Chapter 3 Healthcare Quality
In the Quality Strategy we have established three Quality Ambitions that provide the focus for prioritising and integrating activity across NHSScotland, in partnership with the rest of the public sector, the third sector, and with the people of Scotland. In this chapter, we consider healthcare quality achievements and progress during 2010/11 in terms of their relevance to each of the three Quality Ambitions.
Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
During 2010/11, we have made important progress towards our Quality Ambition for person-centred healthcare. In this section we set out details of progress on the range of initiatives that are being pursued across NHSScotland for the benefit of patients, carers, the public and for staff. Key areas of progress include the implementation of Living and Dying Well: A national action plan for palliative and end of life care in Scotland * - which is already improving care for people at the end of life, ground-breaking legislation to introduce patient rights and the introduction of new services within Community Pharmacies to improve services for patients, while releasing time for General Practitioners ( GPs).
We have made important progress in improving support for people with long term conditions, enabling them to self manage, and reduce the likelihood of needing unplanned hospital care. Recognising the vital role of carers, we have begun the implementation of a new carers strategy to support them in their role and involve them in planning. For staff, we have established a new occupational health and safety framework which will improve the health, safety and engagement of staff across a range of areas. Finally, our approach to partnership working has been recognised as leading the way across the UK public sector - an asset we will build on and develop over coming years to ensure continued progress towards our person-centred Quality Ambition and towards our wider shared aim of sustainable high quality healthcare services.
BETTER TOGETHER - SCOTLAND'S PATIENT EXPERIENCE PROGRAMME
The Better Together patient experience programme is providing national information on patient experience, along with tools and advice to support improvement prioritised through use of this national data as well as through the use of a range of local information activities undertaken by NHS Boards. Better Together is a fundamental component in improving healthcare quality through the person-centred focus of the Quality Strategy.
In late summer 2010, for the first time, NHSScotland published robust and comparable data on the quality of people's healthcare experience by NHS Boards with the publication of results from the second Inpatient Survey. Data was also published by hospital for the 15 participating NHS Boards, as well as board and practice level reports on patients' experiences of GP practices. All participating NHS Boards have established action plans to address the areas people told us were important to them and where we could make improvements. The emphasis is firmly on improving at a local and national level and not on merely gathering information on experiences.
KEY FINDINGS FROM THE 2011 PATIENT EXPERIENCE SURVEY
We sampled patients who had an overnight stay of one night or more from October 2009 - September 2010, with the analysis and reporting undertaken during the first part of 2011.
In August 2011, Scotland's Chief Statistician published national results of the Scottish 2011 Inpatient Patient Experience Survey 7 . The results showed that:
- People continue to report good or excellent experiences of care in hospitals across Scotland with 85 per cent reporting their overall care and treatment as good or excellent;
- Patients were generally slightly more positive about their experiences of doctors with a 4 percentage point increase in the patients who had enough time to speak to the doctors to 82 per cent;
- The percentage of patients who were happy with the food and drink that they received decreased by 4 percentage points to 67 per cent; and
- Of the five stages of the inpatient journey, patients were most positive of their experiences of the staff and least positive about the arrangements made for them leaving hospital.
PATIENT RIGHTS (SCOTLAND) ACT 2011
The Patient Rights (Scotland) Act 2011 gained Royal Assent on 31 March 2011. The Act aims to improve patients' experiences of using health services and to support people to become more involved in their health and healthcare. The provisions of the Act includes: a duty to publish a Charter of Patient Rights and Responsibilities; a set of principles for healthcare provision covering patient focus, quality care and treatment, patient participation, and communication; a 12 week treatment time guarantee; a right to give feedback or comments, or raise concerns or complaints; and the establishment of a Patient Advice and Support Service. Work is now underway to implement the Act, which will be enacted in full by October 2012.
ABOLITION OF PRESCRIPTION CHARGES
Legislation was passed by the Scottish Parliament to abolish prescription charges with effect from 1 April 2011. This removes the financial barrier to good health for many people in Scotland, particularly those with long term conditions who previously were not exempt from paying for their prescriptions. The abolition of charges ensures that everyone can access the medicines they need and make choices about managing and improving their health. People will no longer be deterred from obtaining prescribed medicines because they can't afford it.
SUPPORT FOR PEOPLE WITH LONG TERM CONDITIONS
The Long Term Conditions Alliance Scotland ( LTCAS) has worked with the Scottish Government's Lead Clinician for Self Management to help NHS Boards adopt ways of providing a range of emotional and psychological support to people living with long term conditions, by promoting listening and compassion as an active support, as identified in Emotional Support Matters *. The Self Management Fund for Scotland has so far supported 81 person-centred, asset-based projects which have developed high quality strategies and approaches to self management. Collectively these projects have: improved the availability of support and information; increased involvement of people living with long term conditions and their unpaid carers; increased partnerships across sectors; and improved the ability of people to self manage long term conditions without dependence on traditional services and support. Figures show that the My Condition, My Terms, My Life campaign has contributed to greater awareness, with 88 per cent of people living with long term conditions aware of the term 'self management' compared with only 57 per cent before the campaign started.
PALLIATIVE AND END OF LIFE CARE
In collaboration with other partners, important progress has been achieved through the implementation of Living and Dying Well: A national action plan for palliative and end of life care in Scotland *. This includes: the publication of Living and Dying Well - Building on Progress *; the launch of the Do Not Attempt Cardio Pulmonary Resuscitation ( DNACPR) form and guidance ensuring a consistent approach across Scotland in considering the needs of patients requiring end of life care; and the continued roll out of the Electronic Palliative Care Summary across Scotland to ensure that patients and carers needs are accurately recorded in GP practices and accessible around the clock for health professionals involved in care delivery.
REVIEW OF NO-FAULT COMPENSATION
A review was established to consider the introduction of a no-fault compensation scheme. The review included examination of the cost implications, the consequences for healthcare staff, and the quality and safety of care. It also took account of the wider implications for the system of justice and personal injury liability and examined evidence on the operation of no-fault compensation in other countries. The review group has now submitted its report, with recommendations and advice on the key principles and design criteria that could be adopted for a no-fault compensation scheme.
Our focus continues to be to use Community Pharmacies where appropriate to make services accessible to patients and to reduce pressures on other parts of NHSScotland. The Public Health Service ( PHS) provides a patient-focused service by Community Pharmacies in two areas: smoking cessation, with the provision of a service to help those who want to stop smoking by providing a course of up to 12 weeks nicotine replacement therapy ( NRT) together with advice and support; and a sexual health service, which provides free access to Emergency Hormonal Contraception ( EHC). Both of these services have resulted in positive feedback from users.
The Minor Ailment Service ( MAS) enables people to register with their Community Pharmacy for the treatment of a number of common conditions without the need to visit their GP. The service provides convenient and easy access for patients, while freeing up GP time to deal with patients who have more chronic conditions. The latest figures show that the service is well used, with 790,509 people in Scotland registered for MAS at the end of March 2011.
CHRONIC MEDICATION SERVICE
The Chronic Medication Service ( CMS) has continued to be rolled out. CMS aims to improve patient care through a systematic approach to the pharmaceutical care of patients with long term conditions. CMS uses the skills and expertise of Community Pharmacists in the management of patients with long term conditions, helping to improve patients' understanding of their medicines and helping to maximise the clinical outcomes from their therapy by providing an individualised, patient-centred model of care. The partnership approach and systems in place through CMS are also helping to minimise adverse drug reactions, preventing potential problems with medicines and reducing wastage. By the end of March 2011, 58,758 patients were registered for the service with Community Pharmacies across Scotland.
