NHSScotland Chief Executive's annual report 2015-16

Chapter 2 - Improving Quality of Care

'… people in the driving seat of their care, with support from their professionals to achieve the outcomes that are important to them.'

Asking 'what matters to you?', rather than 'what's the matter with you?' Read more about the approach pioneered at the Royal Hospital for Children in Glasgow at www.nhsscotannualreport.com

Our Quality Ambitions

Through our Healthcare Quality Strategy for Scotland (Quality Strategy) we have set ourselves three clearly articulated and widely accepted ambitions based on what people have told us they want from their NHS: care which is person-centred, safe and effective.

Person-centred - 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.

Safe - 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.

Effective - 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.

Person-centred Care

Person-centred care means real partnerships between the people using healthcare services, their families and carers, and the people delivering those services, which respect people's individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. It means asking 'what matters to you?', rather than 'what's the matter with you?', and listening deeply to the answers. It is an approach that has people in the driving seat of their care, with support from their professionals to achieve the outcomes that are important to them.

The Chief Medical Officer for Scotland ( CMO), Dr Catherine Calderwood, used the publication of her first annual report in January 2016 to engage with clinicians as collaborative leaders, to influence and be a driver for change. In the Chief Medical Officer's Annual Report 2014/15: Realistic Medicine ^[19] , she describes the need to 'place collaborative, relational decision-making and planning at the heart of our system' and the absolute imperative 'to be focusing completely and relentlessly on what matters most to the people who look to us for care, support and treatment.'

While person-centred care is one of our quality ambitions for NHSScotland, the person-centred approach extends across health and social care, supporting people who use care and support services, their families and carers, to live well in communities across Scotland.

Third Sector Partnerships
Driving Change

NHSScotland continued to work with many third sector partners during 2015/16 - at national and local level - as part of the drive to improve care through active participation.

The Health and Social Care Alliance Scotland ( ALLIANCE) continued to work with five adopter sites ( NHS Tayside, NHS Greater Glasgow and Clyde, NHS Lothian, NHS Ayrshire & Arran, and NHS Lanarkshire) to take forward the House of Care ^[20] approach to collaborative care and support planning. This approach, which has an internationally-recognised evidence base, puts people and their families in the driving seat of their care.

Funded by the Scottish Government and delivered in partnership with The ALLIANCE, ALISS (A Local Information System for Scotland) continued to map assets across the community to enable people to more effectively self-manage by connecting them with local sources of support. ALISS has been rolled out across all Community Pharmacies in Scotland and can be accessed through Living it Up ^[21] in a number of areas in Scotland. Work also continued to support people to have the knowledge, understanding, skills and confidence they need to use health information, to be active partners in their care, and to navigate health and social care systems. A demonstrator programme as part of the Making it Easy: a Health Literacy Action Plan for Scotland ^[22] in NHS Tayside will start to report from autumn 2016, reflecting work undertaken throughout 2015/16. It is examining a range of tools and approaches to enable staff to recognise and cater for people's health literacy needs.

In September 2015, the Cabinet Secretary for Health and Sport launched the next round of the Self Management Fund in Scotland. The Fund, which is managed by The ALLIANCE on the Scottish Government's behalf, has been highlighted by Carnegie UK Trust ^[23] as a leading example of the way to drive the change described in the Christie Report. Over the past three years, the Self Management IMPACT Fund has provided grants, both large and small, to third sector groups to encourage the development of new approaches in supporting people to live well, on their own terms, with whatever health conditions they have.

Supporting People to Have Greater Choice and Control in Social Care

In 2014, the Scottish Government legislated to integrate health and social care services to ensure those who use services get the right care and support, whatever their needs, at any point in their care journey. Over the past year, the Scottish Government worked with strategic partners and people who use services to support people, their carers and families to make informed choices about what their social care support looks like and how it is delivered. This work is based on the understanding that having greater control of your life and decision-making leads to improved health and wellbeing.

