DESIGNED TO CARE

Renewing the National Health Service in Scotland

12. The objective of a National Health Service designed for patients is to provide better services for them in ways that are responsive to their needs and wishes. Good quality health care delivered consistently and to a high standard must be a key objective of the NHS in Scotland. It is a shared responsibility of everyone working in the NHS, and covers all aspects of health care including the effectiveness of clinical practice, the environment in which it is delivered, and responsiveness to the needs of patients.

13. Essential to achieving this objective is:

• improving reliability and co-ordination of care through use of new technology;
• improving clinical effectiveness by ensuring that performance meets agreed standards and that these standards are driven upwards;
• promoting the adoption of more effective care based on evidence;
• involving patients to a greater extent in decisions about their own care and treatment;
• providing patients with more information about their health and about the options for treatment when they are ill.

14. Our starting point is that every aspect of the planning and delivery of services should be designed from the perspective of patients. There is encouraging evidence of the benefits that flow when services are designed from this perspective, for example in breaking down organisational barriers and improving communication among different groups of staff involved in an individual patient's care, and in speeding up the processes of diagnosis and treatment. Such approaches can also enable staff to provide services to patients in the way they would wish, ensuring privacy and dignity are respected, and, despite the streamlining of care, again ensuring that time remains to treat patients individually and with humanity. The Government therefore expect all parts of the NHS to give priority at the highest level to the examination of services from the perspective of patients and to making changes designed to improve their experience of the NHS. This will be a key test of organisational performance.

Co-ordination and Reliability of Care

15. Information technology opens up new possibilities for improving the reliability of care by enabling its more effective co-ordination. Co-ordination of care can be improved through telemedicine, by enabling consultation with hospital specialists to take place in the GP's surgery. There are already examples in Scotland of the use of telecommunications to support patient care directly by reducing or eliminating the need for patients and clinicians to travel. Without leaving their GP's surgery, a clinic, or sometimes even their own homes, patients can be examined over video links by specialists based at any hospital which is also connected to the NHS telecommunications network. This can also carry the output of diagnostic machinery, such as radiological images. Co-ordination of care can also be improved through speeding up the processes of transferring records, transmitting test results and making appointments.

16. To the patient, the NHS is a single entity geared to providing a co-ordinated and comprehensive care service. Patients expect to move from general practice to hospital, ward to ward, and hospital to community with ease. Information related to them should move with equal ease, but it does not always do so. As a result, patients can become by default the means of transporting information. The Government wish to change this. A safe flow of information about patients between GPs, hospitals, and other healthcare professionals is needed, and new technology is enabling them to share it, under professionally agreed safeguards. We intend to accelerate this process.

17. One of the first steps is to use the same number to identify patients wherever they are treated, and the Community Health Index number creates this opportunity. This unique patient identifier gives the NHS the means by which we can securely bring together the right information about a patient at the right time and place. Over the next two years we will ensure that all Health Service systems are able to use this number. We will continue to work with healthcare professionals through their Royal Colleges to define the key sets of information which need to be communicated. As well as referral and discharge letters, key information items are being specified for particular conditions and diseases so as to help ensure best clinical practice. The computer systems which will deliver this information are also important. They will first and foremost be designed for use by healthcare professionals in carrying out their clinical tasks. For example, ordering blood tests by electronic links is quicker and more reliable than filling in forms; and getting the results back on that same screen is not only just as useful, but quicker. To achieve these links, the whole of the NHS in Scotland will be linked to secure health service telecommunications systems over the coming year to ensure there are no obstacles in the way of assembling the right information.

18. For all these reasons, the major emphasis will rightly be on clinical care information. But accurate management information is also needed to help make sure services are delivered efficiently and performance targets met. This information should be a by-product of information collected for patient care purposes, and the NHS should be relieved of the need to supply variations on the same data to its many different users.

