skills across a broad range of clinical areas. Inaccessibility of training programmes may lead to skills decay and increases in clinical risk and stress at work (Douglas and Laird, 2004).

Workforce drivers

60 The current service relies on the contribution of dedicated professionals, many of whom are reaching the latter stages of their working lives and have contributed long periods of on-call service in addition to their standard role. Replacing this workforce with younger healthcare professionals who are more used to working in the wider NHS in extended teams will be a major challenge. Extended teams protect them from the frequent on-call rotas and clinical diversity that is the bread and butter of remote and rural health care.

61 Compliance with developments such as the European Working Time Directive often requires larger clinical teams, but there may be insufficient workload to support larger teams in rural and remote areas. A rural environment may not be able to support the career pathways seen as desirable in the current specialist practice environment. Working in a remote or rural environment may therefore be seen as a career cul-de-sac.

Quality drivers

62 National quality improvement programmes may not be sensitive to the needs of small teams working in a rural environment. Although clinical and service outcomes are often good and patient evaluation of service provision is positive, services may not be able to satisfy the detail of process requirements.

Implications

63 The fragility of services and closeness of the public to service providers means that remote and rural areas often feel the effects of change sooner than urban areas (Skills for Health, 2004). They act as a 'litmus test' for the health service as a whole. Addressing the drivers acting in remote and rural Scotland on a whole-systems basis will be of benefit to all.

64 Many potential solutions will be the same. They will include transport arrangements, service access, professional standards and accountabilities, multidisciplinary team working and education and training structures. It is, however, unrealistic and unsustainable to expect the same configuration of care to be used throughout Scotland.

65 Developing a model (or models) that balances equitable access with sustainability is the challenge for the whole service in Scotland. Remote and rural areas are at the forefront of these developments.

Finance and performance

66 The NHS in Scotland and England has seen very rapid growth in total funding in recent years. NHS expenditure grew by 56% in both England and Scotland between 1997/98 and 2002/03, amounting to growth levels of 38% in real terms.

67 This is a continuation of a trend in per capita expenditure on health in which Scottish expenditure has largely paralleled English. Figure 3.4 shows NHS expenditure per capita for Scotland and England from 1979/80 onwards and projected expenditure for 2004/05 to 2007/08.

Figure 3.4
Per capita NHS expenditure. Scotland and England. Financial years 1979/80 to 2007/08 (projected)

68 Over the period as a whole, per capita NHS expenditure has grown considerably in both countries, reflecting both inflation and real increases in NHS spending. Scotland has maintained its absolute advantage in terms of per capita spending, but it has not kept pace with the overall increase in spending since the early 1990s. The ratio of Scottish NHS expenditure to that in England has consequently declined steadily.

69 During the 1980s and into the early 1990s, per capita NHS expenditure was around 25% higher in Scotland than in England. By 1999/00, the advantage had shrunk to 20%, with spending in Scotland at £974 per head compared to £813 in England. By 2002/03, the real gap had narrowed further to an order of magnitude of 14% difference in per capita spend. (The apparent widening of the gap in 2001/02 and 2002/03 was due to Scotland adopting a change in accounting base two years earlier than England.) Scotland's relative advantage in terms of NHS spending, while still considerable, has been shrinking steadily in recent years. By 2007/08, the gap is projected to have declined to around 11% (Figure 3.5).

Figure 3.5
NHS expenditure per head of population. Scotland as a percentage of England. 1979/80 to 2007/08 (projected)

70 These figures refer only to state-funded healthcare spending. Scotland has a lower level of private healthcare provision. The gap in terms of total healthcare spending would consequently be somewhat smaller. In terms of the wider context, the Scottish level of per capita spending on health care is now around the European average (Audit Scotland, 2004).

71 Higher spending in Scotland is reflected in a higher level of staffing per head of population across a range of categories. Scotland has been reported as having 0.71 GPs per 1000 population, while England has 0.52. There were 1.68 hospital medical staff in Scotland per 1000 population in 2001 compared with 1.35 in England. And Scotland employed more nurses per head of population than England, with 7.3 per 1000 population compared with 5.4 in England (Civitas, 2004).

72 Comparison of the number of beds per head of population is complicated by Scotland's greater (but declining) use of long-stay or continuing care beds. If these are included in the total, Scotland appears to have twice as many beds as England per head of population (6.2 as against 3.0). If the comparison is restricted to acute beds, however, Scotland has 3.5 beds per 1000 population compared with 2.8 for England (Audit Scotland, 2004).