Through the Social Care (Self-directed Support)(Scotland) Act 2013, Local Authority social work departments have a legal duty to offer people who are eligible for social care a range of informed choices over their care and support. Even if a person is not eligible for a formal public service or personal budget, any assessment process, contact with universal public services and engagement with voluntary organisations about care and support should follow the principles in the Act. This approach is called Self Directed Support ^[24] .

Achievements in Self Directed Support

The Scottish Government has invested £50 million in making the transition to this new approach between 2011 and 2016. During 2015/16 this included £3.52 million to Local Authorities to support system and culture change with staff. The Social Care Survey 2015 shows that 35,000 people made a choice about their support during 2014/15 ^[25] .

In 2015/16, £2.8 million was invested in 34 third sector organisations through the Support in the Right Direction Fund. In the six months between October 2015 and March 2016: 3,200 people were supported to access their existing community resources; 2,400 individuals received training and development support; 1,000 people received brokerage support; 950 people were helped to set up and manage their care packages; and 800 people were helped to employ and manage personal assistants ^[26] .

Just over £1 million was invested in 21 third and independent sector providers of care through the Innovation Fund. Projects built the capacity of social care providers and the social care workforce to deliver more flexible and creative support. Key outcomes achieved between October 2015 and March 2016 include: facilitated peer support and sharing of learning about Self Directed Support for practitioners and providers; Self Directed Support training and materials for practitioners and providers; and enabling people to use their social care budgets more creatively. As an example, ClickGo ^[27] is a digital tool that enables people to direct and manage their social care support. It won a commendation from The Herald Scottish Digital Business Awards 2015 ^[28] .

In the reporting year, £0.4 million was invested in workforce development with projects including action learning sets, collaborative work with the Care Inspectorate and the development of a risk resource. A further £0.8 million was invested in developing guidance, engagement, evaluation and independent living, including Self Directed Support Financial Guidance developed by the Chartered Institute of Public Finance and Accountancy ( CIPFA) ^[29] .

Supporting People in Their Caring Role

During the year, there was a strong emphasis on carers and the role they play in our communities. The Scottish Government worked with individuals and organisations across Scotland to deliver the Carers (Scotland) Act, which was passed in February 2016. The Act will make a meaningful difference to unpaid carers and will contribute towards the improvement of their health and wellbeing, ensuring that they can continue to care, if they so wish, and have a life alongside caring.

The package of provisions in the Act includes, amongst other things: a duty on Local Authorities to provide support to carers, based on the carer's identified needs which meet the local eligibility criteria; a specific Adult Carer Support Plan and Young Carer Statement to identify carers' needs and personal outcomes; a requirement for each Local Authority to have its own information and advice service for carers; and a duty on NHS Boards to ensure that carers are fully involved in the hospital discharge process of the person that they care for. The main provisions of the Act will be commenced on 1 April 2018.

In the meantime, funding of nearly £34 million has been provided between 2008 and 2016 to NHS Boards and the Scottish Ambulance Service for direct support to carers, of which £5 million was allocated in 2015/16. Over the year, NHS Board priorities included funding for carers' centres that provide a range of services such as advocacy and advice; training for carers and the workforce; information on income maximisation; and projects that support black and minority ethnic and other hard to reach groups.

Listening to the voices of carers through initiatives such as the Carers Parliament and Young Carers Festival has allowed the development of legislation and policies, and the allocation of funds, based on what's important to carers. The implementation of the Carers (Scotland) Act will be a high priority for the Scottish Government over the current and coming year.

Improving Palliative and End of Life Care

The Scottish Government published the Strategic Framework for Action on Palliative and End of Life Care ^[30] on 18 December 2015. It sets out the ambition of ensuring that by 2021 everyone in Scotland who needs palliative care will have access to it, supported by £3.5 million over the next four years. It also highlights the need to identify all those who need palliative care, and to ensure the professionals they encounter are appropriately skilled to support them with timely and focused conversations, to plan their care and support in line with their wishes.