19. The Government's objective is to use technology to promote a seamless pattern of care. With this in mind we have decided to fund a number of demonstration projects focusing on two issues of current concern to patients:

• the establishment of one-stop clinics where all tests are carried out in a single visit, and results and diagnosis, where possible, are available the same day. We will set a timetable to ensure that this practice becomes widespread within the NHS in Scotland;
• during 1998 we will electronically link up every GP surgery in Scotland. By the year 2002 patients will know the date of hospital appointments when they leave the surgery.

Clinical Effectiveness

20. The effectiveness of clinical care and treatment has always been and will remain central to the quality of health care. Considerable effort and resources in Scotland are being devoted to the provision of guidance on best practice in the delivery of clinical services. The development of clinical guidelines and good practice statements provides clinical staff with information, based on available evidence, about most effective practice. Their impact is evaluated through clinical audit and the development of clinical outcome indicators which allow critical reviews of performance.

21. Scotland leads the United Kingdom in its work on clinical effectiveness. The creation of the Clinical Resource and Audit Group (CRAG) in 1989, under the chairmanship of the Chief Medical Officer, has provided a focus for this work and has resulted in:

• the development of systematic programmes of clinical audit at local and national levels accounting for some £6.5m a year;
• the creation of the Scottish Intercollegiate Guidelines Network (SIGN), a collaborative venture undertaken by the Scottish Royal Colleges and other health professionals, which is producing a series of clinical guidelines, 18 of which have been published to date;
• the publication of reports on clinical outcome indicators which facilitate critical review of performance by clinicians. Since 1993, 31 indicators have been published.

22. Working alongside CRAG, a number of other agencies also contribute to work on clinical effectiveness: the Chief Scientist Office funds a major research and development programme; the Scottish Health Purchasing Information Centre (SHPIC) produces advice on the cost-effectiveness of different treatments; and the Scottish Needs Assessment Programme (SNAP) provides a public health perspective to the health needs of people in Scotland. All these efforts have been directed towards the further development in Scotland of health care based on the evidence. Working closely with the professions, we intend to build upon this record of substantial achievement. A review of the role of CRAG, led by the Chief Medical Officer, is close to completion and has as its major objectives:

• development of a stronger strategic direction for the clinical effectiveness programme;
• promotion of a more integrated and co-ordinated approach; and
• the establishment of a mechanism for ensuring an appropriate proportion of its resources are devoted to nationally-determined priority areas.

Effective implementation is vital so as to ensure that the results of these efforts are applied in improving clinical practice and the quality of care for patients, which must be continuously monitored.

23. The NHS in Scotland already invests a great deal of time and effort in monitoring the quality of service provision to ensure and improve standards of care. Many hospitals and departments have achieved accreditation under schemes such as the King's Fund Organisational Audit, ISO 9000 and Investors in People; increasing numbers of laboratories are accredited by Clinical Pathology Accreditation (CPA); and both the breast and cervical screening programmes have well-established quality assurance arrangements in place.

24. But the work as yet remains uncoordinated. A review of all this activity has therefore been commissioned as part of the Acute Services Review (paragraph 50), which is examining existing methods of quality assurance and accreditation with particular emphasis on mechanisms to assure the quality of clinical services. Our intention is to build a nationally organised process of quality assurance which involves those closest to patient care in the systematic and continuous review of service quality. We believe that such an approach, which may include external review of services, will give added confidence to patients and NHS staff that service quality is the focus of management attention, and complements our approach to clinical governance (paragraph 68) and our intention to publish a range of clinical indicators (paragraph 55).

25. In primary care, the Regional Dental Officer Service has an important quality assurance role in dentistry. For General Medical Practice, the Royal College of General Practitioners has introduced Fellowship by Assessment and has recently launched the Quality Practice Award which has been developed and piloted in Scotland. This award, which covers all aspects of general practice including clinical care provides objective criteria against which practices can assess the quality of care they are offering to patients. The Government wish to encourage such approaches.