73 Scotland's higher levels of spending on health are therefore reflected in higher levels of staffing and beds.

74 Is the Scottish healthcare system less cost-effective than the English? The answer depends upon the extent to which Scotland needs its extra healthcare expenditure to overcome unfavourable factors that work against delivering comparative health outcomes. The effect of higher levels of deprivation in Scotland has already been discussed. Higher levels of rurality and remoteness in Scotland are also a significant factor. They make it much more difficult to fine-tune the relationship between needs and resource. Ensuring adequate access to health care for people in remote parts of Scotland - and particularly inhabitants of the Scottish islands - can be much more expensive than in urban or central belt areas. For example, spending per head of population in 2003 in Fife was £1034, compared with £1868 in the Western Isles. And the smaller size of the private sector in Scotland will affect the amount of NHS money that needs to be spent to achieve equivalent aggregate healthcare outcomes.

75 A definitive answer is impossible to find. What is unarguable, however, is that Scotland spends a good deal more money on health care than England, although, as we have seen, Scotland's extra spending has been steadily declining in proportional terms. What Scotland gets for that extra investment is much less clear and needs to be addressed.

76 Relatively high levels of spending on health in Scotland and the relatively poor record of Scotland in terms of ill-health and mortality are long-term historical legacies (Dixon et al., 1999). It has been suggested that the performance of the NHS in England in recent years has improved in areas such as emergency care and waiting times to an extent that has not been matched in Scotland. It may be that because of its relatively lower levels of capacity in terms of staffing and beds, England reached a 'crunch-point' several years ago which forced the adoption of more aggressive modernisation and reform policies. Scotland's higher levels of capacity may have allowed the Scottish system a few more years of being able to avoid facing up to the need to modernise the system. If so, we have an opportunity to make the necessary changes before they are forced on the system by the kind of generalised bed crises that were beginning to occur in England.

77 In the light of the demographic and other analysis elsewhere in this chapter, one thing is clear. Increases in resources will be required to meet increased demand. But it is equally clear that no matter how generous those resources - and the planned health budget will exceed £10bn per annum in a few years - the answers to the challenges are not wholly financial. It will be necessary to find ways to fully account for the service change that increased resources bring, but it is also important to ensure that the nature of the service changes to meet the changing needs of patients, and that the financial system is sufficiently flexible to be able to shift resources where they are needed.

Workforce

78 The size and composition of the workforce is a key determinant of the capacity of NHS Scotland. A number of developments have brought workforce dynamics to the forefront of planning concerns:

• fewer people of working age
• an increasing proportion of women in the medical workforce
• 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
• Modernising Medical Careers and the move to a consultant-delivered service
• skills shortages in some specialist areas
• remote and rural challenges with respect to recruitment and retention.

79 Between 1998 and 2002, the number of health-sector employees increased by more than 12%, compared to an increase in other sectors of 5.4%. The health sector has been growing recently in absolute terms and as a proportion of all employees (Future Skills Scotland, 2005).

80 The recent Review of Basic Medical Education reported that there is 'clear evidence of increasing difficulty in filling medical posts in NHS Scotland, with vacancies for both consultants and GPs rising and very small shortlists for vacant posts.' The service faces increasing difficulty in recruiting to its current posts at a time when it is seeking to expand its workforce (Calman and Paulson-Ellis, 2004).

81 Scotland's five medical schools produce sufficient medical graduates for the needs of NHS Scotland. As is made clear in Securing Future Practice (Temple, 2004), however, this picture disguises the fact that many of those who study in Scotland intend to practice elsewhere following qualification.

82 Despite this, while the number of doctors per capita in Scotland is not high by international comparisons, it is high in relation to other parts of the UK. This is somewhat offset by the higher numbers of hospitals per head of population in Scotland and greater levels of illness and demand.

83 The European Working Time Directive stipulates changes in the terms, conditions and working hours of health-service staff which will drive a revolution in the way health services are delivered across the UK. There are particular issues around the delivery of services in rural and sparsely populated areas in light of these changes, and the need to secure European Working Time Directive compliance raises particular issues for staffing small or isolated sites. The necessary move from on-call rotas to shift patterns will in all likelihood make some smaller units non-viable in their current form.