The commissioning of palliative care and end of life care became the responsibility of Health and Social Care Partnerships in April 2016. One of the 10 commitments in the framework for action is to provide new commissioning guidance on this critical work. We expect this guidance to be available to Health and Social Care Partnerships in spring 2017. Other commitments being progressed with partners in health, independent hospice, academic, care and third sector partners include supporting the improvements in palliative care in at least five Health and Social Care Partnerships, the appointment of three training leads working across health and social care and the creation of a research forum, all of which are laying the groundwork for achieving the ambition.

Welcoming Feedback and Using it for Improvement

NHSScotland and the Scottish Government are jointly committed to supporting a culture of openness and transparency in NHSScotland, that welcomes feedback, comments, concerns and complaints, and uses them all as a valuable source of intelligence to drive continuous improvement.

In June 2015, the Cabinet Secretary for Health and Sport announced Our Voice ^[31] at the NHSScotland Event. Our Voice is designed to create a voice with a purpose, that is representative and inclusive, informed, and focused on quality improvement. It has been developed through open engagement with citizens, led by a partnership involving the Scottish Health Council, Healthcare Improvement Scotland ( HIS) public partners, COSLA, the Scottish Government, The ALLIANCE and other third sector organisations.

Our Voice will operate at individual, local and national level to support improvement and empower people to be equal partners in their care and will include: at national level, citizens' panels and new models of deliberative engagement that will create opportunities for people to engage in national policy debate; at local level, peer networks to support people to engage purposefully in local planning processes; and at individual level, support for people to feed back about the care and services they receive, and for this feedback to be used to drive and inform continuous improvement to services.

Work started in 2015/16 to develop the infrastructure that will support the new framework, including the ourvoice.scot website, which launched at the end of 2015.

As part of its Person-centred Health and Care Programme ^[32] , Healthcare Improvement Scotland began work in 2015/16 with three NHS Boards across Scotland to test 'real-time' approaches to gathering feedback about people's experience of using care, and using that feedback to identify and act on opportunities for service improvement. Two NHS Boards are also testing 'right-time' enquiry (two or three weeks after the experience of care), as there is some evidence that people feel able to provide more candid feedback on their experience of care within this time period.

Healthcare Improvement Scotland also supported the development and testing of Experience Based Co-design Methodology ^[33] . This is a method for working with groups of people who access support or care and the staff that provide it, to co-design improvements to services. Experience-based co-design draws on knowledge and ideas from design sciences, where the aim of making products better is achieved by involving the people who use those products in the design process itself.

Work also started in 2015/16 to review the NHSScotland complaints procedure, to bring a sharper focus to the early, local resolution of complaints and support NHS Boards and their service providers to deliver a consistently person-centred service. A steering group chaired by the Complaints Standards Authority ( CSA), and involving representatives from across NHSScotland as well as the Scottish Government, the independent Patient Advice and Support Service ( PASS) and Healthcare Improvement Scotland public partners, met in September 2015 to begin the review, and has developed a revised procedure to be implemented from April 2017. This work has been taken forward in response to a recommendation in The Scottish Health Council's Listening and Learning: how feedback, comments, concerns and complaints can improve NHS services in Scotland ^[34] report. It will help to address the current differences in the management of complaints across health and social care by bringing the NHS complaints procedure more closely into line with other public sector services.

The Patient Rights (Scotland) Act 2011 ^[35] introduced the right for people to give feedback, make comments, and raise concerns and complaints about the services they receive from NHSScotland, and places a duty on the NHS to actively encourage, monitor, take action and share learning from the views they receive. In accordance with the regulations associated with the Act, NHS Boards once again published annual reports, showing where lessons have been learned and describing actions taken to improve services as a direct result of feedback, comments, concerns and complaints.

