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Section three An integrated NHS for the whole of Scotland

Our objectives of high-quality services and better productivity will be achieved by promoting the integration of services. Service co-location will support the aim of integration, but much more important are the development of a culture and the creation of working practices that enable co-operation and teamwork.

At the heart of our programme to promote integration is a strategy to increase sharing of information, with unified databases, effective communication links and standardised protocols.

We set out below the national eHealth strategy for the application of information and communications technology, built around an Electronic Health Record.

Our objective also requires a clear understanding of the way different services interact, especially in the way resources - hospital facilities and health care professionals - have to be mobilised to meet distinctive needs.

In this section, we therefore:

• address the challenges of managing unscheduled (including emergency) care and elective (planned) care
• outline opportunities for reshaping specialist services in hospitals, applying them to specific patient groups such as those who access rural health services, mental health services, children's health services and neurological services
• outline our plans to link service redesign with workforce planning as it develops in line with our National Workforce Planning Framework, published in August 2005.

3.1 eHEALTH STRATEGY

A common information and communications technology ( ICT) system is essential if NHSScotland is to deliver the integrated care services we require. Health care providers around the world recognise the opportunity for faster, safer, more efficient and more patient-centred services that ICT offers. International evidence suggests that an Electronic Health Record can address many current problems for patients and services. For instance:

• one in seven hospital admissions occurs because care providers do not have access to previous hospital records
• 20% of laboratory tests are requested because the results of previous investigations are not accessible
• 15% of hospitalisations are complicated by medication error.

A comprehensive health information system built around an Electronic Health Record is vital to achieve the shift away from reactive, crisis-management, acute-oriented care towards anticipatory, preventative and continuous care.

Delivering the eHealth agenda will be extremely challenging. Many changes will be necessary, such as adhering to more rigorous record-keeping standards and ensuring that communications are marked properly with the patient's Community Health Index ( CHI) number to enable clinical information to be safely and securely shared in an electronic environment. Wherever possible, clinical staff will record their interventions directly into Electronic Health Records, rather than transcribe to written records. Adherence to security standards will be built in so that patients and clinicians can be confident that records remain confidential.

Clinical staff will be increasingly involved in agreeing the criteria for Electronic Health Records. A degree of local configurability is necessary, but only the adoption of rigorous technical and information standards will ensure that patient information is available and reliable at the point of need. Previous freedoms to procure and implement systems locally will be curtailed to ensure that local systems align with the move to Electronic Health Records.

Much work is already underway in Scotland (see Box 3.1 for an example).

The general effort can be split into two streams.

Stream 1 of the work focuses on the short to medium term and includes the elements set out in Table 3.1.

Stream 2 consists of planning and implementing the Electronic Health Record. Planning work has now begun. Deployment of a new system is expected to start in 2007, and will be completed in 2010.

We will complete procurement by June 2007 and will only authorise developments that are consistent with and support the migration to a single record.

The national budget for eHealth will increase almost threefold over the next three years, from £35.3m in this year to £100.3m in 2007/2008. Much of this resource will support the local infrastructure required for the Electronic Health Record. NHS Boards will be obliged to demonstrate that existing local IT budgets are planned for growth over the same period to ensure that NHS staff across all Board areas have the right IT tools, support and training to deliver beneficial changes to patient care in line with the eHealth strategy.

A second element of Stream 2 will be the establishment of a Scottish Centre for Telehealth. The Centre will provide practical help to NHS Boards as they seek to realise the potential of telehealth development projects (see Box 3.2 for an example). Following evaluation of development projects, approved National Telehealth Reference Solutions will be brought to the attention of NHS Boards, and we will promote the development of standardised solutions.

The core functions of the Scottish Centre for Telehealth will be to:

• provide a centre of expertise to define and disseminate best practice and develop inter-operable standards, protocols and processes to support telehealth solutions
• provide practical and informed support to telehealth projects in their development phase and to NHS Boards implementing National Telehealth Reference Solutions
• co-ordinate the evaluation of projects capable of evolving into National Telehealth Reference Solutions and support the process of awarding funds to projects.
• evaluate the impact of telehealth solutions on service redesign

The Centre will harness the skills and expertise of key groups across Scotland from medicine, operational management, and telehealth technology and impact evaluation. NHS Grampian will provide the hub for the Centre, building on local experience of telemedicine.