AMBULANCE SERVICE AND PATIENT TRANSPORT
Working with patients and carers, the Scottish Ambulance Service improved Patient Transport ( PTS) punctuality for appointments, and invested in new vehicles and shock boxes for PTS crews. Cancellations were reduced, and an ambitious improvement programme has commenced. For emergency and urgent patients, new care pathways were developed for falls, diabetes, alcohol and mental health conditions.
The Ambulance Service launched anticipatory care schemes involving paramedics working within primary care to tackle health inequalities and to help patients manage chronic conditions. The collocation of Emergency Dispatch Centres with NHS 24 and out-of-hours services was achieved, and the specification for the common clinical triage tool was developed. Air ambulance clinical triaging was refined, ensuring that critically ill patients are prioritised and decision support arrangements were established for ambulance crews.
CARING FOR SMILES - BETTER ORAL HEALTH FOR OLDER PEOPLE
Older people face more constraints on health and mobility, which can make attending the dentist within their community more difficult. This is especially the case if they are in residential care or being cared for in their own home. Caring for Smiles is an initiative introduced to assist oral health professionals to deliver training for staff in care homes so they can provide a high standard of oral care for dependent older people. The training provided highlights to care staff that good oral health is important for overall general health and encourages them to see oral care as an integral part of personal care.
ACTION PLAN FOR ALLIED HEALTH PROFESSIONALS IN MENTAL HEALTH
Realising Potential: An Action Plan for Allied Health Professionals in Mental Health * was published in May 2010. It provides a collective and clear set of statements about the role of Allied Health Professionals ( AHPs) in mental health and suggests ways to further improve service delivery and the quality of care for service users and their carers. In particular, it identifies five main clinical developments for AHPs in Scotland: early access and timely intervention; supported self-management and recovery; promoting physical health and mental wellbeing; designing and delivering psychological therapies; and integrating vocational rehabilitation in mental health.
HEALTHY WORKING LIVES
Following the publication of Health Works: A Review of the Scottish Government's Healthy Working Lives Strategy * work has continued to deliver identified actions. A national forum has been established to develop the principles of the Scottish Offer which describes how healthcare services should include work outcomes within patient care. Information and advice has been provided for employers, employees and healthcare professionals to support the introduction of the new medical certificate or Fit Note. The Scottish Government has invested approximately £1.5 million in 2010/11 in Working Health Services Scotland, providing support to more than 2,500 people working for small and medium-sized enterprises, enabling them to remain in or return to work. The Scottish Centre for Healthy Working Lives has published, Health Profits: An introductory guide to protecting and improving employee health *, a toolkit for small and medium-sized enterprises, providing accessible advice on a wide range of workplace health, safety and wellbeing issues.
With support from the Scottish Government of £5 million in 2010/11, NHS Boards and the Scottish Ambulance Service have taken forward a wide range of initiatives to support carers and young carers, including the provision of information, advice and support. This is helping to ensure that carers are better supported to sustain them in their caring role. Where carers are involved in planning and designing hospital discharge arrangements and individual care packages, there is less likelihood of readmissions that are costly and stressful.
FAMILY NURSE PARTNERSHIP PROGRAMME
The Family Nurse Partnership programme works closely with teenage mothers from early pregnancy until the child reaches the age of two. The Family Nurse Partnership Team in NHS Lothian enrolled 148 clients within the agreed nine-month recruitment period (January - October 2010). During the recruitment period, the programme was offered to all eligible women who were 19 and under, first-time mothers, living within the geographical boundaries of Edinburgh Community Health Partnership. Almost one-third of women were recruited by 16 weeks gestation, and all women were recruited by 28 weeks. Early signs are that the women are engaging with the materials and building trusting relationships with the nurses.
NHS BOARD ELECTIONS AND ALTERNATIVE PILOTS
The Health Boards (Membership and Elections) Act 2009 was passed unanimously by Parliament on 12 March 2009. The Act gave the Scottish Government the powers to hold two pilot elections and two alternative pilot elections to NHS Boards in Scotland, whereby a proportion of the membership of each board would be made up of elected members to expand public participation in NHS Board decision-making. The pilot elections for health board members in NHS Fife and NHS Dumfries and Galloway were held on a postal basis and took place on 10 June 2010. In Fife, 60 candidates stood for 12 health board seats and in Dumfries and Galloway, 70 candidates for 10 health board seats. An independent evaluation of the pilot elections is being carried out by the London School of Economics and the University of St Andrews, with the final report expected in Autumn 2012. This report will be laid before Parliament, which will debate and decide on any future roll out of Health Board Elections. The alternative pilots are being conducted in NHS Lothian and NHS Grampian to consider enhancing the current public involvement and public appointment processes and attracting a wider range of applicants.
ORGAN DONATION AND TRANSPLANTATION
A high-impact advertising campaign was run, using a new creative approach, to raise awareness and encourage sign-up to the NHS Organ Donor Register with 37 per cent of Scots now on the Register - the highest percentage in any part of the UK. During 2010/11, additional specialist nurses and clinical leads were appointed, helping to make donation a usual part of end of life care. Donation Committees were established in mainland NHS Boards with links to island boards.
LIFE BEGINS AT 40
Work was undertaken with NHS 24 to produce an online questionnaire that allowed people turning 40 to assess their own health online or over the phone. From the information given, people are provided with health information specifically tailored to their needs, and are directed to other sources of information on national and local services. Following a successful pilot in the Grampian area, the project was rolled out on a national basis in February 2011.
The Working Well Challenge Fund enables NHS Boards to develop and share good practice in staff development, which in turn, leads to improvements in both staff and patient experience. In 2010/11, the Fund supported a total of seven projects with a combined value of £194,000. These projects were around key themes such as tackling violence and aggression against staff, addressing stress and health promotion.
OCCUPATIONAL HEALTH AND SAFETY STRATEGIC FRAMEWORK
Safe and Well at Work *, the new occupational health and safety framework for NHSScotland, is a person-centred framework setting out how NHS Boards should approach occupational health and safety in order to keep staff motivated, healthy, engaged and safe. It adopts an approach based on the integration of occupational health and safety provision with wider approaches to improving staff health, safety and wellbeing. Four priority areas for action have been identified: mental health and wellbeing; musculoskeletal disorders; violence and aggression; and slips, trips and falls. The Occupational Health and Safety Strategic Forum will monitor progress in implementing the framework.
KNOWLEDGE AND SKILLS FRAMEWORK
The Knowledge and Skills Framework ( KSF) underpins our commitment to learning and development for staff working in NHSScotland. The KSF development review process is based on good human resource practice. It requires managers to have at least one annual discussion with staff to review how the individual is applying her or his knowledge and skills to meet the demands of the post. Research has found that regular staff appraisal, alongside other human resource interventions, can result in improved health outcomes through, for example, reduced errors, lower infection rates, reduced mortality rates and improved patient experience.
In 2009, NHS Boards achieved the HEAT target of having KSF personal development plans in place for staff. During 2010/11, NHS Boards built on this foundation by working toward the further HEAT target of having summary information on at least 80 per cent of development reviews recorded on the electronic monitoring system e-KSF by the end of March 2011. Overall, as at that date, NHSScotland achieved a level of 85 per cent of NHSScotland staff with summary development review information recorded on the e-KSF system.
2010 NHSSCOTLAND STAFF SURVEY
Over 40,000 staff took part in the 2010 NHSScotland Staff Survey held between October and November 2010. Some of the key highlights of the survey were: the majority of respondents (88 per cent) were happy to go the 'extra mile' at work when required; over 70 per cent feel a sense of achievement from their work; the number of employees who would recommend their NHS Board as 'a good place to work' increased to 58 per cent - compared to 55 per cent in 2008; and almost 80 per cent of employees intend to be working in their NHS Board in 12 months time - compared to 77 per cent in 2008.