There were 21,456 complaints made about NHS services in Scotland in 2015/16 - a 4 per cent fall in the total number of complaints, compared to the previous year. This figure includes hospital visits and GP, dental and ophthalmic appointments, and represents the equivalent of 0.05 per cent of all NHSScotland activity ^[36] . NHS Boards must listen to all of the complaints they receive, learn from them and take action where necessary in order to continuously improve services.

The Scottish Government has also supported NHSScotland to continue to engage with the independent website Patient Opinion ^[37] , which provides an online route for people to share their experiences of care - whether good or bad - directly with NHS Boards and engage in constructive dialogue with them about how services can be improved. All of Scotland's Territorial NHS Boards were reading and responding to stories posted on the Patient Opinion website in 2015/16. There were 1,779 stories shared about NHSScotland in 2015/16, which were viewed 600,000 times. Fifty-four per cent were positive, 81 per cent were responded to in five days or fewer, and 63 changes and improvements to services were made or planned as a direct result of a story shared in this way ^[38] .

The Scottish Government has developed innovative approaches to supporting systematic analysis and learning from the care experiences being shared on Patient Opinion, and in 2015/16 it began a series of meetings with senior leaders in NHS Boards to promote this source of intelligence. With more than 5,000 experiences on the platform, it has become a rich source of knowledge about how people in Scotland are feeling about their NHS, what is working well and what could be improved. Work will continue to explore the potential of Patient Opinion to support quality improvement work and a series of follow-up visits will be undertaken in 2016/17.

Measuring and Improving Satisfaction with NHSScotland - National Surveys

Satisfaction with NHSScotland remains high, with 90 per cent of hospital inpatients who participated in the Scottish Inpatient Patient Experience Survey 2016 ^[39] reporting overall care and treatment to be good or excellent and 87 per cent who responded to the Health and Care Experience Survey 2015/16 ^[40] rating the overall care provided by their GP practice as good or excellent.

In autumn 2015, the first national Cancer Patient Experience Survey ^[41] was launched to provide high quality national and local data on patients' experiences of cancer care. This provides a measure of what matters to people with cancer and forms the basis for the learning to be able to improve the experience of cancer patients in Scotland.

The results published in June 2016 found that 94 per cent of patients rated their care positively (giving an overall rating of seven out of 10 or above). The cancer survey also found areas where improvements could be made, particularly around helping patients access support for their wider emotional, financial and practical needs.

These results will inform a range of actions being taken forward under the Scottish Government's cancer strategy Beating Cancer: Ambition and Action which is supported by an investment of £100 million.

The second Maternity Care Experience Survey ^[42] was conducted in 2015, which again showed a very positive picture of women's experiences of maternity care overall. In most instances women said that they received excellent care from staff (92 per cent of women rated their care during labour and birth as either excellent or good), although postnatal care in hospital was rated less highly than other stages of care.

Achieving Better Outcomes for People with Dementia, Their Families and Carers

Workforce education, training and development is at the centre of national and local work to improve dementia services and support, and to implement the Standards of Care for Dementia in Scotland across the care pathway and in hospitals. The Scottish Government has an ongoing national commitment to fund this activity through the implementation of Promoting Excellence, backed by around £500,000 per year.

As part of this activity, there are 608 Dementia Champions, all trained to 'Enhanced' level on the Promoting Excellence Framework, with over 10 per cent in social services. A further 100 Dementia Champions are currently being trained. In social services, over 1,000 Dementia Ambassadors have been inducted, with around 850 currently active ^[43] .

All Promoting Excellence initiatives, which are complemented by an ongoing and expanded national approach to improvement through Focus on Dementia ^[44] , are contributing to better service responses and better outcomes for people with dementia and their families and carers. This includes implementation of the national post-diagnostic commitment, integrated support at home and national action specifically focused in general hospitals and NHS specialist dementia care.