Table 3.1 Stream 1 activities

3.2 HOSPITAL SERVICES: PLANNED AND UNSCHEDULED CARE

Our planned investment in Scotland's hospitals will enable us to deliver care that is quicker, safer and more reliable, whether the patient requires emergency or planned care. The programme includes:

• two 'walk-in' hospitals in Glasgow (at Stobhill and the Victoria Infirmary)
• the renewal of the Southern General Hospital in Glasgow
• a new Children's Hospital in Glasgow
• a new hospital for Forth Valley at Larbert, with associated walk-in hospitals at Stirling and Falkirk
• the partial rebuild and refurbishment of the Victoria Infirmary in Kirkcaldy and the redevelopment of the Queen Margaret Hospital in Dunfermline.

Many smaller developments are also under way, including:

• redevelopment of Ailsa Hospital in Ayr
• development of Ayrshire Community Hospital
• Phase 2 of Glasgow Royal Infirmary
• refurbishment of wards at Dumfries and Galloway Royal Infirmary
• redevelopment of Chalmers Hospital in Grampian.

These developments are consistent with the models for hospital care described in the National Framework for Service Change.We will require NHS Boards to:

• plan all subsequent hospital developments to be consistent with these models
• organise existing services to promote the separation of unscheduled and planned care
• work together on a regional basis, and with the Scottish Ambulance Service, to ensure effective networks of hospital care are in place.

Unscheduled care

The rise in emergency admissions to hospital in recent years is striking. It has been accompanied by a significant increase in the proportion of bed days occupied by emergency patients: in 1983, 59% of bed days were occupied by emergency patients, compared to 80% today.

Welcome changes to the training of doctors and the gradual implementation of the Working Time Regulations by 2009, when weekly working limits of 48 hours will apply (to support patient safety by ensuring that doctors achieve sufficient rest), mean that the model of unscheduled care must be reviewed. We will therefore develop other parts of the service to prevent emergency admissions, while acting to maximise the input from trained doctors and to develop a multi-disciplinary approach that makes best use of contributions from other members of the clinical team.

The need for unscheduled care can be reduced through the actions we set out in Section 2. There will, however, always be some patients identified by general practitioners, or who seek help by calling the emergency ambulance service, or who present at A&E departments, who require immediate admission. We intend to redesign the model of unscheduled care throughout Scotland, building on the National Framework and the Unscheduled Care Collaborative Programme.

Developing a stratified unscheduled care system will improve integration, quality and productivity by:

• maintaining care at local level for the majority of unscheduled cases through multi-disciplinary teams working in Community Casualty Units
• allowing a greater separation of planned and emergency care wherever possible to protect capacity in both
• reducing the number of appointment cancellations for patients, and reduce waiting times
• achieve a more efficient use of limited facilities and specialist staff across the country.

"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."

NHS 24 has a key role to play in supporting NHS Boards to deliver unscheduled care in the future. The recent review of its activities has produced a detailed report with recommendations. NHS 24 will work with its partners across the NHS to implement the changes that will allow a sustained improvement in performance. As that review makes clear, an effective service requires a responsiveness to local needs and good systems to distinguish genuine emergencies from routine calls.

We will:

• begin the implementation of new, accredited models of unscheduled primary care based on multi-disciplinary care teams from 2006
• continue to invest in the Scottish Ambulance Service to ensure delivery of the key eight-minute response target by the end of March 2008, and require it to develop proposals for the development of its services, consistent with the National Framework, by September 2006
• develop hospital unscheduled care in line with the model of the National Framework, separating planned and unscheduled care where appropriate
• use telemedicine to integrate the various levels of the unscheduled care system; this will help to avoid inappropriate referrals and unnecessary travel for patients by fostering better communication among health care professionals
• support the development of networks of Community Casualty Units linked to appropriately staffed and resourced Emergency Centres
• allow emergency specialists to concentrate on dealing with complex cases by focusing key medical resources in well-staffed and resourced Emergency Centres
• plan emergency admitting services on a regional basis to ensure the most appropriate distribution of services and staff for the needs of the Scottish population in the 21st Century

NHS Boards and Regional Planning Groups have begun to work on these issues. They will be required to report their conclusions by the end of 2006. Our objectives are clear - to deliver urgent care that is tailored to individual needs locally if possible, but always safely.

Planned care

We set out some of the practical measures NHS Boards will take to manage demand for planned care in hospitals in Section 2. Our principal objective for the improvement of planned care remains a further reduction in waiting times, with specific national targets set (see page 6).

NHS Boards need to work together in the Regional Planning Groups to insulate elective care from the impact of emergency care and to retain most elective procedures in local facilities.

Streaming of planned care will improve integration, quality and productivity by:

• improving predictability of workflow and facilitating the matching of supply and demand
• reducing cancellations
• making best use of facilities
• improving access for patients.

Benefits realised through the focus on planned care in cardiac and orthopaedic services at the Golden Jubilee National Hospital in Clydebank illustrate what can be achieved, particularly in relation to improving productivity and reducing inpatient waiting times for inpatient and day case treatment.