REDUCTION IN SICKNESS ABSENCE
The annual sickness absence rate for NHSScotland staff fell in 2010/11 to 4.74 per cent from a high of 5.55 per cent in 2006/07. This is the fourth consecutive year that the rate has fallen. The Scottish Government and NHS Boards are working in partnership with the trade unions to promote attendance rather than just managing absence. Safe and Well at Work * sets out how NHS Boards should approach occupational health and safety to keep staff motivated and healthy, engaged and safe.
PARTNERSHIP WORKING IN NHSSCOTLAND
The interim results of the University of Nottingham Economic and Social Research Council ( ESRC) funded research study into partnership working in NHSScotland were published in January 2011. This included very positive results and indicated, for example, that the employment relations model within NHSScotland is arguably the most ambitious and comprehensive labour-management partnership so far attempted in the UK public sector, and is significantly better than those employed elsewhere in the NHS. The final report of this phase of research is expected to be published in November 2011.
There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
NHSScotland has received international acclaim for its approach to implementing improvements in patient safety. We have now established a shared Quality Ambition for no avoidable injury or harm across all aspects of healthcare services. During 2010/11, we started the roll-out of the successful Scottish Patient Safety Programme from the hospital sector into mental health, primary care and paediatrics.
In this section we set out the progress which has been made so far for patients and the public, and for staff. Key areas of progress include: the significant downward trend in the hospital standardised mortality rate of over 7 per cent since 2006/07; and huge reductions in Healthcare Associated Infection, including a 71 per cent reduction in Clostridium difficile since 2007/08.
THE SCOTTISH PATIENT SAFETY PROGRAMME
The Scottish Patient Safety Programme has been implemented in every acute hospital in Scotland to reduce mortality rates by 15 per cent and to reduce adverse events. It has already contributed to a range of activity resulting in significant improvements in patient safety with continued reductions in: ventilator associated pneumonias; critical care central line blood stream infections; and Staphylococcus aureus bacteraemia incidents in Intensive Care and High Dependency Units. In June 2010, the programme was extended to paediatric hospital services; and work is underway to develop national safety programmes in primary care and in mental health.
KEY RESULTS FOR PATIENT SAFETY
Considerable progress has been made as we continue to work towards achieving the key aims of the Scottish Patient Safety Programme. Achievements of the Programme across NHSScotland (covering 1 April 2010 to 31 March 2011 compared to the baseline) include:
- Scotland-wide there has been a 15 per cent increase in on-time antibiotics as a result of increased use of the surgical checklist. There has also been a 73 per cent reduction in Central Line Infections, a 43 per cent reduction in Ventilator Associated Pneumonias and a 23 per cent increase in safety briefings.
- In NHS Ayrshire and Arran, Crosshouse Hospital has seen a reduction of 19 per cent in their Hospital Standardised Mortality Rates up to 31 March 2011 from the baseline.
- Borders General Hospital Intensive Care Unit have achieved 776 days since their last Central Line Bloodstream Infection.
- In NHS Fife, six wards have achieved 300 days or more without a Staphylococcus aureus bacteraemia and eight wards report no Clostridium difficile incidents over the year. Over 85 per cent of patients have had optimal blood glucose results in Intensive Care and High Dependency Units for over one year. Over 95 per cent of patients have received on-time antibiotic prophylaxis before surgery.
- NHS Greater Glasgow and Clyde has reported that 280 clinical teams are participating in the Scottish Patient Safety Programme. 80 per cent of the peri-operative teams in NHS Greater Glasgow and Clyde have a reliable process for surgical pause with associated reductions in wrong site surgery.
- NHS Grampian has 10 theatres, as of March 2011, with 100 per cent compliance with peri-operative briefings.
- NHS Lothian has seen a reduction of adverse events across all its adult acute hospitals of 42 per cent and they have gone 424 days without a catheter-related blood stream infection compared to the baseline of 15 days. NHS Lothian reported a 400 per cent increase in the use of surgical pause between April 2010 to March 2011.
- Dumfries & Galloway Royal Infirmary Intensive Care Unit has achieved 785 days since their last Central Line Bloodstream Infection and 507 days since their last Staphylococcus aureus bacteraemia. It has also achieved a 16 per cent reduction in its Hospital Standardised Mortality rate up to 31 March 2011 from the baseline.
- In NHS Highland, Raigmore Hospital ICU has achieved 571 days between a Ventilator Associated Pneumonia and 383 days between Central Line Bloodstream Infections.
- NHS Tayside has reported no central line-related infections across surgery between November 2010 to March 2011, with medical High Dependency Unit having no new central line infections reported since the unit opened in 2007. NHS Tayside has seen an overall 46 per cent reduction in surgical site infections from 2007 to December 2010. Ninewells Hospital has reported an 11 per cent reduction in its Hospital Standardised Mortality Rates.
- NHS Western Isles has achieved 703 days since its last Central Line Bloodstream Infection.
- Within critical care in NHS Lanarkshire, Wishaw General Hospital has achieved 723 days between a Ventilator Associated Pneumonia. Monklands Hospital has achieved 677 days and Wishaw General Hospital 521 days between Central Line Bloodstream Infections. Hairmyres Hospital has not had a Central Line Bloodstream Infection since the Programme started. Hairmyres Hospital has achieved 398 days between Staphylococcus aureus bacteraemias.
HEALTHCARE ASSOCIATED INFECTION
Tackling Healthcare Associated Infection has been a priority for the Scottish Government and NHSScotland. The Scottish Government HAI Taskforce Report On Delivery Programme: 2008-2011 *, published in March 2011, highlights the success of a range of measures taken to drive down infection rates. The national target to reduce Clostridium difficile Infection ( CDI), together with support to NHS Boards on prudent prescribing through the Scottish Antimicrobial Prescribing Group, has resulted in the lowest CDI levels in Scotland since monitoring began. MRSA infections have reduced significantly too. A sustainable package of measures to reduce rates of infection and building on the significant progress already made is being taken forward by a revised taskforce.
CENTRAL LINE INFECTIONS
Central line infections are hospital-associated infections which have occurred in all intensive care units for many years. They lead to considerable suffering for patients and their families. In addition, patients have to stay in critical care for longer leading to risk of further harm, increased length of stay and associated costs. The Scottish Patient Safety Programme has been working to eradicate central line infections and there has been a dramatic reduction since the beginning of 2008. In March 2011, there were no central line infections in Scotland.
Adverse events are difficult to measure but it is clearly important to reduce them as far as possible. The Scottish Patient Safety Programme ( SPSP) has an aim to reduce adverse events by 30 per cent by the end of 2012. The SPSP measure adverse events by using a specific tool called the Global Trigger Tool which is a system of reviewing notes to measure harm suffered by patients. NHS Lothian has worked hard to create a reliable measurement system across the three acute hospital and even harder on reducing these adverse events. They have demonstrated a 43 per cent reduction.
To reduce all Staphylococcus aureaus bacteraemia (including MRSA) cases by 30 per cent by 31 March 2010 and to achieve a further reduction in cases of 15 per cent by 31 March 2011; and to reduce the rate of Clostridium difficile infections in patients aged 65 and over by at least 30 per cent by 31 March 2011.
NHSScotland has delivered a 37 per cent reduction in Staphylococcus aureaus bacteraemia between March 2006 and March 2011, against a HEAT target of 41 per cent.
NHSScotland has also delivered a 71 per cent reduction in Clostridium difficile since 2007/08 against a HEAT target of 30 per cent.
HEALTHCARE ENVIRONMENT INSPECTORATE
In its second full year of operation, the Healthcare Environment Inspectorate ( HEI) continued its programme of inspections. The HEI was established to provide independent and rigorous scrutiny and assurance of hospitals in Scotland in order to achieve improved performance in tackling Healthcare Associated Infections and to ensure that patients and the public can have complete confidence in the cleanliness of hospitals and the quality and safety of services. All acute hospitals will receive one announced and one unannounced visit in a three-year cycle. During 2010/11, HEI conducted 32 inspections of 29 acute hospitals across ten NHS Boards. Following each inspection a detailed set of recommendations for improvement action were made, and followed up by the relevant NHS Board.