Supporting People with Autism and Learning Disabilities to Live Healthier Lives

Scotland is at the mid-point of a 10-year Scottish Strategy for Autism ^[45] , launched in November 2011. The recommendations of the strategy were reframed into an outcomes-based approach ^[46] , which identified the priorities for 2015-2017. These outcomes focus on improving services so that people with autism can live healthier lives, have choice and control over the services they receive, and are supported to be independent active citizens with the same rights as all citizens to contribute to a fair, equal and prosperous Scotland. Work has started to develop a future outcomes approaches which will identify strategic priorities for delivery in 2017-2019.

The Keys to Life - Improving Quality of Life for People with Learning Disabilities ^[47] is a 10-year programme published in 2013 designed to meet the needs of people with learning disabilities. A refreshed delivery approach was developed which identified four strategic outcomes: a healthy life; choice and control; independence; and active citizenship. The delivery approach aims to address the wider socio-economic factors which contribute to the significant inequalities faced by this population. It is aligned to the United Nations Convention on the Rights of Persons with Disabilities and identifies key activities for 2015-2017. It places a greater emphasis on the cross-policy connections required to achieve the identified strategic outcomes. This approach will help us to prioritise and deliver the aims of the Keys to Life strategy in shorter periods over the 10-year lifetime of the strategy. The first of these shorter implementation plans has been developed for a two-year period 2015-2017 ^[48] and will inform future plans throughout the duration of the strategy.

Supporting Survivors

Scotland is one of the few countries in the world that has dedicated funding for support services for survivors. In addition to the investment in the In Care Survivors Support Fund, the Scottish Government is committed to supporting all survivors of child abuse. Innovation and Development Funding of almost £1.8 million was allocated to a total of 21 organisations across 27 separate survivor services for 2015/16 to support the delivery of these strategic outcomes and priorities.

The strategic framework Survivor Scotland Strategic Outcomes and Priorities 2015-2017 ^[49] was published on 1 October 2015. This delivery approach is grounded in what survivors tell us is important to them and has three identified outcomes:

• A Healthy Life: Survivors are enabled and supported to enjoy an attainable standard of living, health and family life;
• Choice and Control: Survivors are treated with dignity and respect and are empowered and enabled to access the right support; and
• Safety and Security: Survivors have access to resources and services which are trauma informed and have the capacity and capability to recognise and respond to the signs of childhood abuse.

Through consultation during 2015/16, survivors expressed the need for services that are designed around their own individual circumstances, including specialised counselling, physical and mental healthcare, and support in terms of education, employment, benefits, legal advice, housing and practical matters. In response, the Scottish Government identified funding of £13.5 million over five years (2015-2020). This was announced in March 2016 by the Cabinet Secretary for Education and Lifelong Learning to develop a bespoke In Care Survivor Support Fund Service.

The Support Fund will offer a person-centred, outcomes-based approach that identifies what matters to survivors. This approach places people at the centre of their own support and is not restricted to health and social care needs, but rather encompasses a much wider range of support.

Safe Care

We have set ourselves clear aims to ensure that there will be no avoidable injury or harm to people from the healthcare they receive, and that an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times. The internationally-acclaimed Scottish Patient Safety Programme ( SPSP) continues to drive improvements across a number of key areas of healthcare. Significant new work has been done to draw together improvement support resources across health and social care with the Improvement Hub based at Healthcare Improvement Scotland ( HIS) going live on 1 April 2016. Work has also been undertaken to provide assurance across health and social care with the development of a clinical and care assurance framework. Work is also continuing to ensure our hospitals are safer and cleaner with support from the Healthcare Environment Inspectorate.

Making Healthcare Safer

The Scottish Patient Safety Programme is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered. From an initial focus on acute hospitals, work now includes safety improvement programmes for the following areas:

• Acute adult;
• Healthcare Associated Infection;
• Maternity and children;
• Medicines;
• Mental health;
• Primary Care; and
• Dentistry.