84 From 1 August 2004, doctors in training have been subject to weekly working time limits, which will apply progressively as follows:

• 58 hours from 1 August 2004
• 56 hours from 1 August 2007
• 48 hours from 1 August 2009

85 A number of new contracts for the NHS workforce are now being implemented, including the General Medical Services contract for GPs, the Consultant contract, and Agenda for Change. These are all expected to drive efficiency in the longer term. In the short-term, the ability of GPs to 'opt-out' of providing out-of-hours cover decreases the number of medical hours in the local health economy and increases demand for staff.

86 The UK is almost unique in the Western world in its reliance on doctors-in-training to deliver the service. The hours limits imposed by the European Working Time Directive and the New Deal for Junior Doctors limit the amount of service they can provide. The intention is to move towards a consultant-delivered acute service in which the ratio of consultants to junior doctors is greater, consultants are more directly engaged in emergency care, and junior doctors develop their skills through more structured training as opposed to the 'on-the-job' training they currently receive. Modernising Medical Careers facilitates this shift, which is intended to deliver a higher quality service to patients. There can be no doubt, however, that these changes will place significant additional demands on the consultant workforce, particularly in the short term.

87 Compared to other parts of the UK, Scotland also has a high number of nurses per head of population. International recruitment drives in the United States, Australia, Canada and the Republic of Ireland will pose retention problems in Scotland and other healthcare economies. The Wanless Report estimates that demand for nurses in the NHS will grow by up to one third by 2022 (Wanless, 2002). Meeting that demand while replacing an ageing nursing workforce will be challenging.

88 The allied health professions ( AHPs) include podiatrists, dieticians, occupational therapists, speech and language therapists, orthoptists, physiotherapists, radiographers, prosthetists and orthotists, and art, drama and music therapists. In the last decade, there have been large increases in the six largest AHP staff groups. Despite this increase in numbers, growing demand for AHP services has led to a small increase in the number of AHP posts that have been vacant for three months or more, with the highest proportion of long-term vacancies in 2004 being in speech and language therapy.

89 Over three-quarters of the health service workforce is female. Women are particularly dominant in nursing and midwifery, the allied health professions and administrative and clerical posts. We are also witnessing an adjustment to the medical workforce in favour of women. While in 2003 only slightly over 40% of medical staff were women (Scottish Executive Health Department, 2004), some 60% of the Scottish medical student intake is now female (Temple, 2004). As this trend becomes established in the service, it may have major implications for total workforce numbers, given the greater tendency for women to seek flexible working patterns and to make use of career breaks.

90 Interestingly, nursing, midwifery and dental staff saw more full-time working in 2003 than in 1993 (Scottish Executive Health Department 2004). There has been a small increase in the proportion of males working in nursing and midwifery compared to a significant increase in the numbers of females working in the medical and GP groups, but this would not seem to account for the very different changes in part-time working recorded between these groups.

91 The Scottish population is falling. This decline is accompanied by a shift in the age structure of the population, with a reduction in those of working age. The changing demography of Scotland will result in greater demand for health services at the same time as the gender balance of the workforce changes, as working hours are being restricted, and as the labour market simultaneously contracts.

Clinical standards and quality

92 Alongside improvement in the health of the people of Scotland, the provision of good-quality health care delivered consistently and to a high standard is the key objective of NHS Scotland.

93 The Scottish Executive has put in place arrangements to set standards for NHS Scotland and to monitor its performance against them. The Performance Assessment Framework includes standards for access (waiting times) and clinical quality standards. This reflects the Executive's commitment to achieve and to demonstrate quality improvement and to reduce variations in access and quality in different parts of the country.

94 Clinical standards are now key drivers in NHS Scotland in relation to:

• clinical practice: enabling healthcare professionals to assess, review and where necessary change the way in which they treat particular conditions and care for patients
• service planning and design: providing evidence on safe and effective clinical care to guide decisions on service configuration
• performance assessment: enabling objective measurement of performance for use by each
  NHS organisation and across the NHS through benchmarking by the Scottish Executive as part of the Performance Assessment Framework, and by NHS Quality Improvement Scotland ( NHSQIS) in its monitoring role
• patients and the general public: providing a clear statement of what they should expect from the NHS and a means of reporting to them on performance.

95 In January 2003, a range of organisations involved in work on the quality of clinical services were brought together into a new special health board, NHS Quality Improvement Scotland ( NHSQIS). NHSQIS is responsible for delivering a co-ordinated strategy for improving clinical effectiveness and the quality of patient care.

96 Clinical standards define the levels of performance that are expected of an individual healthcare professional, a unit, a hospital, a practice or a healthcare system. They provide a mix of quantitative and qualitative statements of performance that are accessible to healthcare professionals, managers, patients and the general public.