ADVANCED HEART FAILURE STRATEGY
The Scottish National Advanced Heart Failure Strategy * was launched on 14 February 2011 to enhance the care and treatment of heart failure patients. The Golden Jubilee National Hospital has been working on the identified priorities of: improving access to specialist expertise through outreach arrangements to local hospitals and communities to ensure a consistent, equitable, Scotland-wide referral pathway for those with the most advanced heart failure; increasing the number of heart transplants; and enhancing the current Scottish mechanical 'heart' service (Ventricular Assist Devices) at the hospital.
CODES OF CONDUCT AND PRACTICE
A Direction from Scottish Ministers made a set of Induction Standards and Code of Conduct for Healthcare Support Workers ( HCSWs) and a Code of Practice for their Employers mandatory across NHS Boards. The Direction was effective for new start Healthcare Support Workers from 31 December 2010. This model is now enhancing the awareness, motivation and confidence of Healthcare Support Workers and is focusing supervisors on the vital role they play. The standards and codes equip Healthcare Support Workers at a fundamental level, to do their best to protect patients and members of the public in every way they can during the course of their duties. The model in Scotland is recognised across the UK as one of the potential alternatives to a statutory model of regulation.
The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
Many of the areas for improvement which have been prioritised during 2010/11 make a direct contribution to our Quality Ambition for more effective healthcare services. A clear focus of this activity has been to identify those improvements where there is clear and agreed evidence of clinical and cost effectiveness, and to support the spread of these practices where appropriate to ensure that unexplained and potentially wasteful or harmful variation is reduced.
Key areas of progress are set out in this section for both patients and public and for staff. They include further reductions in waiting times for both outpatient and inpatient appointments, and good progress towards achieving 18 weeks Referral To Treatment ( RTT) due for delivery by December 2011. In addition, a number of high impact changes have been implemented for people with long term conditions which have already resulted in a reduction in the rate of older people requiring emergency admission to hospital. We have launched a new dementia strategy to support recognition of the condition, and to improve treatment and support for people affected and their carers. The roll-out of a successful programme is increasing the amount of time nurses have to spend with patients, and there have been marked improvements in emergency response for people in remote and rural areas, including the roll-out of the new Emergency Medical Retrieval Service - our Scottish equivalent of a flying doctor service - which is saving lives and improving outcomes for people in the most remote parts of Scotland.
Patients want prompt access to treatment, delivered as locally as possible. Cutting waiting times improves outcomes for patients and ensures effective and efficient use of resources. Since 2005/06, the UK Comparative Waiting Times Group ( UKCWTG) has analysed a list of 11 inpatient procedures and the length of time a patient has waited for treatment. The Office of National Statistics published the latest report including data up to 2009/10 in November 2010. The 11 procedures include: Cataract Surgery, Hip replacement, Knee replacement and Endoscope of bladder. The report showed that:
- Scotland has the lowest median waiting time for seven of the 11 procedures; and
- Scotland has the lowest 90th percentile waiting time for seven of the 11 procedures.
Deliver 18 weeks Referral to Treatment from 31 December 2011. No patient will wait longer than 12 weeks from referral (all sources) to a first outpatient appointment from 31 March 2010. No patient will wait longer than nine weeks from being placed on a waiting list to admission for an inpatient or day case treatment from 31 March 2011.
NHSScotland has continued to deliver the existing maximum waiting times standards of 12 weeks or less for their first outpatient appointment; nine weeks for inpatient/day case surgery and six weeks or less for one of the eight key diagnostic tests. This was a significant achievement given the need to reschedule patients' appointments and elective operations over the severe winter when it was not safe for patients to travel.
Significant progress has been made on 18 weeks Referral to Treatment ( RTT) with statistics for March 2011 showing 85 per cent of patients having their treatment within 18 weeks of referral.
There were considerable pressures over the last winter on the 4 hour A&E access standard with performance at 94 to 96 per cent against a standard of 98 per cent. The 4 hour standard had its origins in public dissatisfaction about long waits, particularly where patients remained on trolleys. A growing body of medical evidence suggests that long waits do not merely impact on patients' experience, but also on their quality of care. The Scottish Government is currently providing active support where performance needs to improve.
SPECIALIST CHILDREN'S SERVICES
The National Delivery Plan for Children and Young People's Specialist Services * was a three-year plan (2008-2011) with £32 million of funding to support the improvement and expansion of services. It has a recurring commitment of £19.5 million from 2011/12. The Plan had 55 commitments, which have now been completed and which were overseen by an implementation group. Funding for the National Delivery Plan has provided a number of new posts (whole time equivalent) including 33 consultants, over 75 Allied Health Professionals and 138 nurses. Multi-disciplinary teams are now in place and more care is being delivered closer to the patient's home, reducing travel time for patients and their carers.
The Scottish Cancer Taskforce published its Better Cancer Care Progress Report * in November, which sets out progress made in improving cancer services and outcomes for those affected by cancer. Specific achievements include a collaborative project to agree the standard radiotherapy equipment for procurement over the next two years, and a structured work plan for the development of Quality Performance Indicators for specific tumour groups which was established to measure services for their safety and effectiveness. In addition, a 'Vision for Scotland' was launched to improve services for those living with and beyond cancer. In Scotland, too many people are already in the advanced stages of the disease before they see a doctor. A Detect Cancer Early initiative is now being pursued with the aim of increasing the number of cancers detected at the early stage of disease. This 'whole systems' approach aims to increase cancer survival rates and raise Scotland's cancer survival rates to those in the rest of Europe.
Official waiting times figures published in December 2010 showed that cancer waits were beating HEAT targets more than a year ahead of schedule. This continued to be sustained throughout the year - with even more patients included. Figures showed 97.3 per cent of patients urgently referred with a suspicion of cancer between July and September 2010 started treatment within 62 days. The figures also showed 98.1 per cent of cancer patients started treatment within 31 days of a decision being taken to treat - again showing early delivery. The target now includes patients referred through the breast, bowel or cervical cancer screening programmes. Previous statistics had recorded only patients urgently referred with a suspicion of cancer by their GP or dentist or through Accident and Emergency.
LONG TERM CONDITIONS
By the age of 65, nearly two-thirds of people will have developed a long term condition. People with long term conditions are twice as likely to be admitted to hospital, will stay in hospital disproportionately longer and account for over 60 per cent of hospital bed days used. The Scottish Government has supported NHS Boards, through the implementation of the Long Term Conditions Action Plan * and a collaborative approach, to empower people with long term conditions to become more involved in managing their own health and healthcare, and to reduce the need for hospital care. A HEAT target was agreed with NHS Boards to reduce the number of emergency bed days for people with Chronic Obstructive Pulmonary Disease ( COPD), Coronary Heart Disease ( CHD), Diabetes and Asthma by 8 per cent between 2006/07 and 2010/11. The collaborative has focused on the use of proactive, planned and integrated case management and an anticipatory approach to care that encouraged a better flow of people out of hospital and a shift towards self management, innovation and building capacity for care at home. By 2009/10, NHS Boards had delivered an 11 per cent reduction.
ACCESS TO LOCAL INFORMATION TO SUPPORT SELF MANAGEMENT ( ALISS) PROJECT
The ALISS project aims to make it easy for people to find very local information and resources to support self management. The ALISS project is an example of mutual development and innovation in healthcare systems. A working model (the ALISS Engine) has been developed with users and key stakeholders such as information providers to refine requirements. Tests of the model have demonstrated improvement in accessing local information.