Building on the successes achieved to date, the Scottish Patient Safety Programme has been developing the key priorities for safety going forward, identifying three core themes to support achieving National Health and Wellbeing Outcome 7: People using health and social care services are safe from harm ^[50] .

The three core themes are: prevention, recognition and response to deterioration; medicines; and system enablers for safety.

The Scottish Patient Safety Programme is led and coordinated nationally by Healthcare Improvement Scotland, supporting implementation within NHS Boards through local teams within hospitals, GP practices, mental health inpatient units and community pharmacies. The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model ^[51] , using national learning sessions to bring NHS Boards together to share and learn from each other. This is interspersed with action periods where local teams test and implement changes using improvement methodology - The Model for Improvement - to bring about improvements in care provision. The programme is supported by a range of stakeholders including NHS Education for Scotland.

In response to the integration of health and social care across Scotland, during 2015/16 Healthcare Improvement Scotland worked with a range of partners including the Joint Improvement Team and the Quality and Efficiency Support Team ( QuEST) to develop a new improvement resource called the Improvement Hub (iHub) ^[52] . This resource came into effect on 1 April 2016 and will support Health and Social Care Partnerships and NHS Boards to improve the quality of health and social care services by: supporting the development of cultures of continuous quality improvement so that every person working in health and social care is engaged in the work of improving their day-to-day practice; and supporting the work to design systems, services and processes which enable people to receive the right support and care, in the right place, at the right time whilst also reducing harm, waste, duplication, fragmentation and inappropriate variation.

Examples of key achievements of the quality improvement work across NHSScotland are set out here.

Making Acute Care Safer

Mortality Rates

Within acute care there has been an overall reduction in Hospital Standardised Mortality Ratios ( HSMR) of 16.5 per cent between October-December 2007 and October-December 2015. The methodology used by ISD was updated in August 2016 and progress towards the new aim to reduce hospital mortality by a further 10 per cent by December 2018 is measured from the end of a new baseline period (January 2011 to December 2013 to the latest quarter). The HSMR for Scotland has decreased by 4.5 per cent since January to March 2014 (first quarter after the new baseline) and January to March 2016 ^[53] .

Figures from the Scottish Patient Safety Programme, show that during the period January 2011 to January 2016, there has been a 21 per cent reduction in mortality from sepsis ^[54] and that there has been a 19 per cent reduction in cardiac arrest rate ^[55] for 11 of 25 hospitals that have reported consistently from February 2012 to December 2015.

Reducing Falls and Pressure Ulcers

The Scottish Patient Safety Programme acute adult programme has been working with clinical and improvement teams to reduce falls by 20 per cent and harm from falls by 25 per cent within acute hospitals. This is being done through supporting a variety of process improvements including risk assessment, falls bundles and post falls reviews to identify opportunities for learning and improvement. Following the transition of pressure ulcer improvement work from Leading Better Care in 2013, we have committed to reducing pressure ulcers in acute hospitals by 50 per cent. Current improvement work suggests development and implementation of more robust systems and processes for pressure ulcer recording have led to an increased confidence in the data of pressure ulcers reported. This increasing confidence in the quality of outcome data is supporting focused improvement work.

Reducing Healthcare Associated Infections and Tackling Antimicrobial Resistance

Reducing Healthcare Associated Infections ( HAIs) and containing Antimicrobial Resistance ( AMR) remains a priority for the Scottish Government and NHSScotland. Patients and the public must have complete confidence in the cleanliness and safety of Scottish hospitals and the quality of NHS services. We will continue to support and work closely across NHSScotland and with key stakeholders to reduce HAIs and tackle AMR to deliver further improvements for the safety of patients.

Significant progress has been made to reduce Healthcare Associated Infections across Scotland. From January-March 2007 to January-March 2016, cases of Methicillin-resistant Staphylococcus aureus ( MRSA) and cases of Clostridium difficile Infection ( CDI) in patients aged 65 years and older have reduced by 88 per cent and 87 per cent respectively ^[56] .