National Tariff

We will introduce a national tariff for hospital procedures to increase transparency in how the NHS uses its money. The national tariff will form the set price list for activity carried out by one NHS Board on behalf of patients who reside in another NHS Board area.

The objective of the national tariff policy is to:

• create a set of standard prices for most procedures to simplify the process for service level agreements between Boards
• create a system that is transparent and fair, and takes into account both volume and case-mix complexity
• create an incentive for efficiency by encouraging benchmarking among Boards, and
• improve the accuracy of financial data by ensuring better recording of both cost and activity data.

The application of the national tariff to cross-boundary activity will be phased in starting in 2005-6, using a selection of specific procedures. NHS Boards have been asked to agree financial flows for this activity using the national tariff by the end of November 2005. The range of procedures to which the tariff will apply will be increased progressively over the next two financial years.

The Executive will monitor the implementation of tariffs, closely benchmarking Boards' performance against the tariff and ensuring that data quality is improved over time.

Independent sector

The long-term relationship between the NHS and the independent health care sector can help to deliver faster access and innovative solutions to some of the challenges identified in the Kerr report. It can support our objectives for a greater separation of elective and emergency work and for faster access to diagnostic services.

We have pledged £45 million over 3 years to negotiate contracts with the independent sector to enable NHS patients to receive their operations more quickly where clinical quality and value for money can be guaranteed. Such a commitment can help to build capacity and bring down prices.

There are three strands to our independent sector purchasing strategy:

• Effective use of existing private sector health care capacity within Scotland, with strict rules on additionality and value for money.
• Use of mobile diagnostic facilities.
• Creation of fast track diagnostic and treatment centres.

During 2004/5, the Executive, through the National Waiting Times Unit, allocated £10m to NHS Boards in Scotland to purchase additional capacity from the independent sector. A further £10 million has been allocated for 2005/6. This has enabled patients throughout Scotland to be treated more quickly in specialities such as orthopaedics, urology, ENT, plastic surgery, ophthalmology and general surgery.

Independent sector 'see and treat' initiatives have been successful in both Greater Glasgow and Tayside, where patients were assessed as outpatients and if treatment was required, operations were provided. Further examples are in Box 3.3.

We may also see the adoption of more short term mobile solutions over the next year, in specialties such as ophthalmology, general surgery and MRI.

Diagnostic services

Diagnostic services are a key part of inpatient, outpatient, primary care and emergency care pathways. The wait for diagnostic tests, however, often presents a bottleneck in the care pathway and leads to uncertainty and heightened anxiety for patients.

The CCI's Diagnostics Programme is supporting NHS Boards to address bottlenecks by matching capacity and demand through the application of basic redesign tools and best practice waiting-list management approaches. We will improve patient access to the eight key diagnostic tests for which national targets have been set (see page 6).

We will take a number of steps to redesign diagnostic services:

• regional and national oversight of service planning to ensure a rational distribution of services, including specialist services
• an information system with a nationally agreed dataset used consistently across Scotland
• extension of the working day to reflect the pattern of demand for services
• systematic planning of key equipment replacement across Scotland on a rolling basis to avoid the creation of backlog of outdated equipment.

With planned investment of £50m over three years, we will minimise waiting times, within a maximum waiting time of nine weeks for eight key diagnostic tests, including MRI and CT scan, by December 2007.

There will be inevitable growth in demand for certain services as a result of Scotland's demographic trends, and requests for complex imaging, including CT, MRI, ultrasound and, in the near future, PET (positron emission tomography) are increasing in preference to standard x-rays. We will proactively plan for the changing nature of demand for diagnostic services and will keep the configuration of services under continuous review.

Management of diagnostic services must focus on the needs of patients by providing services when there is a need for them. While many hospitals have 24-hour x-ray services in or near A&E departments, most provide very limited 24-hour laboratory services, leading to the unnecessary admission of patients who might otherwise be discharged. As new techniques emerge and the uptake of existing technologies accelerates, point-of-care testing should expand considerably as part of the drive towards a more patient-centred service, but not at the expense of the quality assurance of diagnostic tests.

The roll out of digital imaging ( PACS) across Scotland will bring major benefits. PACS captures, stores and displays digital images such as radiology images, x-rays and scans. It is an efficient way to acquire and store images which also allows flexibility in display. When linked to a single CHI-based Electronic Health Record, PACS allows separation of image acquisition, scanning of the patient and analysis and reporting on the scan. This means the patient and reporter do not need to be in the same place, avoiding the need for patients to travel to a specialist centre for some scans. Separating the reporter from the likelihood of interruptions during the process will also improve quality and efficiency.