In August 2010, NHS 24 launched NHS inform, a national service which provides a broad range of quality assured health information through web and telephony services to people across Scotland. Delivered in partnership with the Scottish Government, NHS Boards and voluntary organisations, NHS inform is becoming the first point of contact for the public, carers and healthcare professionals seeking healthcare information. This service is now available on digital television, thereby making it more accessible.
HEART DISEASE AND STROKE
The Better Heart Disease and Stroke Care Action Plan * focuses not just on providing the best possible care in the acute setting, but in helping people's longer-term recovery in their own communities, reflecting the increasing importance of the quality of people's healthcare experiences. Future improvements will continue to depend on people's lifestyles - healthier eating, being more active, stopping smoking and drinking sensibly - and we are taking firm action in all these areas to support people to change their lives for the better. The national target was for a 60 per cent reduction in premature (under age 75) deaths from coronary heart disease and a 50 per cent decrease in the age standardised death rate amongst under 75s between 1995 and 2010 from stroke. The number of premature deaths from strokes has been halved a year ahead of schedule, while early deaths from heart disease have decreased by almost 60 per cent.
The Scottish Centre for Telehealth helped develop an Out of Hours Telestroke Service across the South East of Scotland NHS Boards and NHS Tayside. NHS Lothian now provides a stroke 'Hub' supporting NHS Forth Valley, NHS Dumfries and Galloway, NHS Borders, and NHS Fife. This service ensures rapid access to specialist stroke diagnostics and thrombolysis for patients during the out of hours period, thus delivering effective care which saves lives and supports patients to achieve the fullest possible recovery.
SUCCESSFUL COMPLETION OF MENTAL HEALTH COLLABORATIVE
The Mental Health Collaborative three-year improvement programme (2008-2011) has supported NHS Boards, and their key partners to use improvement approaches and techniques to improve services in mental health through identified targets. A HEAT target was agreed to reduce psychiatric readmissions by 10 per cent which was significantly exceeded with an overall reduction of 19 per cent across NHSScotland. NHS Boards also ensured that over 50 per cent of key frontline staff had been educated and trained in using suicide assessment tools and suicide prevention training programmes. Conservative estimates indicate that over 2,000 staff working in mental health have now received training in service improvement techniques over the last three years.
Scotland's National Dementia Strategy *, the first such strategy in Scotland, was published in 2010, establishing dementia as one of the Scottish Government's clinical priorities. Since publication of Standards of Care for Dementia in Scotland *, standards have been developed which relate to everyone with dementia, regardless of where their care and treatment is delivered. The Standards are supported by Promoting Excellence: A framework for all health and social services staff working with people with dementia *, a framework which details the skills and knowledge needed by all staff working with people with dementia. NHSScotland delivered the HEAT target to increase the number of people with a diagnosis of a dementia by 33 per cent by March 2011.
RELEASING TIME TO CARE
Since May 2009, the Releasing Time to Care ( RTC) initiative has been implemented in over 500 clinical settings in NHS Boards including in community teams, acute, community hospital and mental health wards. The programme has resulted in staff spending more time providing face-to-face care for patients. In turn, this has resulted in increased direct patient care and measurable improvements to the working environment and to patient care. In addition Senior Charge Nurses have been developing their teams by improving the problem-solving skills of staff and empowering them to be involved in continually improving how their workplace functions on a day-to-day basis.
NHS Boards, the Scottish Government and NHS Health Scotland have been working closely to develop new communication materials to ensure that those invited for screening have the information they need to make an informed choice, particularly in the most deprived areas of Scotland. The continuation of breast, bowel and cervical screening throughout Scotland ensures early diagnosis of cancer, allowing early treatment and better outcomes for those affected. The most recent uptake figures of 75 per cent, 53 per cent, and 74 per cent respectively for each programme are consistent with figures in previous years. Improvements to the pregnancy and newborn screening programmes have also been made with the introduction of new and more sensitive screening tests for Down's Syndrome, haemoglobinopathies such as sickle cell disorders amongst others within the newborn bloodspot screening programme.
DENTAL CAPITAL INVESTMENT IN REMOTE AND RURAL AREAS
Significant capital investment in dental premises has continued to deliver improved access to dental treatment and outcomes for patients and the public, with the latest projects to open in rural NHS Board areas. The £2.7 million Dental Centre at Campbeltown was developed to provide accommodation for local independent dental practitioners, and a clinical teaching environment and training facilities for undergraduate outreach dental training. The new £4.7 million Dental Centre in Stornoway provides accommodation for the collocation of general dental practitioner surgeries and patient areas with undergraduate training. Both centres will be linked through IT with centres in Dumfries and Inverness to allow teaching to be delivered to all centres simultaneously.
EMERGENCY MEDICAL RETRIEVAL
The Emergency Medical Retrieval Service was rolled out in October 2010, providing wider cover to the north and northern isles of Scotland. Working in collaboration with the Scottish Ambulance Service, it is responsible for providing a safe and responsive medical retrieval service for the most ill patients in Scotland, by transferring them from remote facilities to more specialist centres of care.
NATIONAL MUSCULOSKELETAL ( MSK) PATHWAY
The development of a national community Musculoskeletal ( MSK) pathway, utilising a central referral management and triage service, is being rolled out in two NHS Boards. An economic analysis undertaken on the central referral aspect of the pathway indicates that proposed changes to the referral pathway for patients with MSK disorders offers the potential for the NHS to achieve substantial efficiencies. This pathway should reduce the number of GP appointments and referrals to outpatients. In addition, by encouraging more self-management, fewer people will be referred for physiotherapy. One immediate benefit should be a reduction in the backlog of patients on waiting lists, and in future, much shorter waits for appointments. Earlier access to services will deliver further benefits given the evidence that early management reduces the extent to which conditions become chronic and the intensity of treatment required as a result.
RESHAPING CARE FOR OLDER PEOPLE
Reshaping Care for Older People: A programme for Change 2011-2021 * was launched, setting out our vision that 'Older people are valued as an asset, their voices are heard and they are supported to enjoy full and positive lives in their own home or in a homely setting'. Thirty-two partnerships across Scotland outlined how they will use their share of a £70 million Change Fund as a catalyst to improve quality, efficiency and outcomes for older people. Already, through improved quality of care and support, more older people are living at home and spending less time in hospital. Since 2008, there has been an increase in the proportion of people aged 65 and over with high levels of care needs who are cared for at home. The latest figure of 32.3 per cent as at March 2010 census shows a 1.1 percentage point increase on the 31.2 per cent at March 2008.
REMOTE AND RURAL HEALTHCARE
The Remote and Rural Implementation Group has made important advances in providing safe and accessible care for patients in the most remote and rural parts of Scotland.
The delivery of more locally accessible services is consistent with the Quality Strategy's ambition for safe and effective care, as local as possible. The achievements of the Remote Rural Implementation Group were presented in its final report to the Cabinet Secretary for Health, Wellbeing and Cities Strategy in October 2010. These included the piloting, and roll out of the Emergency Medical Retrieval Service, the development of Obligate networks where remote and rural NHS Boards establish an agreement with other Boards to provide advice and capacity to support specific services, and a framework for the delivery of emergency response in remote and rural areas.
DELIVERING QUALITY IN PRIMARY CARE
Delivering Quality in Primary Care ( DQPC) is ensuring more active and productive policy discussions about the crucial role that the behaviour of those involved in primary care plays in realising whole system improvements in the quality of healthcare services. The DQPC action plan sets out national-level priorities for primary care and has made significant progress in keys areas such as: work to improve patient safety in primary care; identifying and developing priority pathways; and developing pragmatic ways for increased clinical leadership and engagement at local community level.
The Quality and Outcomes Framework ( QOF) continues to incentivise GP practices to provide high quality care to patients with long term conditions. The average number of points achieved by GMS practices increased from 972.2 in 2009/10 to 976.3 in 2010/11 out of a maximum of 1,000 points in each year.