The Healthcare Environment Inspectorate ( HEI) carries out inspections of Scotland's hospitals and has played a vital role in supporting hospitals to reduce incidents of infection. This year, the HEI started inspecting NHS Boards against new Healthcare Associated Infection ( HAI) standards, published by Healthcare Improvement Scotland in February 2015 ^[57] . These standards are more expansive than the 2008 standards they supersede, and provide more detail and clarity to care providers about what is expected of them and how they can provide evidence to show how they prevent and control infections. In 2015/16 the HEI carried out 31 inspections of which 27 (87 per cent) were unannounced ^[58] .

In 2015/16, £11.5 million was provided to support projects to help reduce HAI and AMR and funding of £4.2 million was granted to the Scottish Infection Research Network to set up a Scottish Healthcare Associated Infection Prevention Institute ( SHAIPI). This five-year project, which commenced in April 2015, is the largest single investment into research into Healthcare Associated Infections in Scotland ever.

In 2015, the Controlling Antimicrobial Resistance In Scotland ( CARS) Group was established to oversee Scotland's contribution to the UK AMR Strategy 2013-18 ^[59] . CARS has taken forward a number of significant work streams to improve knowledge and understanding of antimicrobial resistance through the capture and use of better information on prescribing and antibiotic resistance.

Improving Child and Maternal Health Safety

In paediatrics, work has focused on reducing harm from ventilator associated pneumonia, central venous catheter bloodstream infection, unplanned admission to intensive care, medicines harm and child protection harm. One example of improvement can be seen in NHS Greater Glasgow and Clyde, where staff in the NHS Board have achieved a reduction of 78 per cent in the ventilator associated pneumonia rate. Work is ongoing to spread this success.

Making Medicines Safer

The Scottish Patient Safety Programme medicines programme brings together improvement activity related to medicines across acute, Primary Care, maternity and children's services and mental health. It has a focus on: reducing medicines harm across transitions (medicines reconciliation); and high risk medicines with a whole systems approach to these two priority areas.

Improving Patient Safety in Mental Health Services

Mental health is a major public health challenge in Scotland. It is estimated that around one in four people are affected by mental illness in any one year. The Mental Health Safety Programme has worked with mental health clinicians and service users. An increasing number of wards and units are showing improvements in rates of violence and restraint, seclusion and percentage of individuals self harming. There are examples of reductions in restraint of up to 64 per cent, reduction in the percentage of patients who self harm of up to 75 per cent and reduction in the rates of violence of up to 80 per cent ^[60] .

Reducing Harm in Primary Care

The Primary Care strand of the Scottish Patient Safety Programme aims to reduce the number of events which could cause avoidable harm from healthcare delivered across the wide range of Primary Care settings. Launched with an initial focus on General Practice, a range of tools and resources has been developed to support those working within Primary Care to improve the quality of care to patients, developing the patient safety culture within their teams and making higher-risk processes reliable.

Within Community Pharmacy, in four NHS Boards (Fife, Grampian, Greater Glasgow and Clyde and Highland), tools and interventions were piloted over two years in 27 pharmacies. Pharmacy teams tested care bundles for two high risk medicines: warfarin in NHS Fife and NHS Grampian; and non-steroidal anti-inflammatory drugs ( NSAIDs) in NHS Greater Glasgow and Clyde and NHS Highland. They also piloted a pharmacy safety climate survey to improve the 'safety culture' in their pharmacies and nearly all of them identified areas for team improvement. In year two, participating pharmacies and dispensing practices have begun to test a medicines reconciliation care bundle by collecting data on a small sample of patients recently discharged from an acute hospital. The learning from this pilot will inform Quality Improvement in Community Pharmacy.

