The Scottish Government

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Section one Where we are now

1.1 A POLICY FOR HEALTH

Our overarching aim is to improve Scotland's health. Policies and actions across the Scottish Executive support that central objective.

We are building an integrated approach to health that has the NHS at its core. The approach sets out to tackle determinants of population health, particularly through action to close the 'health gap' that blights the lives of people in our disadvantaged communities.

This plan is therefore about more than the future shape of our NHS. It also brings together elements of wider policy the Scottish Executive has been developing for a number of years that impact on Scotland's health.

Health care makes an important contribution to health improvement. Our plans for the health service to reach out with earlier intervention (anticipatory care) make this link explicit, emphasising the importance of delivering health care that is fair to all and personal to each.

We expect the NHS to provide care that is tailored to the needs of the individual, drawing on the efforts of appropriately skilled members of the health care team. This means encouraging team members to get out of the 'service silos' that have for too long led to patients being passed from one service to another without proper co-ordination.

Figure 1.1 summarises the key elements of our broad approach to Scotland's health. It requires us to:

• reach out further with our health improvement programmes
• continue to reduce the longest waiting times
• improve access through service redesign
• improve the quality of health care by raising the standards of all to those of the best
• get best value from the £8bn we already spend each year on the NHS
• build on the Kerr Report to deliver an NHS fit for the future.

Figure 1.1 Scotland's health policy

"Our aim is to improve the health of the people of Scotland . . . with a shift towards preventive medicine and more continuous care in the community. Our strategies, policies and actions are intended to support that key objective."

1.2 PROGRESS

We have a good foundation on which to build. We are heading in the right direction, and can illustrate progress in five particular areas:

• health improvement
• reducing deaths from killer diseases
• shorter waiting times
• redesigning services around the needs of patients
• improving patients' experiences of health care.

1.2.1 HEALTH IMPROVEMENT

Improving Health in Scotland - The Challenge, published in 2003, identified areas where action was required to achieve a more rapid rate of health improvement.

Among the main advances achieved over the last few years are:

• enacting legislation to secure smoke-free, enclosed public spaces in Scotland from 26 March 2006
• increasing smoking cessation services, targeting areas of disadvantage
• appointing 600 active schools co-ordinators
• encouraging healthier eating at school through the Hungry for Success programme
• providing free fruit and drinking water in primary schools
• taking action on oral health, particularly for children and young people
• launching a new Plan for Action on Alcohol
• taking action on mental health through the See Me and Choose Life initiatives.

We put emphasis in the first phase of The Challenge on raising the profile of health improvement and getting effective structures in place. We now need to sharpen the focus on delivery, ensuring that services are reaching those who need them most and that real health improvement is demonstrated, especially in our most disadvantaged communities.

1.2.2 REDUCING DEATHS FROM KILLER DISEASES

Coronary heart disease ( CHD), stroke and cancer are the major killer diseases in Scotland. They are recognised among the national clinical priorities for NHSScotland.

We have devoted considerable resources to ensure progress is made in these areas. The formation of Managed Clinical Networks ( MCNs) has enabled the redesign of services, raising standards and improving outcomes. We have set challenging national targets for these services and are making good progress.

Coronary heart disease/stroke

Scotland has had considerable success in recent years in treating patients with CHD. The premature mortality rate has fallen by 43.6% since 1995.

But there are still around 500,000 Scots with CHD, with 180,000 being treated at any one time. Our target now is to reduce premature deaths by 60% (among people aged under 75) between 1995 and 2010, and progress to date suggests that this target is achievable. Figure 1.2 shows progress since 1980.

MCNs in each NHS Board have taken the lead in prioritising bids for funding under the CHD and Stroke Strategy. Extra national funding (£40m between 2003-2006) has been committed to CHD and stroke services to support rapid-access chest pain clinics, heart failure and cardiac rehabilitation services, and to develop stroke units. MCNs are developing primary and secondary prevention strategies, drawing on lessons from national projects such as Have a Heart Paisley and the National Heart Health Learning Network. These initiatives are aimed at reducing the incidence of CHD, with emphasis on promoting healthier lifestyles.

Mortality from CHD is higher in disadvantaged communities. We have consequently set an additional target - to reduce premature mortality by 15% above the national rate, for people in the most disadvantaged communities (see health inequality targets in section 2.3).

Progress is also being made in the prevention of stroke and the care and treatment of stroke patients. The number of people admitted to hospital with cerebrovascular disease has fallen by 13% since 1995.

Specialist stroke units providing acute and rehabilitative care are recognised as the way forward. These units now exist in most NHS Board areas and are integral to the stroke MCNs.

The national target is to reduce premature mortality for people aged under 75 by 50% between 1995 and 2010. Figure 1.3 indicates that we are on track, with a reduction of 40% to date.

