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Section two Making improvement happen

Health services have to change if they are to keep pace with population trends, patient needs and medical advances. That is why, since 1999, we have developed and implemented policies designed to improve the quality and productivity of NHSScotland. We have supported these policies with record levels of investment in the NHS workforce, in new equipment, and in modern buildings. Over the next three years, we have allocated:

• £135m for medical and diagnostic equipment
• £115m for primary medical and dental services
• £107m for information and communication technology ( ICT).

We are also funding major hospital developments (see section 3.2).

National strategies or action plans are being delivered for the national clinical priorities (cancer, CHD/stroke and mental health), sexual health, oral health and dental services, and pharmaceutical care services. Strategies for eye care in the community and community hospitals are in preparation. A comprehensive set of national targets, including targets for waiting times, has been set out in Fair to All, Personal to Each.

We now need to make a decisive shift in the balance of care within the NHS. The National Framework for Service Change outlined the challenges of an ageing population, which will result in a growing number of people living with long-term conditions. The framework summarised the way in which the NHS needs to work to meet this challenge (Table 2.1) - we endorse this model, which is central to our plans for the future.

TABLE 2.1 The future model of health care

To deliver this model of care we must:

• strengthen services in local communities through more substantial Community Health Centres with diagnostic and treatment services, networked with GP practices
• adopt more proactive approaches to care for people with long-term conditions, with resources targeted to where they are needed most and with greater support for self-care
• enable the NHS to play a full part in promoting good health through community planning, giving greater emphasis to preventive medicine and earlier intervention ('anticipatory care'), especially in areas with the poorest health
• promote a more productive approach to specialist care in our major hospitals, with shorter hospital stays and more resources targeted at pre-admission and rehabilitation services to enable quicker admission and discharge.
• shift the balance of care through CHPs expanding the range of services available locally, determined by the needs of their communities.

There are four big priorities for investment and reform to reshape the NHS in this way:

• the NHS as local as possible
• systematic support for people with long-term conditions
• reducing the inequalities gap
• actively managing hospital admissions.

This section sets out a programme of actions under these important themes.

2.1 THE NHS AS LOCAL AS POSSIBLE

Shifting the balance of care

Three factors will drive the Scottish population's changing need for health care over the next 10 years:

• the growth in the number of older people, and in particular the number of relatively frail older people
• the emergence of long-term conditions as the main challenge facing the health service
• changing expectations from patients for more personalised care.

We will respond to these challenges.

Extending the availability of locally responsive, community-based services will improve integration, quality and productivity by:

• enabling a wider range of services to be delivered in community settings through a modern and collaborative primary care infrastructure
• establishing a base for local diagnosis, treatment, advice and outreach in Community Health Centres
• providing the opportunity to co-locate and more closely integrate health and social services
• providing Community Health Partnerships ( CHPs) with the tools they need to deliver a consistently good service to those at greatest risk in their communities.

No-one has challenged the case for extending and enhancing local health care services to build healthier communities. This is entirely consistent with our view that NHSScotland should be as local as possible. Hospitals should be our last resort for most health care needs, not our first port of call.

General practice and the development of Primary Care Teams are great strengths of the NHS. They have enabled us to deliver health care that is personal, continuous and local. They also perform a 'gatekeeper' function, managing patients' access to specialist care services.

To enhance primary care, we need:

• to build stronger teams in appropriate facilities
• GP practices to have access to shared resources, facilities and expertise in a collective mode
• multi-disciplinary and multi-agency responses to tackle the determinants of ill health
• to extend the roles of health care professionals.

Community Health Centres, whether in purpose-built facilities or housed in existing accommodation (such as large medical centres or community hospitals), can provide a wider range of local services such as specialist outpatient clinics, diagnostic tests (directly accessible by GPs) and day surgery. They provide a base for GPs and other practitioners with special interests and for NHS staff who will in future reach out into local communities (particularly disadvantaged communities) to provide anticipatory care.

Primary care

Local GP surgeries will continue to provide most of the health care people need, working in partnership with community pharmacies, dental practices, optometrists, and NHS 24. They will also provide direct access to health care professionals for patients with acute illness and many long-term conditions. But local practices must become integrated with other community services as part of the whole NHS system of health care delivery.