97NHSQIS standards are designed to support the delivery of:

• higher standards of care
• improved outcomes for patients
• better experiences for patients and carers
• better use of resources (in recognition of the fact that money used ineffectively in one area is money that could be put to better use elsewhere).

98 The work of NHSQIS in setting standards for clinical services and in monitoring performance against these standards is fundamental to future service improvement. Change, whether in clinical practice or service design, needs to be driven by safety and quality considerations, as defined in evidence-based standards, if it is to gain clinical and public credibility and be delivered effectively and sustainably. If it cannot be demonstrated that a change will lead to improvement in the safety or quality of clinical care and treatment, there is little chance of it winning clinical or public support.

99NHSQIS standards are the culmination of well-established and varied processes designed to establish best practice in terms of clinical effectiveness and feasibility. They also provide an evidence-based means of addressing variations in standards of care in different parts of the country.

100 Standards do not in themselves resolve the debate, nor should they be, as is sometimes claimed, drivers of centralisation of services. Rather, they inform the debate on such issues and enable decisions on clinical and cost effectiveness to be guided by evidence. Standards, if used properly, can guide and support the processes of clinical and service change.

Medical science

101 The early decades of the 21st Century will see a rapid acceleration in the introduction of innovative medical devices and procedures. These will have an impact on the quality and outcomes of care delivered to patients, as well as the location of that care.

102 The expected revolution is a result of the convergence of a number of separate strands of technology and science. The technologies can be described using a range of often overlapping terms, including miniaturisation, biosensors, bioengineering, nanotechnology, biomaterials science, micro-electronics and tissue engineering.

103 In parallel, advances in drug discovery and development will continue to ensure that new treatments become available. While these will often offer incremental improvements on existing medicines, breakthrough products that allow remediation of previously incurable or intractable conditions can also be anticipated. Similarly, advances in biotechnology are providing new understanding of diseases and their treatment that will make possible much more tailored approaches to disease management in the future.

104 These anticipated advances will have considerable implications in, for example, the treatment of age-related and chronic degenerative conditions. They will raise a number of financial, social and ethical issues that will have to be addressed, but the potential impact is difficult to understate. As the American futurist and physician Dr Patrick Dixon has said,

'Two great techno-revolutions will impact on the future of health care; digital and genetic. The digital changes what we do - the genetic has the power to change who we are. Both together will transform every aspect of health services.'
(Dixon, 2004)

105 At the forefront of these changes will be a clear understanding, as a result of genetic screening, of the susceptibility of each individual to particular conditions, with the probable shift from secondary care interventions to guided self-care this will entail. It is also likely that a number of technologies and devices have the potential to significantly increase healthy life expectancy, ameliorating some of the predicted cost of caring for the ageing population.

106 It appears likely, then, that there will be a further shift in emphasis towards home care with varying degrees of support, alongside the development of new highly-specialised treatments which, in a country the size of Scotland, will be delivered in a small number of centres.

107 It is also clear that these improvements will come with a cost, at least in the short to medium term. In most developed countries, healthcare spending is outstripping economic growth, with new medical technologies and drugs playing a key role in increasing demand (and consequently expenditure) in response to continuing advances in medical research. Longer term, the potential for better avoidance of ill health may offset the increasing costs of treatment.

Information and communication technology ( ICT)

108 The development and use of ICT in Scotland still largely reflects the UK situation outlined in the Wanless Report in 2002, with low levels of spending compared with other sectors and health systems. Wanless reported that:

'In the UK health service, ICT systems have typically been developed and implemented in a piecemeal way at local level. While there are many examples of systems which work well for particular hospitals or GPs, the systems are not integrated across organisations or indeed sometimes across a single hospital'
(Wanless, 2002)

109ICT in NHS Scotland is currently a hindrance to change, rather than a driver for change. Its potential to help us transform the way health services are delivered is, however, immense. Conversely, if there is not a step change in the rate of implementation of the right kinds of ICT solutions, our ability to deliver the required service changes in the NHS will be highly compromised.

110 The following are some of the ways in which ICT can contribute to transforming the health service.

The Electronic Health Record

111 The universal implementation of an Electronic Health Record ( EHR) is central to the modernisation of the health service. It will allow access by all appropriate professionals to necessary clinical information whenever it is needed - whether at the GP surgery or the Accident and Emergency department. The EHR will remove the inaccurate and frustrating process of repeatedly asking the patient for the same information. The development of a comprehensive system for the management of patients with long-term conditions, involving as it does team-working in the context of patients with complex needs, is particularly dependent on a fully-functioning electronic health record.