Figure 1.2 Age-specific mortality rates per 100,000 population: under 75s dying from CHD

Cancer

Cancer continues to be one of the main challenges facing NHSScotland. We have the highest mortality rate for cancer in Western Europe. Each year, 26,000 people in Scotland are diagnosed with various forms of the disease, and 15,000 die.

The national target is to reduce premature mortality from cancer by 20% between 1995 and 2010. The latest available data show a decrease of 14.8% (Figure 1.4), so this target still represents a considerable challenge.

In line with advice from the regional cancer MCNs, an additional £25m a year is being invested to improve cancer diagnosis, treatment and care through innovation and spreading good practice. Extra staff and equipment have also helped to reduce waiting times, but NHS Boards still need to achieve significant further reductions in waiting times, in accordance with the National Cancer Delivery Plan. This will require NHS Boards to improve management information in this area.

As is the case with Scotland's other killer diseases, efforts to promote healthier lifestyles are being targeted at disadvantaged communities, where the incidence of cancer is particularly high.

Figure 1.3 Age-specific mortality rates per 100,000 population: under 75s dying from stroke

Figure 1.4 Mortality rates per 100,000 population: under 75s dying from cancer

1.2.3 SHORTER WAITING TIMES

Patients and their families want prompt access to services. Prompt access can also result in benefits in clinical outcomes through early diagnosis and treatment.

The majority of patients who require hospital inpatient or day case treatment are treated quickly. Almost 54% of patients treated in NHSScotland hospitals are admitted immediately and never join a waiting list. Of those who do wait, 41% are admitted within 1 month and almost 70% within 3 months. But for those who have to wait, it can be a period of anxiety and uncertainty. That is why reducing waiting times for patients is one of the Executive's key priorities for NHSScotland.

There is now a clear downward trend in the length of time people wait for hospital inpatient and day case treatment. The national maximum waiting time was reduced from 12 months to 9 months at the end of 2003, and will be further reduced to 6 months by the end of this year and to 18 weeks by the end of 2007. The latest available figures (for 30 June 2005) show that:

• the number of patients with a guarantee waiting over six months for inpatient and day case treatment is the lowest ever recorded, representing a fall of 30% from the previous quarter (figure 1.5), and a reduction of 82% from the previous year.
• for the fourth successive quarter, no patient with a guarantee waited more than 18 weeks for angioplasty or surgical graft for heart disease.

Our commitments on waiting times for inpatient and day case treatment and for cardiac revascularisation are firm guarantees to patients of the maximum time they will wait. If a patient's host NHS Board is unable to provide treatment within the target time, the patient must be offered treatment elsewhere in the NHS, in the private sector, or in exceptional cases, overseas.

The number of patients with a guarantee waiting more than 6 months for inpatient and day case treatment fell from 8,014 on 30 June 1999 to 1,121 on 30 June 2005. This performance is shown in the following graph.

Figure 1.5 Number of inpatients/day cases with a guarantee waiting more than six months

"Our aim is to improve the health of the people of Scotland . . . with a shift towards preventive medicine and more continuous care in the community. Our strategies, policies and actions are intended to support that key objective."

On outpatient waiting times, the majority of patients referred by a GP or dentist for a first outpatient appointment at a consultant-led clinic are seen quickly, with nearly 54% of patients being seen with 9 weeks of referral and 66% within 13 weeks. For those who have to wait longer, we have set a national maximum waiting time target of 26 weeks from referral to consultation, by the end of 2005. This will be reduced to 18 weeks from the end of 2007.

To ensure performance is monitored effectively, Partnership for Care included a commitment to establish a national outpatient waiting list. Information on this list was published for the first time on 30 September 2004, and has been published quarterly since then. On 30 June 2005, 15,432 patients without an availability status code had waited more than 26 weeks for a first outpatient appointment - a reduction of 6,706 since 31 March 2005, demonstrating that NHSScotland is on track to deliver the commitment that no-one will wait more than 26 weeks by the end of this year.

Fair To All, Personal To Each - The next steps for NHSScotland, published in December 2004, set out the biggest and most comprehensive package of improvements promised by NHSScotland. In addition to setting maximum waiting times of 18 weeks for a first outpatient appointment and for hospital inpatient and day case treatment from the end of 2007, it included the following additional waiting times commitments to be delivered by that date:

• for patients with chest pain, a maximum wait of 16 weeks from GP referral, through a rapid access chest pain clinic or equivalent, to cardiac intervention, from the end of 2007
• for those patients not presenting with chest pain, a maximum wait of 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment
• a maximum wait of four hours from arrival to discharge, admission or transfer for A&E treatment
• a maximum wait of 18 weeks from referral by a GP or Optometrist to cataract surgery
• a patient entering a specialist orthopaedic unit for surgery, following hip fracture, will be operated on within 24 hours of admission.