Integration can be fostered by enabling health care professionals to work in Community Health Centres (including community hospitals), as well as in their practices. It will call for a shift in emphasis away from the independence of individual practices towards a more extended primary care team ethos. It will also need a radical review of the infrastructure in the community, particularly the premises from which services will be provided, and better use of integrated ICT to support patient care wherever it is delivered.

The challenge is to make this vision happen. Examples already exist (see Box 2.1), and we will play our part in ensuring that primary care capital allocations support investment in this type of infrastructure, and that NHS Boards adjust their investment programmes to give priority to these changes.

The new General Medical Services ( GMS) Contract already provides a mechanism for NHS Boards to contract with GP practices to extend local services. The Quality and Outcomes Framework aligns GP services with the needs of local communities.

In forthcoming negotiations, we will be looking to modify the GMS Contract to achieve the outcomes we have described. We will also begin to implement anticipatory care and local diagnostic services through NHS Boards and their CHPs.

"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."

The arrangements for Primary Medical Services also allow NHS Boards to provide or commission services for particular patient groups where the traditional system may not be appropriate.

Community pharmacy

Community pharmacists are key members of the primary care team. They are highly skilled professionals delivering important services to patients such as safely and efficiently dispensing the 72 million NHS prescriptions written in Scotland a year; advising patients on the appropriate use of both dispensed and purchased medicines; checking for drug interactions; and providing a convenient first port of call on the high street for advice on healthy lifestyles to the 600,000 members of the public who visit pharmacies in Scotland every day.

That is why we are negotiating a modernised Community Pharmacy Contract to be implemented from 2006, which will reward pharmacists for the delivery of four main services:

• the Acute Medication Service will continue to provide patients with access to the pharmacy of their choice for the dispensing of acute prescriptions and associated advice
• the Minor Ailment Service (already successfully piloted in Tayside and Ayrshire and Arran NHS Board areas) will enable patients who are exempt from prescription charges to register with a community pharmacy of their choice and have their common conditions treated by a community pharmacist on the NHS without the need to visit a GP
• the Chronic Medication Service will allow patients with long-term conditions to register with a community pharmacy and have their medicines supplied, reviewed, adjusted and monitored over a 12-month period as part of a shared care arrangement between patient, GP and pharmacist
• the Public Health Service will engage community pharmacy in the task of health improvement for individuals and local communities. The Public Health Service is designed to utilise the network of community pharmacies as healthy living walk-in centres and to encourage the involvement of pharmacists and their staff in supporting self care and promoting healthy lifestyles in order to help address Scotland's poor health record.

In addition, the Contract will promote the improvement and use of pharmacies as 'walk-in healthy living centres', where other care services can be provided.

The new ways of working are being underpinned by an extensive ePharmacy programme that exploits ICT to support patient care services. Building on early development work on the electronic transmission of prescriptions ( ETP), the ePharmacy programme was established in 2003-2004 to develop a range of hardware, software and ICT initiatives to support the implementation of the new Community Pharmacy Contract. To date, some £11m has been invested in the programme.

The future roll-out of new technologies such as electronic prescribing and robotic dispensing systems in primary and secondary care will allow delivery of even safer pharmaceutical care services.

These improvements will be supplemented by our plan for a 50% increase in the number of non-medical prescribers by Spring 2008, through the provision of education and training programmes. Prescribing by health care professionals such as nurses, pharmacists and allied health professionals ( AHPs) has allowed NHSScotland to make better use of all members of the health care team and improve patients' access to the right level of care first time.

The role of CHPs

Community Health Partnerships ( CHPs) will drive the shift in the balance of care we have outlined above. They will need to identify specific and measurable service improvements, according to local needs, in the following areas:

• easing access to primary care services
• taking a systematic approach to long-term conditions
• providing anticipatory care
• supporting people at home
• avoiding hospital admissions
• identifying opportunities for more local diagnosis and treatment
• enabling appropriate discharge and rehabilitation
• improving health and tackling inequalities
• improving specific health outcomes.