We will investigate the feasibility of centrally co-ordinated on-call services for radiologists, and will consider if the new national MCN for Pathology should be used as a model to develop further regional and national MCNs for diagnostic services across Scotland.

Managed Clinical Networks

Managed Clinical Networks ( MCNs) are now a well-established part of NHSScotland's approach to the management of long-term conditions, promoting integration of services and patient focus through the strong involvement of patients and clinicians.

Bringing health care professionals together in these networks can also support collaborative working between hospitals and between a hospital and a Community Health Centre. Box 3.4 illustrates recent progress in Tayside in promoting such collaboration.

All NHS Boards have MCNs for cardiac services, stroke and diabetes, which support locally the implementation of our national strategies for these conditions. Many NHS Boards have established (or are setting up) a MCN office as a generic administrative resource to support a number of networks.

At regional level, cancer MCNs are key to the implementation of Scotland's Cancer Plan, and there are MCNs for neurological conditions such as epilepsy. There is also a small (but growing) number of national MCNs, such as those for cleft lip and palate and for mentally disordered offenders.

It is time to take stock of the MCNs' role in the light of experience gained to date and the developments signalled in this report.

SEHD will produce revised guidance by summer 2006 on MCNs aimed at strengthening their authority and increasing their influence over the way in which resources are allocated for services, particularly for service developments identified as a priority. The guidance will also deal with issues such as the way CHPs should link to MCNs, and how the networks fit with the generic approach to long-term conditions.

Transport

The Transport (Scotland) Act 2005 provides for the creation of regional transport partnerships, which will develop regional transport strategies. These strategies will have regard to, amongst other things, the transport needs of health care services including people accessing those services and the wider health impact of transport policies. Health Boards will be statutory consultees for regional transport strategies and will have to act in accordance with them as far as possible. The work by NHS Greater Glasgow, as part of its Hospital Modernisation Programme, in conjunction with other public authorities illustrates this kind of joint working in practice. At a national level we will also consider transport and health issues in the context of the forthcoming National Transport Strategy.

As we refine the shape of planned and unplanned hospital care, we will need to review NHS transport arrangements, particularly those that relate to inter-hospital transfers. At present, there are some 73,000 inter-hospital transfers each year. Only 10% of the transfer work is classified as 'emergency', but two-thirds are carried out by front-line emergency resources. By December 2005, the Scottish Ambulance Service will prepare proposals for a dedicated inter-hospital transfer service that will:

• free paramedics and other practitioners in the emergency service to develop their emerging role as providers of mobile health care in the community
• improve performance on front-line emergency and non-emergency ambulance services
• improve integration of national, regional and local services
• support NHS Boards as they redesign hospital services in accordance with the National Framework for Service Change.

3.3 HOSPITAL SERVICES: AS SPECIALISED AS NECESSARY

We endorse the National Framework for Service Change as the basis for NHS Boards to take future decisions on the reconfiguration of specialist health care services. It reflects considerable professional and patient input and records the substantial consensus that was achieved on these difficult issues.

Volume and outcomes

We will continue to develop a better evidence base about the relationship between the volume of a complex health care intervention and the quality of outcome for the patient. We now know that, across a range of procedures, there is variation in the relationship between increasing volume and improved outcome (reduced mortality and/or improved recovery). We also know that:

• for a condition that is not common and is relatively complex, the improvement tends to be greater: the more operations of a particular type a surgeon performs, the better the outcome
• for a more common, less complex condition, the improvement in outcome is greater initially, but tends to level off: after some threshold level of activity is met, outcome benefits do not continue to grow.

The pattern for many services lies between these ranges, with the precise position being determined by a number of factors. Figure 3.1 shows this relationship.

There is a strong case for ensuring volume is maintained in complex cases. In a country the size of Scotland, that can only be done by offering those procedures in a few locations. Clinicians (and their teams) should undertake common procedures locally, provided there are sufficient cases to maintain clinical skills and it represents a good use of public resources.

But it is the area between the two lines in Figure 3.1 that remains problematic. For some disorders, even though the evidence is less abundant and the effect not so dramatic, the consequences may still be important. For example, a reduction of a few per cent in mortality from myocardial infarction (heart attack) could be associated with many lives being saved in Scotland.

In general, it would be reasonable to suggest that there may be a very small extra risk (increased complications, slightly poorer outcomes) by keeping some treatments local. To inform our future decision making, we need to do more audit, data collection and evaluation to collect information we can use to compare and contrast outcomes according to individual clinicians' and hospitals' workload, improving the quality of our own health care and contributing to the international debate on specialisation. We will establish an expert group to examine this issue and will publish the early results by December 2006.