Electronic booking

112 Electronic booking can allow patients to choose a convenient date and time for their initial hospital appointment, booking electronically immediately at their GP's practice or using the telephone or internet at a later stage. While bringing immense benefits in terms of patient choice and convenience and reduction in administrative overheads, electronic booking is proving difficult to introduce for reasons which are less technical than organisational and cultural.

Picture archiving and communications systems ( PACS)

113PACS, currently being introduced across the NHS in England, is a digital system that allows images to be captured, stored, distributed, displayed as static or moving digital images, and attached to the patient's electronic record. It has huge potential to smooth the journey for the patient and improve the efficiency of the service. Simultaneous analysis of images by specialists in other parts of the country - or the use of spare capacity of specialists outside NHS Scotland to reduce waiting times and delays - is now completely feasible, with appropriate investment in the infrastructure. Patients at Minor Injuries Units in rural areas could particularly benefit from PACS, avoiding unnecessary and time-consuming visits to busy Accident and Emergency departments at the nearest population centre.

Electronic prescribing and electronic transmission of prescriptions

114 Currently, the electronic processing of prescriptions is limited to the computer generation of a paper prescription. Electronic transmission of prescriptions eliminates the paper stage by allowing prescriptions to be transferred electronically to the community pharmacist nominated by the patient, improving patient safety by reducing prescription errors and providing better information at the point of prescribing and dispensing. Electronic prescribing information would become part of the Electronic Health Record, allowing much better monitoring of outcomes and side-effects.

Telemedicine

115 Telemedicine is the delivery of health care remotely using the electronic transfer of information in the form of video-links or the transfer of digital images. It has many uses including:

• facilitating the ability to deliver a service in remote or rural areas which would otherwise be unsustainable for cost or population-density reasons
• allowing GPs to consult specialists remotely to avoid unnecessary referrals
• establishing networks of learning for clinicians to reduce professional isolation and disseminate best practice
• allowing monitoring of and full communication with vulnerable people in their own homes.

116 Scotland is well to the fore in applying telemedicine to help solve the problems of maintaining services in remote and rural areas. More generally, the development of video-links between professionals and patients in their own homes in combination with the development of other systems of electronic monitoring have the potential to revolutionise the extent to which we can 'look after' vulnerable people at home.

NHS 24

117 The first aim of NHS 24 is to act as a comprehensive 24-hour point of access to health care in Scotland by offering assessment, advice and appropriate referral. Its second aim is to offer high quality health information. In this role, it is at the forefront of proposals to develop systems to make available high quality health information online. As the NHS begins to put a much greater emphasis on encouraging and empowering patients to become active partners in the provision of health care, the development of high quality health information systems will become all the more important.

Implications

118ICT has the potential to be a major lever in transforming a fragmented, disjointed and inefficient health service into one which is integrated, co-ordinated and centred on the needs of the patient. ICT and telemedicine systems should not just be 'bolted on' to a reconfigured health service; they are central to its development, and understanding their capabilities should be integral to service planning in the future.

119 It is clear that other healthcare providers have already developed systems which meet the needs of health care in the 21st Century. They have demonstrated that implementation problems are surmountable; we must learn from them.

Drivers for change: implications

120 In this chapter, we have outlined the main factors driving change in NHS Scotland. What do these drivers mean for healthcare delivery in 20 years' time?

121 All of the drivers described will have an impact, but three in particular - and our response to them - will determine the shape of health care in Scotland in 2024:

• demographic change and associated shifts in the pattern of ill health will determine the demands on the health care system
• workforce pressures will be the bottom line in determining how we are able to respond to these changes in demand
• developments in technology, and in information and communications technology in particular, will give us the tools to fundamentally reshape how health care is delivered.

122 The next 20 years will see an ageing population, a continuing shift in the pattern of disease towards long-term conditions, and growing numbers of older people with multiple conditions and complex needs. These changes in themselves will make the current model of healthcare delivery unsustainable.

123 We will no longer be able to afford a healthcare system which more often than not waits for a medical crisis before providing care. This reactive approach too often results in an unnecessary, damaging, expensive and prolonged hospital admission. We need a healthcare 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.

124 Not only will there be more older people in 20 years time, but their demands - along with the rest of the population - will be different. They will be less deferential and less unquestioningly accepting of treatment. They will demand to understand and be involved in the care they are offered. They may have full access to a range of evidence on best practice via the internet.