More effective care

26. A key aspect of more effective care is providing accurate information for doctors on the clinical and cost-effectiveness of new drugs and treatments. The further development and prescription of more effective medicines will continue to bring great benefits to patients. However, prescribing costs represent one of the major areas of expenditure for the NHS in Scotland and it is important to ensure that our resources are targeted appropriately, that every patient in Scotland has the same access to effective medicines and treatments, and that resources are not squandered inappropriately on treatments which will not provide effective and significant health gain. At Health Board level, expenditure on Family Health Services drugs will be combined with other budgets within a cash-limited total, allowing for the first time much greater flexibility in the use of resources and incentives for all GPs to develop their prescribing patterns.

27. To drive forward our commitment to safe, cost-effective developments, the Government intend to take a new initiative by supporting the setting up of a Scottish Health Technology Assessment Centre. The Centre will evaluate and provide advice to the NHS on the cost-effectiveness of all innovations in health care including new drugs. It will draw on appropriate professional expertise to prepare this advice.

Patient Involvement

28. Central to a designed health care system is involving patients more in decisions about their own care and where possible allowing them to exercise choice, in consultation with their GP or the consultant to whom they have been referred. The desire of patients to become more active participants in decisions about their own care reflects similar developments in many other services, reflecting wider changes in society. In the NHS, however, there is a special relationship built on trust between clinicians and their patients at times of anxiety and vulnerability. This makes it particularly important that clinicians are able to communicate effectively with patients and their relatives, and the Government welcome the increasing attention paid to the acquisition of these skills in professional training. Some patients have particular needs and require additional help to express their concerns, and the Government have recognised the need to develop independent advocacy for them. A guide to good practice was issued in September 1997 in order to assist Health Boards in extending the services already available.

29. The Patient's Charter has played a part in providing a framework to focus the attention of the NHS on these issues. In Scotland, close involvement of staff in developing and implementing local standards within this national framework has resulted in significant progress in recent years. However, greater effort needs to be devoted to ensuring that local Charters are targeted on the quality and success of treatment, that they deal with the issues which concern patients most, and that standards rise steadily. For this reason, the Government intend to issue a new national Charter which will balance the rights and responsibilities of patients and set a framework for continuing local development of standards, an approach which has worked well in Scotland.

30. When things go wrong, it is important that people are able to complain and that their concerns are handled quickly and fairly. A new complaints procedure came into effect in April 1996 and an evaluation of these arrangements will start in 1998. The Government will look carefully at the conclusions of that evaluation in order to decide whether further changes are required.

Patient Information

31. Patients will be able to become more involved in the decisions about their care if they are also better informed. Access to improved information will promote greater personal responsibility for health and enable patients to use health services more effectively. The public is entitled to accessible and useful information about:

• how to stay healthy;
• particular conditions or illnesses, including the options for treatment (for example, the effectiveness of particular interventions, any side-effects, choices as to where to be treated);
• the services available, such as waiting times, admission arrangements, practice in relation to length of stay, visiting arrangements and entitlement to travelling expenses.

32. More information is available than ever before on matters such as these, not only as a result of the efforts of the NHS but also from a wide range of voluntary organisations and the media; and access to such information is increasingly possible through electronic means such as the Internet. In spite of this, patients still report that they have not been given adequate information, or that it was not provided in a way that they could easily understand and remember. This is not surprising, for even well-informed patients can feel at a disadvantage when dealing, at a time of anxiety, with issues as complex as health care.

33. The Government believe that the public is entitled to as much information as possible about all aspects of the NHS and that this information should:

• be up-to-date, accurate and intelligible to its target audience; and
• reflect local circumstances, including local protocols regarding the treatment of particular conditions.

For our part, we will by 1999 extend the NHS Helpline to provide local information on health and social care services. The public will be able to ring the Helpline and receive local health information from trained nurses.

34. The Government will therefore require the NHS to continue to make progress in this area, exploiting to the full the use of IT. In particular, it should:

• promote a continuing emphasis on informing the public about standards of care and performance against those standards;
• provide patients, on discharge from hospital, with summary information about the treatment they have received, drugs they are to take, and any follow-up consultations with their GP or at the hospital; and
  
• ensure access to information by children, elderly people, people with physical and learning disabilities, members of ethnic minority communities and others who find this difficult.