Figure 3.1 Acute Interventions: volume and outcome

In taking future decisions about service changes, the Scottish Executive will approve proposals where:

• there is evidence of improved clinical outcomes
• there are resource or workforce constraints and it can be demonstrated that:

• the services are highly specialised and a clinical benefit will result, or
• the services include 24-hour receiving of seriously ill patients, or
• the services involve care for medically unstable patients through the night, and
• service redesign will not achieve a sustainable outcome.

3.4 RURAL HEALTH SERVICES

One in five people in Scotland lives in a remote and rural area. Service models that are effective in urban areas may be unsuitable in such locations. We will respond by developing a framework of care specifically for remote and rural communities.

Community health care

The framework will maximise the role of local health care services, especially of GPs, pharmacists and community health teams. This will involve GPs and local primary care teams taking on extended roles (see Box 3.5). The work to develop an accredited programme for GPs and practitioners with special interests, referred to in Section 2, will be an important element, for example in specialties such as:

• dermatology
• ear, nose and throat
• ophthalmology
• musculoskeletal medicine.

CHPs will have a role to play in overseeing the distribution and co-ordination of these skills to serve appropriate populations. That will also mean local practices working collaboratively to provide a range of services for local populations.

The efficiency of visiting clinicians must be maximised. That means co-ordination between visiting consultants and local GPs with special interests to ensure that specialists are concentrating on the most complex cases while also providing support and education for local clinicians.

Community Hospitals will play a key role, treating patients who cannot be cared for at home but who do not require the specialist care provided by a more distant hospital. Their services should include pre-admission and routine testing, outpatient and specialist clinics, day surgery, convalescence, rehabilitation and palliative care. Community Hospitals will remain a key resource if they can refocus their services to meet the changing needs of the population.

Out-of-hours services

As a local Community Health Centre, Community Hospitals can provide a base for out-of-hours care. Many presentations of illness outwith the normal working day can be dealt with properly in the local community. Community First Responders, drawn from the local community and supervised by the local heath systems, can also contribute (see Box 3.6).

Rural communities should have immediate access to emergency triage and dispatch for out-of-hours emergencies. There should also be access to appropriate diagnostic facilities when diagnosis cannot be made at the incident. This could be provided at a Community Hospital or a Rural General Hospital, allowing the most serious cases to be transferred to a specialist trauma centre.

A key requirement in bringing all this together is transport. The Scottish Ambulance Service, NHS 24 and NHS Boards will work collaboratively at regional level to ensure that a resilient transport system for urgent cases is in place.

Rural General Hospitals

Collaboration through, for example, MCNs and greater use of eHealth systems will be needed to ensure that Rural General Hospitals ( RGHs) function efficiently and effectively. They must have defined links with neighbouring RGHs and with larger hospitals. This network of hospitals must share responsibility for ensuring that the bulk of remote communities' health care needs (both unscheduled and planned care) is met locally.

Rural General Hospitals cannot be maintained through providing only trauma and acute illness care. A range of planned services should be provided to maintain local services and consultant skill levels. Each RGH should examine what level of elective service it can safely support, based on guidance on day case surgery as a starting point and looking at how this might be appropriately extended through MCNs. The North of Scotland Planning Group is taking the lead in agreeing a list of safe core services for RGHs that will comprehensively reflect health care needs in rural communities.

We will establish a group that includes NHS Education for Scotland, the Scottish Medical Royal Colleges, NHS Boards and other partners to:

• consider the evidence around standards of care in remote and rural areas by December 2006
• consider operational issues associated with the delivery of health care in remote and rural areas, including how staffing can be assured and clinicians' skills maintained in low-volume procedures, and report in December 2006
• develop appropriate training for remote and rural practitioners and report by June 2007
• consider how this training can best be incorporated into posts in these areas and report by June 2007.

The group will also develop a proposal for a virtual School of Rural Health care by the end of 2006 to build on existing initiatives and develop world class approaches to the development and training of the rural workforce.

3.5 MENTAL HEALTH SERVICES

Mental health remains one of our three national clinical priorities. Good mental health improves the quality of life for people with serious physical illnesses and may contribute to longer life. Of older adults who have physical illness such as heart disease, stroke, cancer and arthritis, about 25% may also be depressed.

The structure and organisation of care is as important in mental health as it is for other services delivered by the NHS, and the messages of the National Framework apply. Integrated and well-organised care, based on up-to-date research and accurate information about the patient, delivered in appropriate settings by teams of professionals, is our shared objective.

The policy context for mental health since 1997 has been the Framework for Mental Health Services in Scotland. It remains relevant, but there is a need for greater clarity about the changes required to deliver a modern and effective mental health service.

We will collect our work to improve mental health services in a national Delivery Plan, to be published by the end of 2006.