We will continue to promote joint working with local authority services through:

• sustaining the focus of the Scottish Executive Health Department ( SEHD) and the Convention of Scottish Local Authorities ( COSLA) on measurable outcomes (and, if necessary, outputs from joint services) in the context of a framework of national and local targets
• adopting a whole-systems approach based on common outcomes, and working within the community planning framework - the Joint Improvement Team we established in 2005 will help to ensure a focus on the key issues
• accelerating the development of joint premises shared by NHS Boards and local authorities.

Extending professional roles

We know that 90% of patients' interaction with the NHS starts and ends in primary care. We want to build on that by devolving further, rather than centralising.

We will support innovation which explores new approaches to delivering services. If we are to achieve a health care system that is genuinely embedded in local communities, we need to redesign services, extend roles and cut across some of the historical demarcation lines. But in doing so, we must seek to minimise clinical risks.

SEHD is already leading various initiatives to extend the roles of health care professionals (see Box 2.2). Work is under way to implement the frameworks for role development for AHPs and nurses. We will ensure that these frameworks also support the development of new and extended roles for community services.

AHPs have a vital role in rehabilitation, supporting people to remain at home, preventing unnecessary admissions and enabling patients to be discharged timeously from hospital. SEHD will develop a rehabilitation framework to support services for older people, people with long-term conditions and people returning to work after a period of ill health. The framework will promote a co-ordinated approach to delivering integrated care in community settings, focusing on the roles of AHPs. Our proposals will be published by May 2006.

SEHD will also undertake a review of nursing in the community to develop a modern, redesigned community nursing service to support the future model of care we have described. It will be published by May 2006.

Practitioners with special interests

At present, a GP requiring specialist guidance on how to care for a patient has no alternative but to refer to a hospital-based consultant. GPs and other practitioners, who are trained in a special interest, can provide additional treatment options.

A Referral Management System, as described in Section 2.4, can help to determine the most appropriate service for some patients. The potential benefits are significant. For example, work done by the NHS Modernisation Agency in England has shown that up to 40% of orthopaedic referrals to outpatients can be treated by practitioners working in community-based practices.

We need to identify and develop the number of practitioners with special interests to achieve these kinds of service improvements. Already, we have supported the introduction of over 30 GPs with special interests ( GPwSI), over 50 specialist nurses, and over 60 specialist practitioner AHPs in the CCI's Outpatient programme.

The SEHD supports the continued development of practitioners with special interests. We will work closely with the RCGP, NES and QIS to ensure that the development of these roles continues, is driven by local need and is focused on the most clinically appropriate specialties.

We will give priority to the training of GPwSI with skills in:

• long-term conditions
• care of older people
• services with demanding waiting time targets, such as orthopaedics and emergency medicine, particularly in more rural areas.

2.2 SYSTEMATIC SUPPORT FOR PEOPLE WITH LONG-TERM CONDITIONS

As Scotland's population lives longer, growing numbers of people will develop long-term conditions they will live with, probably for the rest of their lives.

Introducing a systematic approach to managing long-term conditions will improve integration, quality and productivity by:

• matching more effectively the patient's need for care with the right level of response
• managing someone's care needs as a whole when they have more than one condition
• using information systems to deliver joined-up care
• using the skills of the whole clinical team more effectively
• developing systematic contact and support for patient self care and their carers
• reducing emergency hospitalisation
• ensuring a consistent approach and a spread of best practice across Scotland.

Evidence shows that:

• growth in the number of people with long-term conditions will continue
• an increasing number of people have multiple long-term conditions, which makes their care particularly complex
• people in disadvantaged communities are more likely to have a long-term condition
• a small number of people with long-term conditions account for a disproportionate amount of health care deployment
• long-term conditions can be better managed through:
• increasing support for self care
• strengthening and extending primary care
• offering integrated and responsive specialist care
• managing vulnerable cases by anticipating needs
• people with long-term conditions are significantly more likely to see their GP (accounting for up to 80% of GP consultations), to be admitted to hospital, and to stay longer in hospital following admission.

