Shifting the Balance of Care
Frequently Asked Questions
1. What is meant by "shifting the balance of care"?
This term is used to describe changes at a number of levels - all of which are intended to bring about improvements in health and improvements in service outcomes .
Focus
- The overall aim is to improve the health of the people of Scotland by shifting the emphasis towards preventative medicine and more continuous care in the community. This means making fundamental shifts in the way in which we tackle the causes of ill health and by providing care which is quicker, more personal and closer to home. Our 2010 Keep Well pilots, for example, aim to increase the rate of health improvement in deprived communities by enhancing primary care services to deliver anticipatory care.
- We are changing the focus away from services that are geared towards acute conditions to providing systematic support for people with long term conditions with a strong emphasis on continuous, integrated care, rather than disconnected and episodic care. The CHP Long term Conditions Self Assessment Toolkit will help NHSScotland and its planning partners to measure their performance against a wide range of criteria and draw up action plans to improve health and to improve services year by year.
Location
- We aim to improve access to care and treatment through a general shift in the location of services and care. For example, a wider range of diagnostic procedures and specialist services are being embedded into communities through Community Health Partnerships. We expect to see less acute hospital centred activity as we continue to develop our community infrastructure and community hospitals. This will enable us to get a better balance between planned and unscheduled care. At the same time we will continue to review the configuration of specialist health services to ensure that where there is a strong case for ensuring volume is maintained in complex cases then we will consider offering some procedures in a few locations.
- There will be an increase in the amount of care provided in community settings through greater levels of joint working between the NHS, local authority and voluntary sector partners. With the focus firmly on supporting more people at home; preventing avoidable hospital admissions and providing better rehabilitation services we expect to see changes in the pattern of community and hospital based care. This involves multi agency teams identifying and working with "at risk" individuals and providing better discharge and support for people at home.
Responsibility
- We intend to shift the current view of patients as passive recipients of care towards full partnership in the management of their conditions. There are already high levels of self care by individuals in the community; e g pharmacists provide the public with advice and we have a good track record of helping people to manage their long term conditions. The new pharmacy contract supports this approach through acute and medication services; minor ailments services including public health services.
- We aim to increase support for people, particularly disadvantaged groups, to enable them to self care more effectively. Advances in Telehealth will also play a key role in allowing patients to be monitored at home and to manage their own conditions. A new national strategy for long term conditions will be developed based on the fact that people's experiences of living with long term conditions is a central driver of service change.
Professional Roles
- Shifting the balance of care into community settings requires professionals and staff to continually develop their skills, expertise, roles and responsibilities. This calls for a shift in emphasis away from the independence of individual practices and professionals towards a more extended primary and community care team ethos.
- We need to make the best use of specialist and generalist expertise across community and hospital services. Much has already happened through the development of GPwSI, extended roles of nurses such as Advanced Nurse practitioners; Physician Assistants; AHP Consultants and AHP Assistant Practitioners. And hospital based clinicians are evolving their skills; providing services both within and outside traditional hospital boundaries.
- As more care is provided in the community and services are further integrated, then new approaches to patient care will be required. The development of the new model of community nursing will help in this respect together with the further development of support workers in the community.
2. Why is shifting the balance of care necessary?
- The demography and profile of Scotland's population is changing. We need to gear up for the growth in the number of older people; recognise long term conditions as the main challenge facing the NHS; and respond to patient expectations in terms of more accessible and personalised care.
- Shifting the balance of care is not just a management response to increasing demand. More importantly, it is what people have said they want. People do not want to spend their time travelling to hospitals for outpatient appointments if they can be seen locally. They do not want to stay in hospital for treatment if procedures can be carried out on a day case basis.
- Patients want to have their care managed by integrated teams that understand their needs and can respond quickly and effectively. This approach is best co-ordinated and managed in primary and community care settings, led by professionals and staff working with partners delivering social care services.
3. Does moving more services and care into community settings mean hospitals are not performing well or quickly enough?
- Hospitals are performing well. There have been huge improvements in waiting times and standards. However, we need to design services that address the needs of a changing population and changing workforce.
- Hospitals should be our last resort for most health care needs and not our first port of call. We cannot continue to put unrealistic demands on the acute sector. We need to differentiate between planned and unscheduled care and enable hospital specialists to speed up access to treatment and reduce delays through appropriate use of their skills and expertise. This is why we have set up the Planned Care Collaborative to support this work alongside work underway on unscheduled care and improvements to diagnostic services.
4. Are we now putting unrealistic demands on primary care and community care?
- Shifting the balance of care is an evolutionary process. It requires careful service redesign with the full involvement of patients, users, carers and staff to ensure that services are fit for purpose. And most importantly it requires effective workforce planning and the better use of existing facilities as well as new developments. CHPs are best placed to drive forward these changes in the community working in partnership with local authorities and the voluntary sector and they need to get the pace of change right in their local areas.
5. Will standards of care be as high in community settings?
- Patients currently receive a very high standard of care from primary care practitioners and their teams as the recent results of the QOF indicate. But we are not complacent about continuous quality improvement and NHS Quality Improvement Scotland will be implementing a work plan on Quality Improvement in Community and Primary Care Health Care Services.
- CHPs will also be expected to use their Public Partnership Forum to drive up quality and standards locally. PPFs are the main local mechanism through which CHPs can maintain a formal, effective dialogue between local users and carers and the CHP in relation to service planning and quality improvement.
6. How will we know that the shift in the balance of care has been achieved?
- We can look at the "shift" in terms of activity or outcomes. For example we can look at measures such as:
increase in the number of day case surgical procedures and decrease in the length of inpatient stays in a defined range of conditions
- increase in the amount of outpatient and diagnostic tests/services provided in community settings
- more community based heath and treatment centres provided through community and urban hospitals
- increase in the level of patient registrations with community pharmacists for chronic medication reviews
- more screening and diagnosis by optometrists in the community
- increase in the amount of self care advice provided by NHS 24
- more direct access to X-rays, CT scans, ultrasound scans for specific symptoms
- increase in the level of self referral to non medical professionals working in the community
- decrease in waiting times for "talking therapies" alongside reductions in anti depressant prescribing
- better access "in hours" to planned primary and community care and reductions in unplanned "out of hours" and A&E attendances
- reductions in repeat admissions to hospital for exacerbations of long-term conditions
- reductions in deaths from preventable diseases for disadvantaged groups of people.
- In addition to the above examples, work is underway to develop new national outcome measures for community care as part of the review of Joint Futures. This should provide targeted outcome measures for service improvements covering all community care groups.
- Timescales for improving productivity and delivering better outcomes will vary. For example, better access to "in hours" primary care community care services (activity) may be achieved more quickly than a reduction in health inequalities (outcome) measured by a reduction in deaths from preventable diseases for disadvantaged groups. Both are important and together will contribute to a shift in the balance of care.