Population health

The National Programme for Mental Health and Well-being will continue its focus on population health. This is about promoting well-being and resilience and tackling stigma and discrimination to reduce the risk of mental illness and increase the likelihood that people with mental illness will seek and receive help and support. Specifically, we will implement the report on Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care, and interim targets will be identified to allow us to track progress by 2008 and 2010.

We will focus on improving the physical health and well-being of those with mental illness through work on smoking cessation, diet and physical activity.

Primary care

Up to 30% of GP time is spent in consultations with patients presenting with mild to moderate symptoms of depression, sleeplessness and stress. If we can become more effective in working with this patient cohort, we have the possibility of offering a better, more patient-focused service and of freeing up resources to enable primary care services to play a greater role in long-term conditions management.

We will do this by producing an evidence-based practice guide on depression for primary care in 2006, together with proposals for how the approach can be rolled out across Scotland. This will be based on the lessons from the Centre for Change and Innovation's Doing Well by People with Depression programme (see Box 3.7).

Community services

Expectations of the success of treatments and the possibility of recovery from mental illness has improved in recent years with new medications and therapies, but for many people, mental illness continues to be a long-term condition. Good quality services, such as assertive outreach, enable those with severe and enduring mental illness to remain in the community and live more productive and fulfilling lives.

Evidence shows that crisis services can reduce the need for admissions and enable more people to remain in the community. The Scottish Executive has already provided £575,000 to deliver a range of new crisis services across Scotland. We will take the learning from the crisis pilots and our work on out-of-hours services to develop a national standard for such services in 2006.

National standards will be developed for Integrated Care Pathways ( ICPs) for the main diagnoses (schizophrenia, bi-polar disorder, dementia, depression and personality disorder) by late 2007. Implementation of the standards will be accredited by NHS Quality Improvement Scotland.

General and specialist services

We will develop, by the end of 2006, a national and regional analysis of specialist service needs and the action required to meet those needs, including the implications for service redesign.

We will continue to support the development work of the Forensic Managed Care Network to put in place delivery of new medium secure units, in the west and north-east of Scotland, with redevelopment at the State Hospital by 2009.

3.6 CHILD HEALTH SERVICES

Scottish Ministers have already agreed a high-level vision for children and young people in Scotland:

'…we want them to have ambition for themselves and to be confident individuals, effective contributors, successful learners and responsible citizens. All Scotland's children and young people need to be nurtured, safe, active, healthy, engaged in learning, achieving, included, respected and responsible if we are to achieve our ambition for them.'

Delivering improvements in child health

We have already clarified responsibilities from local to national level, strengthening the role of SEHD in setting the child health agenda and improving links among the new Children and Young People's Health Support Group ( CYPHSG), regional planning groups and NHS Boards. We have also asked NHS Boards and local authorities to draw together their existing planning for children and young people into a single Integrated Children's Services Plan, which describes local improvement objectives and delivery strategies across universal and targeted services for children and young people.

Now that infrastructure issues are being addressed, the CYPHSG will focus on supporting implementation and delivery of improvements in health services for children. We have asked CYPHSG to produce an Action Framework for Children and Young People's Health Services, which will focus on measurable improvements in health outcomes and health care services. This will be issued for consultation by the beginning of 2006.

We have already started with the publication of guidance on the implementation of Health for all Children (Hall4) in April of this year. This focuses on the local delivery of health surveillance and screening, health promotion and redesign of contacts with primary care to ensure that families with greatest need get better access to services.

Children and young people's mental health

Mental health affects children and young people's behaviour, learning and physical health. We must ensure that services and approaches are in place to promote children's mental health, prevent mental illness, and support those children and young people with mental health problems more effectively.

We are committed to the strategic direction set by the Scottish Needs Assessment Programme ( SNAP) report on children and young people's mental health published in 2003. We want to develop and increase capacity within mainstream children's services for mental health promotion and identification of potential mental health problems. We also want to ensure that specialist services are available and accessible for those children and young people who need them.

We have been working closely with CYPHSG and our national project for children and young people's mental health, HeadsUpScotland, to develop a framework that will help local agencies deliver the strategy. We have also been undertaking workforce planning to support delivery, and have committed £1m over two years (to 2006) for workforce development and training. We will work with NHS Boards to support implementation of the framework and to monitor progress.

Specialised acute care for children

The current pattern of specialist paediatric services in Scotland has developed through a process of evolution - it was not designed. In future, decisions on the provision of these services will be taken on a whole-Scotland basis. The current fragmented approach will be transformed to create an integrated service that improves access and equity of care.