The prevalence of diabetes in Scotland, for example, is expected to increase significantly, perhaps even to double over the next 10-15 years. Diabetes can lead to a range of associated complications - increased risk of heart disease, kidney failure, sight loss and foot ulceration that can lead to amputation. Scotland has made considerable progress in the standards of treatment of diabetes through the development of the Scottish Diabetes Framework, and through the Scottish Primary Care Collaborative (see Box 2.3) An updated version of the framework will be published soon, and a national programme of diabetic eye screening to reduce blindness - one of the first in the world - will commence by March 2006.

Population-wide prevention

Research evidence from the UK and elsewhere suggests that patients can be divided into three groups:

• the large majority of patients are usually able to manage their own conditions with the right advice and support
• a second group needs more professional care to, for example, avoid complications or slow the progression of their disease; there is a need for this group and care providers to work as partners
• a smaller group with particularly complex needs require a more intensive level of care, often referred to as 'case management' to signal the need for a co-ordinated and proactive approach.

The levels of care and corresponding service for patients are summarised in Figure 2.1.

The action the NHS needs to take to improve the quality of care for people with long-term conditions is set out in Box 2.4.

The pyramid as a whole includes all people with a long term health condition.

Level 1 is generally held to encompass 70-80% of all people with a long term condition, the appropriate model of care being "supported self care".

Level 2 covers 15-20% of patients with a higher level of risk and who require additional professional input.

Finally Level 3 covers a relatively small group of patients (no more than 3-5% of the population) who are at the highest level of risk with complex and often multiple conditions and who require intensive care management as the appropriate level of care.

Figure 2.1 Patients with long-term conditions: self care and management

"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."

To support local health services in implementing this approach, SEHD will:

• develop and introduce a new approach to risk prediction
• promote a stratified approach to meet the care needs of patients with long-term conditions
• introduce a 'tool kit' to enable CHPs to benchmark the development of local services for those with long-term conditions.

These three actions are linked. The better we can predict the vulnerability of a patient and the risk of hospital admission, the more likely we are to be able to provide people with the right level of support.

We will ensure that service development for long-term conditions is taken forward in a systematic way. We will establish a national strategy for the care of long-term conditions by convening an expert group to agree the development of the risk prediction and benchmarking tools and to identify more fully the implications of the stratified approach to the care of these conditions. We will complete this work by June 2006.

This is a necessary first step in our strategy for long-term conditions, which has two parts. First, we will identify those people at greatest risk of hospital admission and provide them with earlier care to prevent the deterioration of their health. Second, we will equip people at all levels to manage their own health, enabling them to take greater control of their condition and of their life.

Risk prediction

A number of NHS Boards have done work on risk prediction. NHS Ayrshire & Arran and NHS Tayside, for example, are each working on a screening tool that uses a range of criteria to predict vulnerable patients. The criteria include clinical indicators such as multiple chronic diagnoses, multiple prescribed drugs and significant impairment in activities of daily living, and criteria based on hospital attendance and admission.

We have also looked at models delivered in England and in the US. The evidence suggests that the better the predictive capacity of the tool used to identify high-risk patients, the more likely we are to secure better care without the need for hospital admission. SEHD and NHS Quality Improvement Scotland will work with others to determine the optimal set of indicators. We will then make the use of this tool a requirement in NHSScotland for managing long-term conditions.

Intensive co-ordinated management

We will provide comprehensive, integrated care for those with the most complex health care needs and the greatest vulnerability to emergency hospital admission.

Holistic care of this nature is best delivered in the community by primary care teams. Research evidence indicates that GPs should take a particular interest in patients with the most complex health care needs, working with their practice teams to develop personalised care plans to meet their needs.

A member of the primary care team needs to be identified as a fixed point of reference for the patient. This person will take responsibility for the patient, co-ordinating the contribution of various professionals with an interest (including those in social care) and anticipating and dealing with problems before they lead to worsening health or hospitalisation.

A local decision should be taken on who is best placed to offer co-ordinated care. It may be a GP or a nurse, an AHP or social care professional. We will ensure the care co-ordinator has the right skills, knowledge and contacts to provide the joined-up care required for the patient.

The expert group on care for long term conditions will oversee the preparation of guidance for NHSScotland and primary care practitioners. All NHS Boards will be providing care of this nature to the most vulnerable people with long-term conditions by the end of 2007.