In addition, in June 2005, maximum waiting times of 9 weeks by the end of 2007 were set for 8 key diagnostic tests - CT, MRI, Ultrasound and Barium scans and Upper Endoscopy, Cystoscopy, Sigmoidoscopy and Colonoscopy. This 9 weeks maximum waiting times commitment will be included within the maximum waiting times for outpatient consultations and inpatient and day case treatment - they are not additional.

We will ensure these commitments are delivered through the implementation of service redesign and new ways of working, increasing capacity, particularly at the Golden Jubilee National Hospital, and by working with the independent health care sector to increase NHS capacity further.

The Golden Jubilee National Hospital is a unique facility helping to reduce waiting times across Scotland, particularly for those experiencing the longest waits for treatment. Since the facility became part of NHSScotland the hospital has increased its activity from 2,500 procedures a year at the time of purchase to over 18,000 procedures in 2004-05, making a massive contribution to reducing patient waits.

Fair To All, Personal To Each - The next steps for NHSScotland includes a commitment to increase capital investment at the Hospital over the years 2007-2008 to bring all of the available floor space into intensive clinical use; the Executive will provide extra revenue funding to pay for the staff who will care for patients in these new wards. As a result, the Golden Jubilee is expected to be able to carry out 10,000 extra procedures annually by 2007-08 when all of the additional capacity and staff are in place taking the total number of procedures to 28,000 each year.

This expansion is now happening. Two state-of-the-art Orthopaedic operating theatres have been built and 3 Orthopaedic surgeons appointed, increasing orthopaedic activity from 360 in the first year to 1,800 now. A programme of upgrading the Hospital's diagnostic facilities by replacing or upgrading the ultrasound equipment, CT scanner, catheter lab and the MRI scanner has recently been completed. This has enabled investigative procedures to increase from 7,200 in 2003/04 to over 13,000 in 2005/06.

NHS Greater Glasgow and NHS Lanarkshire are currently working with the Hospital on a proposal to establish a single-site West of Scotland cardiothoracic centre at the Golden Jubilee National Hospital.

Scottish Primary Care Collaborative

The NHS is working hard to improve access to local health care services. This year, 96.8% of GP practices have achieved the Scottish Executive Partnership Agreement target of guaranteeing access for patients to a member of the primary care team within 48 hours.

Almost 400 practices are currently involved in the Scottish Primary Care Collaborative, which works to improve access and outcomes for people with long-term conditions. The collaborative programme has improved clinical outcomes for patients with diabetes through proactive and systematic management and by adopting an integrated team approach. We are expanding this programme, so that by December 2005 almost 50% of practices will be involved.

Participating practices now aim to ensure that 90% of patients can access their health care professional routinely within one working day, and that patients can see a GP on a day of their choice (Figure 1.6).

Figure 1.6 Accessing GPs

1.2.4 SERVICE RE-DESIGN

In setting out new waiting time targets, the Minister identified a number of key steps in delivering for 2007:

• new and more efficient ways of working
• better workforce planning - right skills, right place
• more investment in capacity where it matters
• more effective use of the independent sector
• innovative Community Health Partnerships
• more strategic and effective use of information and communication technology ( ICT).

Much of the success already achieved has been made possible by frontline staff redesigning and improving the services they provide (see Box 1.1).

Innovation and service redesign also takes place where health improvement programmes link to health care. The Have a Heart Paisley programme, for example, has supported over 6,000 people through a range of local projects aimed at improving heart health. The programme uses coaching and mentoring to improve health, identify and tackle risk factors, and meet treatment needs that would otherwise be overlooked.

Innovation at local level is only the first step. We must spread good practice and promote a culture of innovation and redesign across the NHS, so staff and managers can learn from innovative, evidence-based schemes from elsewhere. We must ensure that this is done more systematically in the future than is the case at present.

1.2.5 IMPROVING PATIENTS' EXPERIENCE OF HEALTH CARE

Looking at patient satisfaction with services is a very important way to gauge the progress being made by NHSScotland.

A Scottish Executive survey of public attitudes to NHSScotland carried out towards the end of 2004 found that 90% of the 1,937 patients surveyed from all over Scotland were 'very or fairly satisfied' with the service they received (Table 1.1). Patient satisfaction was clearly linked to a number of factors, notably waiting, choice and generally having a greater say in their NHS.

These figures compare favourably with a similar survey carried out in 2000, with a marked increase in satisfaction with local GPs and inpatient services. We are tackling concerns about outpatient services, through targets to reduce waiting times and the Centre for Change and Innovation's Outpatient programme; and we are reviewing the provision of out-of-hours care in the light of the first year's experience of the General Medical Services ( GMS) contract. We want to see further improvements in patient satisfaction, but it is encouraging to note that we start from a sound base, and are on a rising trend.

Table 1.1 Patient satisfaction with services

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