ACCESS TO PRIMARY CARE
Often a patient's first contact with the NHS is through their GP practice. It is vital, therefore, that every member of the public has fast and convenient access to their local primary medical services to ensure better outcomes and experiences for patients. Information from the GP Patient Experience survey for 2010/11 shows that the proportion of positive responses for 48-hour access to an appropriate healthcare professional was 94.3 per cent against a HEAT target of 90 per cent by 2010/11.
MATERNITY CARE AND MATERNAL AND INFANT NUTRITION
A Refreshed Framework for Maternity Care and Maternal and Infant Nutrition: a Framework for Action * was launched at The Best Possible Start conference in January 2011. The framework sets out actions to use strength-based approaches in promoting health and behaviour change in maternity care and in enabling women and their families to improve maternal and infant nutrition. The Refreshed Framework for Maternity Care sets out the need for effective collaboration between clinicians and for effective risk assessments to be in place for the safety of both mother and baby throughout their care. It also states that effective communication, translation and interpretation services should be in place and requires that inequalities-sensitive practice is promoted. It stresses the need to reduce Healthcare Associated Infections during the antenatal, labour, birth and postnatal period. Both frameworks set out actions to ensure that the most appropriate interventions, support and services are provided to enable women to make behaviour changes to improve their health outcomes and those of their babies, and to support NHS Boards to reduce inequalities in access to services and care.
Following the Unscheduled Care conference, which took place in Dundee in June 2010, the Scottish Government Health Directorates published the guide Building on Success: Examples of Progress in Unscheduled Care * to help NHS Boards and others shape the future provision of a safe, effective and person-centred approach to unscheduled care. Other work includes supporting NHS Boards in delivering local improvement trajectories for reducing rates of attendance at A&E; sustaining the maximum 4 hour wait from arrival to admission, discharge or transfer for A&E treatment; and improving whole systems winter planning. In addition, a new national Unscheduled Care Group was established in November 2010 to ensure continuous improvement in the system of unscheduled care and to help achieve our Quality Ambitions.
Seventeen centres throughout Scotland now provide senior dental students with experience of working outwith the dental hospital and school in a primary care environment - delivering NHS care to patients in remote and rural areas or in communities with a high need for dental treatment. The majority of patients attending Outreach do so initially as they require an emergency appointment or are not registered with an NHS dentist. Patient feedback indicates a high level of satisfaction with the standard of care they receive, and a willingness to return for further treatment at the centres. When asked, 99 per cent said they would recommend the student clinic to a friend.
CHILD DENTAL HEALTH
The target of 60 per cent of Primary 1 children to be free of dental decay by 2010 has been achieved. The National Dental Inspection Programme Report of 2010* showed that 64 per cent of Primary 1 children were free of dental decay, an increase of 6 per cent since 2008. Twelve NHS Boards reached the target. However, the majority of dental disease continues to be borne by children from more deprived backgrounds with only 45 per cent of Primary 1 children in the most deprived tenth of the population having no obvious decay compared to 81.5 per cent of those in the most affluent.
Work is continuing to tackle this and the Childsmile programme is making real improvements in the oral health of children in all deprivation categories. From January 2010 to June 2011, NHS Education Scotland ( NES) trained 351 dental nurses in the six-day programme, and additionally provided Continuous Professional Development ( CPD) in the programme to 268 in the dental professions. During the 2010/11 school year, 90,274 children had fluoride varnish applications as part of Childsmile.
87.9 per cent of children aged three to five years old were registered with a NHS Dentist in the quarter ending March 2011 (up from 81.8 per cent during the same quarter of the previous year) against a HEAT target of 80 per cent.
In response to a Scottish Parliament Public Petitions recommendation, an information leaflet New Medicines in Scotland - who decides what the NHS can provide?*was published through Health Rights Information Scotland to explain to patients and the public the 'end-to-end' process for the introduction of new medicines into the NHS in Scotland. This aimed to achieve greater transparency about the complex arrangements by describing them in an accessible and understandable way. The leaflet covers licensing through to how decisions are made about specific medicines for the treatment of individual patients; and signposts further sources of advice. The Petitions Committee recognised the 'real improvements' that had been achieved and closed the Petition on 8 March 2011.
A guide for the Life Sciences industry was published in November 2010 to ensure there are appropriate opportunities for the development and introduction of new products in Scotland, supported and informed by the clinical and service needs of NHSScotland. The guide - known as the MedTech Road Map - is a tool to help companies developing medical technologies to engage with NHSScotland. It assists them in understanding the opportunities for collaborative working and tells them where to seek help and support, including for the trialling and testing of their product. The guide aims to stimulate and support ideas for new technologies, resulting in better clinical care and patient outcomes, and was the result of collaboration between the Scottish Government, NHSScotland Research and Development, NHSScotland procurement, Scottish Enterprise and Industry.
RESHAPING THE MEDICAL WORKFORCE
Workforce modelling has continued to ensure that medical services are delivered predominantly by trained doctors, reducing the number of specialty trainee posts and replacing them with trained doctors. Moving towards a trained doctor delivered service, supported by a multi-disciplinary clinical team, will ensure better health interventions, better treatment and higher quality healthcare services for patients, resulting in improved patient outcomes and clinical safety. Agreement was secured across NHS employers, the BMA, NHS Education for Scotland ( NES) and other partners on the appropriate level of reduction in specialty trainee posts in 2011, the second year of the Reshaping the Medical Workforce project.
MEDICAL REVALIDATION IN SCOTLAND
Work continued throughout 2010/11 to ensure that NHSScotland will be ready to meet its obligations to provide revalidation for all doctors from 2012. The use of patient feedback and critical incident data as part of the appraisal process will support in identifying areas of practice where there are performance concerns, improving effectiveness, and providing information on where development and support are required.
SUPPLEMENTARY MEDICAL STAFFING
A best practice framework was introduced across NHSScotland to address the use of supplementary medical staff. This aimed to enhance patient care and safety and reduce expenditure on supplementary medical staff, including agency staff, where costs had risen from £18 million in 2006 to £36 million in 2010. It set out the steps necessary for NHS Boards to set up an NHS medical bank at local or regional level and has resulted in a £3 million reduction in the cost of supplementary medical staff in the last quarter alone, compared to the same period last year.
LEADING BETTER CARE
Leading Better Care: Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project * was launched in July 2008 and provides a template for the Senior Charge Nurse ( SCN) role as the visible embodiment of clinical leadership in NHS settings, coordinating patient care, marshalling and inspiring the nursing or midwifery team and advocating on patients' behalf with members of the multidisciplinary team. Application in wards of the Clinical Quality Indicators - part of the Leading Better Care initiative - is resulting in benefits for patients in terms of enhanced safety, better experience of services and improved outcomes. All NHS Boards reported that implementation of the Senior Charge Nurse role framework was complete by the end of 2010.
DENTAL WORKFORCE REVIEW
An Analysis of the Dental Workforce in Scotland: A Strategic Review 2010 * was published in March 2011. It provides a clear picture of the skills mix of dental professionals currently providing dental care within Scotland and important information on: the availability of the dental workforce; the number of dentists and dental care professionals; and the impact of the dental bursary scheme. The dental student intake for 2011/12 was agreed following the review. This work enabled us to ensure that we have the right number of people, in the right place, doing the right job but highlighted the need for more robust workforce and activity data in a number of areas including Hospital Dental Service, Dental Care Professionals and individual salaried General Dental Practitioners.