We have already agreed funding of £100m to relocate the Royal Hospital for Sick Children in Glasgow as a centre of national expertise in specialist children's services. It will be co-located with maternity and adult services, providing a 'gold standard' children's hospital. The hospital is planned to open in 2010, once the decision on its new location has been approved by Ministers.

We also initiated a review of specialist children's services in 2003 which will inform future plans. Four pilot reviews covered cancer services, complex respiratory conditions, gastroenterology and neurology. Main recommendations from these reviews included:

• development of MCNs at regional and national level
• redesign of services using a four-level model of care describing how services could be provided and organised at local, District General Hospital, regional and national levels
• an increase in specialist staff to meet Working Time Regulations and service gaps
• development of specialist/consultant roles for nursing and AHP staff
• development of regional and national planning and commissioning of services.

The focus now is on implementation of the recommendations from the reviews that have been completed.

The development of children's cancer services is a helpful model for other specialist paediatric services. Clinicians will work as a managed network, and specialist centres will operate as one service for Scotland. The model means that children with cancer will receive the highest quality of specialist care, and will be able to access routine care in a local setting.

CYPHSG will lead a process to undertake an option appraisal to determine the future shape of cancer services over the next 12 months.

The continued provision of paediatric intensive care ( PIC) and high dependency care ( HDC) is an immediate issue for NHSScotland in the light of trends in activity and case mix that may not be sustainable within current provision. The National Framework report recommended continuation of PIC units in both Edinburgh and Glasgow and that the service should be national, commissioned by National Services Division ( NSD) for at least the next five years.

We accept these recommendations, and the service will be nationally designated by 2007 at the latest. The two PIC units will adapt over time, depending on the relative balance of specialist paediatric service provision in the two centres. There will be integrated planning of PIC, HDC and neonatal surgical intensive care ( NSIC) services. HDUs in Aberdeen, Dundee, Edinburgh and Glasgow will support the provision of a wide range of services, while clear procedures will be put in place for the escalation of the intensity of care, including rapid intensive care transfer to and from the lead PIC units in Glasgow and Edinburgh.

A two-year audit of HDU care will be undertaken by NSD. This will provide information on the future need for dedicated HDUs and how these will relate to the PIC units in Edinburgh and Glasgow. This will commence as soon as possible.

An example of the kind of integrated care we envisage is shown in Box 3.8.

Maternity services

The framework and strategic direction for maternal health in NHSScotland is detailed in A Framework for Maternity Services, published in 2001, and the report of the Expert Group on Acute Maternity Services which followed in 2003. We will continue to implement the conclusions and recommendations of these reports to improve services for Scotland's families, mothers and their babies. The National Framework for Service Change reiterates the central principles of both documents, and we accept the recommendations it makes.

We will establish a National Maternity Services Support Group which will oversee implementation of the national strategy. They will do this by linking with regional support structures, identifying priorities for action and negotiating national work with a range of bodies such as NHS Quality Improvement Scotland and NHS Education for Scotland.

3.7 NEUROSURGERY AND NEUROSCIENCE

The National Framework team chose neurosurgery to help focus its consideration of the way in which highly specialised services should be designed in future.

An options appraisal carried out as part of the review indicated that Scotland should move from its current configuration of four neurosurgical centres towards a single centre for neurosurgical intervention for adults and children, as part of a service model that would provide local outpatient and rehabilitation services as well as pre- and post-operative care and diagnosis.

The review, which took full account of the views of patients, described a future service in which adult and paediatric neurosurgery will be co-located at a teaching hospital with other neuroscience specialties. The service will be integrated across specialist, secondary and primary care using the Managed Clinical Network model, and will be provided as locally as possible, with explicit standards of care across the integrated care pathway.

Sub-specialisation should continue, but on a planned and managed basis. Paediatric neurosurgery should be concentrated in one prime site co-located with paediatric intensive care. Unplanned neurosurgical activity would be managed locally within the model, which supports local unplanned care and subsequent transfer to specialist services through agreed pathways.

Taking a national approach to planning highly specialised services will improve integration, quality and productivity by:

• ensuring that services are developed sustainably
• ensuring that we utilise effectively the distinctive skills of clinical teams providing services
• enabling links between highly specialised services to be managed
• ensuring that the quality of patient outcomes is the prime consideration.

The model therefore is for a single, nationally organised service on three levels (Figure 3.2). Within the model is a new concept - Level N1 - that is designed to promote local access to neurological teams when needed, supported by nurse-led clinics and rehabilitation teams. The service at this level will be focused through CHPs, Community Casualty services and GP practices.