35. It is important that patients are involved in these information initiatives. The Government will take advantage of the growing availability of the Internet to extend the information available to the public on diseases, health promotion, and useful facts about all aspects of NHS services, in particular by using The Scottish Office web site (http://www.scotland.gov.uk). We also aim to ensure that each Health Board, Trust, and national support organisation has its own web site linked with Scottish Health On the Web (http://www.show.scot.nhs.uk). SIGN guidelines will also be appearing on the Internet, and this type of patient access should be very helpful in promoting the uptake of these guidelines by the profession at large.

Responsiveness to the public

36. Services need to be responsive not just to the needs of individual patients but also to the preferences of the public at large. To redesign services from the perspective of patients - and to reflect this in all aspects of health service planning - requires finding out what patients and communities want; and consulting them over proposals for change.

37. As statutory bodies, Local Health Councils have been part of the NHS structure since 1974. In the new NHS based on openness and partnership, Local Health Councils will be able to work co-operatively with their Health Board and agree how the Health Council's activity can be focused to achieve the greatest health gain for the people it serves. In addition, the Government wish to encourage other means of ensuring public involvement in the planning of services; and to require Health Boards to undertake thorough and imaginative consultation on their Health Improvement Programme (see paragraphs 52 and 58 and Annex A).

38. Already the NHS is making use of various means to tap the views of the communities they serve. User surveys both to obtain general feedback and to gauge reactions to particular proposals are well-established. Increasingly too Boards and Trusts are experimenting with new techniques such as focus groups, citizen's juries and survey methods which are targeted on the less tangible aspects of service provision. Building on this experience, the Government look to the National Health Service to step up its efforts to find better ways of involving patients and the public effectively. In each Health Board and NHS Trust, a designated member of the executive team will be given responsibility for making this happen; and progress will be a key feature of The Scottish Office Management Executive's performance management of Boards and Trusts.

39. Particular challenges lie in the field of primary care, and discussions are taking place with consumer organisations about the possibility of an initiative to support patients in developing greater confidence in their dealings with primary healthcare professionals and to explore different mechanisms for securing effective patient participation in practice planning.

40. For its part, the Government will continue to involve lay members in a wide range of committees and working groups and to support them in making an effective contribution. The Government are also committed to extending support for the voluntary sector which makes such a valuable contribution to the NHS. Appointments of non-executive members of Health Boards and Trusts will include people from both of these sectors with the aim of making these bodies more responsive to the community they serve.

Openness

41. Underpinning all these developments is greater openness. The Code of Practice on Openness in the NHS in Scotland, issued in 1995, set out basic principles underlying public access to information about the NHS in Scotland. The Government have already taken its provisions a stage further by requesting all Trusts to hold their meetings in public. It looks to all parts of the NHS - including Health Boards, Trusts and GPs - to adopt the spirit as well as the letter of the Code, not only responding positively to all requests for information (unless they fall within the specified exempt categories) but also looking for new opportunities to reduce secrecy and to share information with patients and the public. Our decision earlier this year to remove "gagging clauses" from contracts of employment is an important step to ensure that matters of public concern are not hidden from public scrutiny.

Conclusion

42. At some time in our lives, every one of us will be a patient. Although the rest of this White Paper is about the nuts and bolts of the renewed NHS in Scotland, we must never lose sight of what that will mean for the patient. Our vision is of a patient making no more than a short trip to discuss their health with their family doctor, a consultation which will take place in premises with a welcoming atmosphere, where the most up-to-date technology is literally at the doctor's fingertips. If more than reassurance is needed, as much as possible will be done for the patient in these familiar surroundings. If more specialist advice is needed, we intend that the patient will leave the surgery certain of what is going to happen next, and where and when it will happen. That is what we mean by seamless care designed for the patient's benefit. We believe these are the concerns of patients. They are at the heart of our vision which the new arrangements in the rest of this White Paper are designed to achieve.