NHSSCOTLAND NATIONAL UNIFORM
The National Uniform, Dress Code and Laundering Policy * was published in December 2010, promoting better service delivery by providing a professional corporate image that is consistent across Scotland, and making it easier for patients and the public to identify staff by their role. The new national uniform for students was issued to the Autumn 2010 student intake. Initial feedback from NHS Boards is extremely positive, with staff recognising the step change improvement in garment quality. The move to a national uniform has resulted in efficiency savings of £1.24 million over the three-year contract period.
NHS PAY MODERNISATION
Pay is a major factor in recruiting, retaining and motivating the staff needed to deliver quality patient care. Modernising the pay system has therefore been fundamental to the modernisation of the health service itself and this has taken the form of a number of new contracts and agreements brought in since 2004, which encourage staff to broaden their skills and embrace new working methods. New contracts for consultants and GPs have been introduced since 2004 as well as the Agenda for Change system which covers nearly all non-medical staff in the NHS. Work to mainstream and realise the benefits of these new contracts continued in 2010/11 as well as scoping work to modernise the current contract for doctors in training. In addition, NHS Boards made further progress in implementing the new Specialty Doctors and Associate Specialist contract.
ESTATES AND FACILITIES
REDUCING CARBON EMISSIONS AND ENERGY CONSUMPTION
Through reducing energy-based carbon emissions and energy consumption, NHSScotland will make a significant contribution towards the Scottish Government's aim to reduce greenhouse gas emissions by 50 per cent by 2050 and the interim target of a 42 per cent reduction by 2020. A reduction in energy consumption is also important in the context of increasing global fuel costs and the impact of their resulting cost increases on the delivery of core NHS services. Both the efficiency target and carbon target are designed to not only achieve NHSScotland's contribution to the Climate Change (Scotland) Act 2009 target but also ensure that NHSScotland continues to lead by example within the public sector. This will ensure NHSScotland contributes to the Scottish Government's National Outcome to 'reduce the local and global environmental impact of our consumption and production'.
The specific targets for NHSScotland are to reduce CO 2 emissions for oil, gas, butane and propane usage annually by 3 per cent to 2014/15; and NHSScotland to continue to reduce energy consumption annually by 1 per cent to 2014/15. During 2010/11, NHSScotland exceeded both of these targets, securing a 4.6 per cent reduction in CO 2 emissions and a 3.5 per cent reduction in energy consumption.
SUPPORTING AND FACILITATING ACHIEVEMENT
The Quality Strategy recognised that there were a number of key national areas of development, which need to be co-ordinated, accelerated and aligned to support and facilitate NHSScotland and its partners to have the maximum impact on the three Quality Ambitions. These include:
- Information Technology;
- Workforce, Education and Training;
- Quality Improvement Hub;
- Communication; and
The national focus on these issues provides an important opportunity to simplify the current complex landscape of activity in these areas, to challenge progress, accelerate pace, and to create linkages and a shared ownership of these vital developments.
Following extensive consideration, consultation and developmental work to identify measures of healthcare quality in Scotland, six Healthcare Quality Outcomes have been agreed. These Quality Outcomes provide a description of the priority areas for improvement in support of the Quality Ambitions. They have been shared widely and will provide a context for partnership discussions with COSLA, SOLACE and the third sector about local and national priority areas for action. They will also inform the future development of HEAT targets.
HEALTHCARE QUALITY OUTCOMES
- Everyone gets the best start in life, and is able to live a longer, healthier life
- People are able to live well at home or in the community
- Healthcare is safe for every person, every time
- Everyone has a positive experience of healthcare
- Staff feel supported and engaged
- The best use is made of available resources
The Healthcare Quality Outcomes form part of the Quality Measurement Framework which provides a structure for aligning the wide range of measurement that goes on across the NHSScotland for different purposes, describing how measurement helps to drive progress towards our Quality Ambitions and providing us with the ability to demonstrate improvement both locally and nationally.
The three levels described by the framework provide a simplified structure for thinking about the intended use of sets of indicators. In summary:
Level 1 (Quality Outcome Indicators) is for national reporting on longer-term progress towards the Quality Ambitions and the Quality Outcomes. These are intended as indicators of quality, and will not have associated targets. It is expected that most Quality Outcome Indicators ( QOIs) will be disaggregated geographically, and by equality groups where possible and appropriate.
Level 2 contains the HEAT targets, which describe the specific and short term priority areas for targeted action in support of the Quality Outcomes. These will be further aligned with the Quality Ambitions over time.
Level 3 describes all other indicators/measures required for quality improvement and performance management and reporting, either by national programmes or locally.
The initial set of 12 Quality Outcome Indicators (level 1) will be reviewed by the Quality Alliance Board after one year. These are currently at different stages of development :
- Healthcare Experience
- Staff Engagement and Potential
- Healthcare Associated Infection
- Emergency Admission Rate/Bed Days
- Adverse Events
- Hospital Standardised Mortality Ratio
- Under 75 mortality rate
- Patient Reported Outcome Measures ( PROMs)
- Self-assessed general health
- Percentage of time in the last six months of life spent at home or in a community setting
- Early years indicator
- Resource use indicator
The Report on the Development of the Outcome Indicators for the Healthcare Quality Strategy for Scotland8 details the process through which these Quality Outcomes and Quality Outcome Indicators were developed, along with technical information about the sources and definitions of the individual indicators.
Developing and supporting the appropriate IT infrastructure to deliver person-centred, safe and effective care is a key priority for NHSScotland. The areas of progress are described here and provide an overview of activity during 2010/11. The second eHealth Strategy for NHSScotland 2011-2017 *, published in September 2011, set out the priority areas for improvement and action to maximise support for the implementation of the Quality Strategy - enabling integration, sharing and continuity together with the safer, more efficient and more effective use of information.
PATIENT MANAGEMENT SYSTEM
A consortium of five NHS Boards, supported by the Scottish Government, undertook a joint procurement exercise and selected the TrakCare Patient Management System.
This collaborative approach has delivered considerable benefits and has resulted in the convergence and standardisation of IT systems at substantially lower cost than could be achieved if Boards were working locally and individually. Local ownership, vital to the successful implementation of these complex changes, has also been maintained. Ensuring NHS Boards are able to use the same system improves clinical and administrative management of patient information and frees up staff to spend more time with patients. Collaborative working amongst these Boards is also leading to standardisation and has helped create a version of TrakCare that is known as the Scottish Foundation System. Together with the one Board previously using TrakCare, six NHS Boards can now share support, expertise and experience, and when fully implemented this system will cover some 75 per cent of NHSScotland by population.
NHS Boards are working in three regional consortia, each developing different aspects of the Clinical Portal programme. This aims to improve the availability of patient information in support of direct patient care. The South and East region NHS Boards have been working to deliver a prototype portal solution, and in February 2011 awarded a contract to deploy a portal across the four Boards during 2011/12. Use of the NHS Greater Glasgow & Clyde clinical portal continues to increase rapidly, demonstrating the value placed by clinicians on the benefit of improved availability of patient information.
CHEMOTHERAPY ELECTRONIC PRESCRIBING AND ADMINISTRATION SYSTEM
A Chemotherapy Electronic Prescribing and Administration System ( CEPAS) began operation at the Beatson West of Scotland cancer hub in December 2010, beginning a roll-out programme that will see implementation across four West of Scotland NHS Boards in 2011. The system will provide improved patient safety, the delivery of person-centred services locally, improved communication, and effective use of resources. Other regional cancer networks are also implementing regionally-networked CEPAS systems. Another shared solution is Renal PatientView ( RPV), which gives patients with renal disease access to elements of their records.
COMMUNITY HEALTH INDEX
The national Community Health Index ( CHI) Programme was established to support universal use of the CHI number as NHSScotland's unique patient identifier. During the lifetime of the Programme from 2005-2010, NHS Boards achieved significant improvements, resulting in a CHI compliance target of 97 per cent on clinical communications being exceeded. Use of the CHI number, as part of safe patient identification, will continue to be key to current and future initiatives such as increased regional working, migration to new Patient Management Systems and increased use of portal technologies.