Improving self management

Self care and self management have become increasingly important for people with long-term conditions as means of maintaining independence and enhancing well-being.

Supporting self care and self management means more than giving patients information about their condition. It also means that health care professionals must empower patients (and involve their family carers) to take greater control over their own care.

We will establish a Scottish Long-Term Conditions Alliance in 2006 to support self management. We will work with the Alliance to:

• ensure that patients and their carers have the skills and knowledge they need, and someone they can contact if required
• develop mentors and 'expert patients' to act as advisers and role models
• pilot home-based information technology to support self management at home.

CHP self-assessment tool kit

We want to be sure that the various changes proposed will actually make a difference to people with long-term conditions. For this reason, we have supported the creation of the CHP self-assessment tool kit to support each CHP to recognise whether it is delivering good, safe and responsive services for people with long-term conditions as locally as possible.

The tool kit, which has been piloted successfully in NHS Lanarkshire, will allow CHPs to benchmark their activities, identify areas of good practice and draw up action plans to improve services and fill gaps. It sets out clearly measurable criteria relating to four standards:

• organisation of long-term conditions management
• patient information and supported self care
• multi-disciplinary and multi-agency working
• inter-disciplinary education and training.

The format, which will be familiar through its use in the accreditation of MCNs, will also include outcome indicators being developed for CHPs.

The tool kit represents an effective way of introducing generic approaches to long-term conditions in a way that helps promote consistency of approach across the whole of Scotland. Use of the tool kit will therefore be mandatory for CHPs.

Supporting unpaid carers

A central theme for future health care policy in Scotland is the recognition of unpaid family carers as key partners and providers of care, as embedded in the Community Care and Health (Scotland) Act 2002.

The enormous contribution of carers was shown in the 2001 Census, which identified over 115,000 unpaid carers caring for 50 hours or more a week. Further evidence was supplied in the recent Care 21 report, The Future of Unpaid Care in Scotland, the most detailed study of carers to date. The report recommends that the NHS and local partners provide carers with the information and training they need for their caring role and build 'carer awareness' into professional training. We will issue guidance later this year on the implementation of NHS carer information strategies to support this work.

2.3 REDUCING THE INEQUALITIES GAP

There are unacceptable differences in healthy life expectancy in Scotland.

Figure 2.2 shows that Scotland's health is improving, but the improvement is greater in more affluent areas. The differences within Scotland in life expectancy and premature mortality are significant and widening.

In 2002, life expectancy at birth for men living in the most disadvantaged areas was 69.5 years, compared with 78.4 years in affluent areas; for women, it was 77.3 years, compared with 82.3 years in the most affluent areas (Figure 2.2).

There is evidence that more people in disadvantaged parts of Scotland are living longer with illness. In 2001, 21% of women living in disadvantaged areas reported they had a limiting long-standing illness or disability, compared to 8% of women in the most affluent areas. The corresponding figures for men were 21% and 9%.

There is also clear evidence emerging of the gap between our most affluent and most deprived communities in more specific indicators of health, as set out in Figures 2.3.

The Executive's approach to closing the opportunity gap by tackling poverty and disadvantage in Scotland will benefit the health of people living in the most deprived communities, by addressing aspects of poverty such as improving people's employability, increasing young people's confidence and skills and regenerating the most disadvantaged neighbourhoods.

Figure 2.2 Change in male life expectancy 1953-2001

MAQ: 20% Most Affluent Areas
MDQ: 20% Most Deprived Areas

Figure 2.3A

Figure 2.3B

Figure 2.3C

"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."

Much work is already being done across the Scottish Executive to address these issues.

The new £318m (2005-08) Community Regeneration Fund ( CRF) will help Community Planning Partnerships achieve community regeneration of the most deprived neighbourhoods, through improvements in employability, education, health, access to local services and quality of the local environment. The fund has a specific focus on health inequalities and will support interventions across a range of health improvement measures including, for example, Public Health Nurses to undertake preventative health promotion in North Ayrshire, substance misuse services in East Renfrewshire and sexual health projects for young people in Dundee.

