Scottish Government

4. Context

When this Government set out its plans for improving Scotland's health and healthcare when it published its action plan Better Health Better Care exactly 2 years ago (December 2007), it made a commitment to:

• improving the health for the whole Scottish population and reducing health inequalities
• Improving the quality of healthcare and healthcare experience, and developing a mutual NHS - offering the people of Scotland new rights and a stronger voice, and
• Maximising the value of our investment in health services in Scotland
• Integrating health, care and other related services

Considerable progress has been made over the last two years through the range of programmes of work which have been developed through the actions set out in Better Health Better Care. As part of the implementation of the Quality Strategy, we need to assess the contribution these and other programmes make to the Quality aims, and accelerate, join-up, re-position or indeed wind-up these programmes where they have completed their aims.

The NHSScotland Chief Executive's Annual Report for 2008/09 set out an overview of the progress which has been made in addressing the priorities for action asset out in Better Health Better Care. This progress has been made through the successful pursuit of a the national targets ( HEAT) and through a range of achievements, many supported by the work streams set up to implement the Better Health Better Care action plan.

In pursuit of the targets and actions set out to improve health and reduce inequalities across the Scottish population, a number of national approaches are being agreed in place to tackle some of the underlying causes of poor health in Scotland including targeted health checks, screening programmes, smoking cessation and prevention, promoting healthy living and preventing obesity, alcohol, reintroducing school-based preventative dental services and implementing an immunisation programme to combat cervical cancer. Equally Well, the Report of the Ministerial Task Force on Health Inequalities set out recommendations for change in policy, practice and delivery across a range of underlying causes and sectors, requiring collaborative action from national and local government and from other agencies including the NHS, schools, employers and the Third Sector. These recommendations are now being taken forward following the production of a shared implementation plan.

A number of significant steps have also been taken towards improving the quality and the value of our healthcare services. In the primary care sector we have introduced the hugely successful minor ailment service, introduced a new effective community pharmacy contract, and developed the use of the Quality Outcomes Framework and the Directed Enhanced Services - all delivering clearly evidenced improvements in outcomes and experience for patients. In the acute sector, waiting times are at their lowest ever levels, and for the first time, ambulances are reaching over 75% of life threatening calls within eight minutes. We have produced strategies to ensure that people with cancer, dementia, heart disease and stroke are getting better and quicker care than ever before and the Scottish Patient Safety Programme is delivering real improvements in our hospitals.

The work we have done in recent years on improving patient safety is an excellent example of how well Scotland is placed to embrace new and effective ways of improving the quality of our healthcare services. Don Berwick (Institute of Healthcare Improvement), a recognized international expert on patient safety, has said, " NHS Scotland has undertaken a bold, comprehensive, and scientifically grounded programme to improve patient safety. The dedication of NHS leadership at all levels to this endeavor is clear, and bodes well for success. In its scale and ambition, the Scottish Patient Safety Programme marks Scotland as leader - second to no nation on earth - in its commitment to reducing harm to patients dramatically and continually." This confirms that we start from a real position of strength in developing and implementing a new quality strategy.

We have recently been leading the world in our collaborative approach to minimising the impact of the A H1 N1 strain of flu. This is a good example of what our Scottish NHS, working with the public and with public services across Scotland, can achieve and how focussed and effective NHS effort to ensure the health of our population can achieve impact and recognition at a global level.

We are continuing to build the basis for the mutual NHS through pioneering work such as the Patients Rights Bill, the Patient Experience Programme, the development of a Carers Strategy and the improvements in support for self-management for long term conditions. Through this mutual approach the NHS in Scotland will continue to learn from and improve on what is most important to the people of Scotland, taking account of the needs of our diverse population - this approach will permeate all our programmes of work.

The publication of 'A Force for Improvement' in January 2009 has already provided the foundations for agreeing the actions required to ensure that the NHS Workforce is supported, developed and equipped to respond to the challenge of the future. There will now be an opportunity to ensure that this action is aligned with the priorities and commitments agreed in the this Quality Strategy.

We have a record on life expectancy and mortality in major disease groups that is challenging, and a range of future demographic, cultural, technological and resource challenges. However, one of our key assets is that Scotland already has a good reputation for its standards in healthcare and its work on quality. So this is not about pulling the plant up by the roots and starting again, it is about challenging ourselves, sharing the pursuit of our ambition with every person in Scotland, focussing our efforts and raising the bar. To do this will require a fundamental shift in culture of delivering excellent, person centred care - it is not about a new set of initiatives, targets and tools.

The Health Foundation QQUIP Project is a respected and authoritative commentator on health quality issues. It recently published a comparison of health quality performance across the UK. This showed:

• Data from the Quality and Outcomes Framework for general practice indicate that the majority of patients across the UK are provided with care that is consistent with evidence-based best practice, with practices in Scotland generally recording the highest achievement scores (alongside Northern Ireland)
• Comparisons in waiting times across systems are difficult but Scotland and England had lower median waiting times than Wales and Northern Ireland for a range of inpatient procedures
• Scotland has the highest number of GPs and hospital beds per 1,000 population
• Patients in Scotland were generally most positive about their quality of care

However, there was also evidence of potential room for improvement in a number of areas including:

• sharing clear specific goals for care and treatment
• sharing information about care or treatment choices and asked for patients' ideas and opinions
• a lack of clear instructions about symptoms to watch for and when to seek further treatment
• written instructions on self-care for people with chronic diseases
• problems due to care not being well co-ordinated across multiple sites or providers

We therefore propose that Scotland generally has well-recognised standards of healthcare quality in specific areas, but there are important challenges in relation to person centredness, and in learning from and rolling out the individual areas of high quality services to create whole-system or integrated world-leading healthcare services.

Future Challenges

For many years we have been well aware of the range of drivers of change which will create very real challenges in the delivery of high quality healthcare services:

• The next 20 years will see an ageing population, a continuing shift in the pattern of disease towards long-term conditions, and growing numbers of older people with multiple conditions and complex needs and the impact of this on them and their immediate carers. There will be more older family carers too many of whom will have their own health needs.
• demographic change and associated shifts in the pattern of ill health will determine the demands on the health care system
• workforce pressures will be the bottom line in determining how we are able to respond to these changes in demand
• Developments in technology and in information and communications technology in particular, will give us the tools to fundamentally reshape how health care is delivered.
• Increased public awareness, diversity and intelligence creating different expectations and requirements around treatments, equipment, access, drugs and therapies

Added to these challenges are the new challenges we face in the current economic climate with tightening financial resources available to respond to the increasing demands suggested by these demographic, cultural and technological changes. A number of strategies and policy documents have already set these challenges out clearly, and recognise the need to change the way we deliver services, so that future generations can also enjoy continually improving health and healthcare.

The Quality Strategy has been developed to provide a renewed focus and momentum on addressing the full range of current and future challenges, and builds on the further developed understanding we now have from local, national and international experience of what needs to be done. Achieving its aims will ensure that the services we provide are sustainable for the future generations in Scotland. We will do this by listening to the messages from staff, patients and carers about what they expect from their NHS and responding to them, by shifting the culture to a more person-centred NHS which is focussed in delivering clinical excellence, and patient safety, while ensuring equity, timeliness and best value. This is why we need a national Quality Strategy for NHSScotland.