The national eReferral programme makes the referral process quicker, safer and better for both patients and staff. By the end of 2010, national monthly performance for referrals received through the Scottish Care Information ( SCI) Gateway had increased to 96 per cent, with 81 per cent of cases being managed electronically, and six NHS Boards had an average referral time of less than six days.
PICTURE ARCHIVING AND COMMUNICATIONS SYSTEMS
The Picture Archiving and Communications Systems ( PACS) programme has supported the seamless acquisition, storage, retrieval and display of digital patient images within and between clinical sites across Scotland. It offers the opportunity for radiology reporting to be done remotely, utilising telehealth and potentially facilitating more flexible working.
EMERGENCY CARE SUMMARY
Use of the national Emergency Care Summary ( ECS) continues to increase in all NHS Boards across Scotland. ECS is a summary of basic information about people's health which might be important if they need urgent medical care when GP practices are closed or when requiring care in A&E departments, and is making a big difference in unscheduled care. In 2009, Emergency Care Summaries had been accessed over 2.1 million times, and in 2010 this had risen to 2.5 million. By the end of 2010, Emergency Care Summaries had been accessed over 6.6 million times since their launch.
The commitment in the eHealth Strategy 2008-11 to replace the most common GPIT system in Scotland ( GPASS) has been taken forward. The Scottish Government commissioned a consortium of NHS Boards, led by NHS Greater Glasgow & Clyde, to develop a business case and run the procurement process. The work was completed in 2010 with a framework contract allowing a choice of two modern commercial products. The products selected were the second and third most common in use in Scotland and will deliver improved IT facilities to GP practices. The choice of system will be consistent with the GP contract and will lead to convergence on fewer, more modern IT systems.
ELECTRONIC TRANSFER OF PRESCRIPTIONS
In 2008, the ePharmacy Programme introduced the Electronic Transfer of Prescriptions ( ETP) between GP practices, Community Pharmacies and Practitioner Services Division ( PSD). This has improved patient safety by reducing transcribing errors, modernised service delivery and increased the efficiency of the processing of prescriptions by removing the reliance on paper. This is the first live national system to fully support ETP in the UK. The programme has also supported the development of a web-based pharmaceutical care planning tool, the Pharmacy Care Record ( PCR), to assist pharmacists in providing pharmaceutical care for patients with long term conditions in order to ensure they get the best outcomes from their medicines.
WORKFORCE, EDUCATION AND TRAINING
An appropriately trained and motivated workforce is essential to our aims for a modern, quality-driven and patient-centred service. Partnership working involving NHS Education for Scotland ( NES), NHS Boards and education providers has, across the spectrum of NHS care, achieved significant gains for practitioners, for those in training, and tangible benefits for patients. This approach to agreeing and developing appropriate training, development and appraisal will provide the fundamental basis for NHSScotland to achieve our Quality Ambitions for person-centred, safe and effective healthcare - particularly focusing on the requirement to ensure that all staff feel supported and engaged in pursuing and achieving world-leading quality healthcare. Progress and key achievements during 2010/11 are set out here. A future strategy for education, training and staff/clinical engagement, which fully aligns with and supports the implementation of the Quality Strategy, is currently being considered.
In preparing NHS Boards to fulfil their statutory requirements on Medical revalidation, NES has delivered appraisal training to some 200 new appraisers, and will roll-out this essential training programme to 400 more medical practitioners over the next 18 months. Revalidation will be based on a more comprehensive evaluation of doctors' practice through assessment of, and reflection on, information brought to a doctor's annual appraisal. Its purpose is to affirm good practice. By doing so, it will assure patients and the public, employers, other healthcare providers, and other health professionals that licensed doctors are practising to the appropriate professional standards.
A Direction from Scottish Ministers issued on 15 June 2010 made a set of Induction Standards and Code of Conduct for Healthcare Support Workers ( HCSWs) and a Code of Practice for their Employers mandatory across NHSScotland, for new start HCSWs from 31 December 2010. The independent evaluation report of the pilot clearly highlighted the benefits of such a model in enhancing the awareness, motivation and confidence of HCSWs, and in focusing supervisors on the vital role played by HCSWs within the healthcare team. The standards and codes will equip HCSWs, at a fundamental level, to do their best to protect patients and members of the public in every way they can in fulfilling their duties. At a UK level, the model tested in Scotland is recognised as one of the potential alternatives to a statutory model of regulation.
QUALITY IMPROVEMENT HUB
The Quality Improvement Hub is a national collaboration between Special NHS Boards and the Scottish Government, which aims to build national and local capacity and capability in quality improvement in support of the Quality Strategy, and to support NHS Boards with local implementation. The aim of the Hub is to bring improvement science into the everyday work of NHSScotland staff, and to support measurable improvement in healthcare. Engagement with key stakeholders established key delivery areas including: implementation; education and learning; measurement for quality improvement; and facilitation of quality improvement networks. These four areas are underpinned by principles of creativity and innovation as vital factors in developing and improving public services. 2011/12 and beyond will see the work of the Hub move beyond its development phase to focus on direct support for NHS Boards.
The need to enable clear and consistent communication of the vision for high quality healthcare, and respective roles and responsibilities with the public and with everyone involved in delivering healthcare, is identified as key in supporting the achievement of the Quality Ambitions. Work has progressed throughout the year to ensure effective communication with staff, stakeholders and the public. Opportunities were identified to share messages and engage with people through a range of media including media releases, speeches, publications, conferences and meetings.
The annual NHSScotland Event has, for the last three consecutive years, provided the platform to engage with staff across NHSScotland on the Quality Strategy and Quality Ambitions. The event has engaged staff on the improvements required to deliver safe, effective and person-centred care, has demonstrated the impact of work being undertaken across NHSScotland and has served to share best practice.
A Communications Action Group is to be established which will include members from a range of stakeholders and experts, which will establish a plan to ensure that appropriate communication and engagement takes place to support the ongoing implementation and momentum building around the Quality Strategy.
A key priority for supporting the implementation of the Quality Strategy is aligning the key strands of governance - clinical, staff and finance - to ensure that our approach provides NHS Boards, Government, Parliament and the public with the assurance it requires to have confidence in the quality of healthcare in Scotland. Appropriate and focused governance will also ensure that early warning is given of any potential areas for improvement, before any issues arise. Progress has been made during 2010/11 in establishing a framework and method for governance. Key areas of activity and progress are described here. During 2011/12, we will develop a single transparent and effective framework to support acceleration towards, and achievement of, our Quality Ambitions.
The Staff Governance monitoring process, which comprises of the Self Assessment Audit Tool ( SAAT) and the NHSScotland staff survey, was significantly improved during 2010/11, providing up-to-date information on staff governance activity in each NHS Board. NHS Boards now receive a comprehensive written review of their SAAT return and staff governance action plan. This outlines areas of best practice and identifies issues that require clarification and potential action. This review also identifies key issues relating to staff governance within each NHS Board that will form part of the agenda for the Annual Review process.
2010/11 was a key year for clinical governance in NHSScotland. NHS Quality Improvement Scotland ( NHSQIS) completed its final cycle of reviews of NHS Boards against the NHSQIS Clinical Governance and Risk Management Standards. A local report was published for every NHS Board, together with a national overview report. These reports make an important contribution in providing a perspective on key systems and processes within NHS Boards in order that patients and staff can have confidence that NHSScotland is delivering person-centred, safe and effective care and services. The findings also provide important benchmarks during the implementation of the Quality Strategy. Healthcare Improvement Scotland (established on 1 April 2011- formerly Quality Improvement Scotland), has the challenge of ensuring the clinical governance and risk management arrangements in the healthcare organisations which fall within its remit are tested robustly.