The Scottish Executive's Central Heating Programme is the biggest investment ever made in a home energy efficiency programme in Scotland. It is aimed at Scotland's most vulnerable households: those whose health or general wellbeing may be at risk from cold and damp housing. Approximately 65,000 householders will receive free central heating, insulation and other benefits under this scheme by March 2006 as a result of this £140 million investment.

We have also provided £64 million through the Warm Deal programme for home insulation grants for low income households and pensioners. This has ensured the insulation of 218,000 homes, nearly one tenth of all of Scotland's housing stock.

The impact of these fuel poverty programmes on health is being assessed by the University of Edinburgh's Research Unit in Health. The report is expected in 2006.

We believe that NHSScotland can do more itself to break the link between deprivation and poor health. We need not only a sustained effort to promote good health and good health care, but also to target our resources at areas of greatest need. This will call for additional service activities to promote and support good health in our most disadvantaged communities and for the lessons learned to be translated elsewhere. An example of an effective health service response to health inequalities is shown in Box 2.5.

We have made clear our determination to achieve progress by setting targets to increase the rate of improvement across a range of health indicators - the incidence of CHD, cancer, smoking, teenage pregnancies and suicide - by 15% by 2008 for the most disadvantaged communities.

We believe the most significant thing we can do to tackle health inequalities is to target and enhance primary care services in deprived areas. Strengthening primary care teams and promoting anticipatory care in disadvantaged areas will reduce health inequalities by:

• targeting health improvement action and resources at the most disadvantaged areas
• building capacity in primary care to deliver proactive, preventative care
• providing early interventions to prevent escalation of health care needs

This approach will ensure that people at greatest risk of ill health are actively identified and offered opportunities for early detection, advice and treatment, enabling earlier identification, prevention and treatment for conditions such as high blood pressure, type 2 diabetes and high cholesterol. Strengthening primary care services in these communities can improve health outcomes through preventive medicine, changing the focus to 'anticipate and prevent'.

The approach requires:

• primary care teams with dedicated resources aimed at identifying and recruiting 'at risk' populations
• targeting identified populations for health checks, screening, advice or referral to community services or treatment
• targeting 'at risk' populations for health improvement promotion and prevention services (putting primary care and CHPs at the heart of measures to promote health and well-being while tackling health inequalities)
• targeting and designing services such as smoking cessation and alcohol and weight management to meet the needs of people most at risk
• working with voluntary and other organisations which are close to local communities and which can therefore be a useful bridge to primary care services
• systematic, regular monitoring and evaluation.

"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."

To strengthen the capacity of primary care teams in these areas, we will examine the scope for new staffing developments to support general practice, in addition to key roles for practice nurses and AHPs.

Activity should be supported nationally by systems to enable patient identification and risk stratification, the development of new skills and roles, and evaluations of the success of interventions.

We will:

• pilot this approach in 2006/2007 in up to five CHPs; this will allow us to generate evidence of what is most effective in achieving better health outcomes
• place CHPs at the centre of work on tackling health inequalities
• continue with tried and tested interventions in the high-risk areas of smoking, alcohol, diet and physical activity, in addition to treating key clinical needs
• use the evidence gathered from pilots to inform more general and widespread application of the 'anticipate and prevent' approach elsewhere, for other people at risk through deprivation.

2.4 ACTIVELY MANAGING HOSPITAL ADMISSIONS

There is now evidence of a sustained reduction in the longest waiting times in Scotland. Much of the progress has been secured through increasing capacity where required and by improving productivity. We can do more to reduce the need for planned hospital admission to ensure that this welcome reduction in waiting is maintained and challenging targets for the future are achieved.

We will implement five simple changes across NHSScotland that will raise the performance of all NHS Boards to the standard of the best. Implementing these five simple changes will improve integration, quality and productivity by:

• enabling more care to be delivered locally, often by the primary care team
• ensuring patient pathways are planned in advance, patients have a seamless experience and are informed about their programme of care
• speeding access to care
• sharing best practice and making NHS Boards accountable for raising their performance.

The changes are evidence based and draw on best practice from around the world. They have been tested on the frontline and have been shown to work. We will ensure that NHS Boards implement all of the changes systematically.

We will require all NHS Boards to develop a three-year improvement plan to introduce these changes, beginning in 2006/2007, including the introduction of referral management centres for appropriate services.

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