SEHD will establish a national implementation team to take forward this work. Specific components of the work now needed include:

• the development of the national model based on the three levels of service set out in Figure 3.2 and using a Managed Clinical Network approach
• a needs assessment for neurosciences
• the development of explicit standards for the neurosurgery service, including mechanisms for assessment of performance against the standards and action plans to address areas of improvement
• the creation of a common minimum dataset and a planned audit programme for the service
• a wide-ranging public consultation on the options for change.

This programme will be completed by December 2007.

3.8 SERVICE CHANGE AND THE NHS WORKFORCE

Workforce planning

This plan will be delivered by putting in place the workforce that can make it happen. Workforce planning flows from service planning and must be fully integrated with it.

We need:

• Regional Workforce Plans to be produced by January 2006 and each September thereafter; NHS Boards in each region will work together to produce a Regional Workforce Plan that addresses those services which serve populations beyond individual NHS Board areas
• NHS Board Workforce Plans to be produced by April 2006 and April thereafter; these will be part of local health planning processes and will provide assessments of the workforce NHS Boards need to underpin strategic service plans, in alignment with the relevant Regional Workforce Plan
• a National Workforce Plan to be produced in December 2006 and each December thereafter; this will be informed by the bottom-up evidence obtained from regional and NHS Board workforce plans on their future demands for staff, and allow decisions to be made on training numbers which will effectively align supply with the projected demand.

The overall aim of the workforce planning framework is to ensure NHSScotland is maximising the efficiency and effectiveness of its use of the workforce. It allows assessment of the numbers of staff we need for the future, the type of staff required, how they will work differently, and changes in education, training and regulation we will need to make to address future needs.

Figure 3.2 Model of service for neurosurgery

We will ensure that the workforce planning framework reflects the implications of service changes for the workforce and identifies actions to be taken at national, regional and NHS Board levels to secure the workforce required.

To ensure that we maximise the contribution of the whole health care team, and consequently improve the effectiveness and efficiency of the service, we will:

• implement the new training arrangements for doctors, Modernising Medical Careers, starting with the Foundation Programme Year 2 in August; programme-based, competency-assessed training will ensure that training arrangements are more effective and that time to train is used more efficiently to ensure future doctors are able to meet patient and service needs.
• build on the publication of frameworks for role development in nursing and the AHPs, focusing on the development of key clinical roles that will support the delivery of actions on unscheduled care, long-term conditions, out-of-hours and emergency services, orthopaedic services and diagnostic waiting times
• review nursing in the community to develop a framework to ensure that community nurses are equipped to provide significant input to the care and treatment of vulnerable people
• ensure that nurses, midwives and AHPs are equipped with core skills and competencies to deliver a modern maternity service, including extending roles for sonographers and preparing midwives as lead professionals for low-risk births
• agree new terms and conditions for Staff and Associate Specialist doctors to support their needs and maximise the valuable contribution they make to the delivery of services
• work with NHS Boards to support service redesign through, for example, the 'Hospital at Night' initiative, which allows for sustainable and effective services that also address the requirements of Working Time Regulations
• put in place a contractual framework for GP practices in 2006/2007 (and beyond) that helps deliver the priorities outlined in this plan, including anticipatory care for high-risk sections of the population, management of long-term conditions in local settings, and greater collaborative working in primary care.

Pay modernisation

Pay modernisation (the new General Medical Services Contract, the new Consultant Contract and Agenda for Change) is a powerful tool for achieving modernisation and service change by providing a platform for new ways of working, the creation of new and extended roles through the development of new skill sets, and better organisation and management of staff capacity. It benefits patient care by providing more motivated staff, working more flexibly and more productively. In essence, pay modernisation is a means to reward, motivate and enable staff to deliver improved services to patients.

Our aim for future pay modernisation will be to deliver new pay systems which directly support the achievement of our priorities for improving services to patients, whether through attaining waiting time targets, better managing chronic disease, or pursuing our health improvement objectives. The new contracts will allow the NHS to:

• manage workloads in a way that improves the working conditions and productivity of staff;
• reward staff fairly;
• replace outdated demarcations;
• provide opportunities for staff to progress by taking on new responsibilities, allowing NHS jobs to be designed around patient and staff needs;
• promote clinical leadership that contributes effectively to NHS objectives; and
• provide a platform for new ways of working that will help deliver seamless care centred around patient needs.

We have already asked NHS Boards to draw up Pay Modernisation Benefits Delivery Plans outlining how they will achieve benefits to services from the new contracts through working in partnership with staff to support redesign and improvements in services. These initial plans have been developed and will now be implemented. They will be updated on a regular basis as part of a process of continuous improvement and modernisation.

This package of workforce measures builds on initiatives mentioned elsewhere in this report such as the integrated care physician, practitioner with special interest and remote and rural physician and provides an integrated workforce response to service change.

"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."

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