125 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 to become expert partners of NHS staff. In this context, the role of healthcare professionals will increasingly be that of supporting and facilitating the management of long-term conditions by patients and carers.

126 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 having a rapid and pronounced impact right now. They require immediate responses, which may have long-term implications.

127 The NHS in 2024 will require a set of staff providing a substantially different service in different working environments and with different skills and roles. The size and composition of the workforce is perhaps the most important determinant of the capacity of NHS Scotland.

128 The impact of the European Working Time Directive, the New Deal for Junior Doctors, new contractual arrangements for GPs and consultants, and the need to improve the standard of care available to patients are among the current factors causing pressure for change in the system. Many of the pressures place limitations on the supply of medical or surgical input; when that is set alongside the potential for much-increased demand, the case for change is obvious.

129 Work on national workforce planning 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. There are issues about the sustainability of our medical schools, just as there are issues about the sustainability of our health services.

130 We also need to be sure that we make the best and most appropriate use of our staff. Given population trends, recruitment may be more competitive in the future. If we are to successfully attract and retain high-quality staff, we need to offer careers in a modern, attractive environment.

131 We also need to ensure that the roles of staff meet the changing demands of the service. If we are right about future trends in service provision, we will need clinical generalists working in local environments with increasing degrees of specialisation in complex and more centralised environments. Given the time lag in training medical staff, we need to be planning urgently for these future scenarios.

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

133 Technology is not a panacea, but information and communication technology has the potential, in combination with organisational modernisation, to revolutionise the way health care is delivered.

134 Many of the interactions between patients and the health service will be conducted electronically by 2024. 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 situation where patients could access officially recognised websites run by physicians and other specialists.

135 The aim of increasing patient involvement would also be much enhanced if patients were able to access and update their individual electronic patient record. We might expect that by 2024 patients will be able to carry a credit card-sized copy of their medical record.

136 An Electronic Health Record will be perhaps the single most important development in ICT aimed at supporting a new model of healthcare 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 constantly be monitored for signs of incipient crises ('kept on the radar'). Again, a comprehensive real-time record is a necessary foundation for such care.

137 As a basic building block for such developments, it will be vital to make universal the use of the Community Health Index ( CHI) in the very near future. Indeed, if we are to maximise the potential of technological advances, NHS Scotland will have to achieve a step change in joined-up information technology.

138 Diagnosis will be fundamentally different by 2024. 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.

139 Communication between healthcare professionals and patients will be revolutionised by broadband video link-ups, enabling visual communication and monitoring on tap. The greatest need of many older, frailer people in the community is to be 'kept an eye on'. Developments in ICT will transform the ways in which this can be achieved.

140 The effect of technological change in general may be to further accelerate some of the changes we are seeing already. It should be possible to do much more diagnosis, treatment and monitoring work 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.

141 It is important to remember that Scotland is not alone in facing many of these changes and challenges. An ageing population and the growing burden of chronic disease are factors common to almost all advanced industrial societies. Because of Scotland's relatively poor health in a Western European context and the prospect of a particularly steep decline in population, there is a tendency to concentrate on problems felt to be uniquely 'Scottish'. We do have to deal with Scotland's particular issues, but it is just as important to understand the challenges we share with other societies.

142 Similarly, many of the workforce pressures the NHS is facing are not unique to Scotland. Other healthcare systems have gone much further in embracing the potential of information and communications technology to transform health care.

143 We need to get much better at learning from how other systems have faced common challenges and embraced new opportunities. Systems such as Kaiser-Permanente and the Veterans Health Administration in the United States, the Canadian healthcare system and, increasingly, the NHS in England are showing the way in facing up to the implications of these broad demographic and epidemiological shifts by developing more proactive, preventive and community-based approaches. We need to learn from such developing responses. The policy environment in Scotland, particularly in terms of Joint Future, Community Health Partnerships and unified NHS Boards, means we are well-placed to share experiences and move forward.

144 Taking all of the above together, the picture that emerges is one in which it is possible to deliver much more close to the patient's home and give more ownership of care to the patient, and in which a new range of highly complex and specialised avenues are opened up. The current trends in health care might be summarised as moving from general care in district hospitals towards better primary care and specialised hospital care. This polarity of care is likely to increase and intensify over time.

145 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. By 2024, the provision of a modern health service in Scotland will require new infrastructure (particularly information technology, where the current position across NHS Scotland seems some way short of best practice), new thinking and new skills. The future of health care will not be 'more of the same'.

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