Within General Practice, the current GMS contract supports two principal pieces of work: reflective review of case notes by trigger tool; and a practice Safety Climate Survey. The trigger tool review, using the NHS Education for Scotland Primary Care Trigger Tool, allows GP practices to analyse a sample of case notes to determine whether any safety events, or near misses, have taken place. The resultant reflective report is discussed within the practice before being shared with the NHS Board so that themes may be developed and further improvement activity undertaken if appropriate.

The Safety Climate Survey is a validated tool for all practice staff, clinical and non-clinical, to express their views in six key areas of safety climate. This data can then be used by practices to determine strengths and areas for development through the formation of a reflective report which is shared with the NHS Board where learning across the system may again be aggregated. The number of GP practices participating in the safety climate survey has increased by 3 per cent since 2013, now totalling 93 per cent of all practices ^[61] . In addition to each of these areas, NHS Boards have commissioned a range of local enhanced services to improve areas of care that are recognised as being of higher risk to individuals.

Making Dentistry Safer

NHS Ayrshire & Arran, NHS Dumfries & Galloway and NHS Fife were recruited following a national recruitment process to allow testing to take place in a wider range of dentistry settings in Primary Care. The collaborative will run initially until December 2016. Dental practice teams will learn more about improvement methodology, pilot the use of tools and interventions to deliver safer, more reliable care, begin to explore their safety climate by undertaking a safety climate survey and share learning within their teams, their NHS Board and with other NHS Boards.

This is a ground-breaking project to test interventions and tools, further expanding the scope and reach of Scottish Patient Safety Programme. Each participating NHS Boards has recruited a dentistry clinical lead, and five dental practice teams, to work together on testing the tools and interventions. The learning from this project will support further work across Scotland and ultimately, it will improve patient safety in dentistry.

Supporting Improvement with Continuous Learning

Learning is central to all of these achievements and Healthcare Improvement Scotland has been supporting this work in a number of ways. Support to NHS Boards to improve their processes for managing and learning from adverse events continues. Implementation of Learning from adverse events through reporting and review: A national framework for Scotland ^[62] , coupled with the development of Board-level learning and improvement summary reports, has enabled improved outcomes at a local and national level.

Healthcare Improvement Scotland has been supporting two Boards - NHS Tayside and NHS Borders - to test a framework for the measurement and monitoring of safety in Scotland. The framework encourages a shift from a focus on past harm to thinking about safety today and in the future at its core is integration and learning. Healthcare Improvement Scotland is now seeking to embed the framework and its principles into existing national programmes and policy to encourage a new view of safety and quality more broadly.

Ensuring Safety Across Health and Social Care

The integration of health and social care will enable people to get the right care at the right time, in the right place. These arrangements are intended to provide safe care which best meets the needs and wishes of people, their families and carers. As part of ensuring safety, a Clinical and Care Governance Framework ^[63] was developed by an expert group. This framework covers those services which, from 1 April 2016, will be the responsibility of Health and Social Care Partnerships and builds on the existing governance frameworks within Local Authorities and NHS Boards.

Effective Care

Many of the areas for improvement that have been prioritised during 2015/16 make a direct contribution to our Quality Ambition for more effective healthcare services. A 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.

Setting Out a Framework for the Development of Health Services

A National Clinical Strategy for Scotland ^[64] was launched by the Cabinet Secretary for Health and Sport in February 2016. It sets out the direction of travel and transformational change necessary to deliver a person-centred, safe and sustainable NHS for the people of Scotland over the next 10 to 15 years. It was developed through wide-ranging engagement with clinicians and staff across NHSScotland, third sector and professional bodies and provides the framework for the future of health and social care.

The Strategy is evidence-based, looking at the projected demographic challenges alongside potential innovations and their impact on the planning and delivery of healthcare services for our population as well as the already significant transformation arising from the integration of health and social care. It provides a platform for the continuous quality improvement of healthcare, social and voluntary services across Scotland to improve outcomes.

Improving Unscheduled Care Planning and Delivery

Scotland's unscheduled care performance was the best performance we have seen since 2011/12. Some 94.1 per cent of patients were seen and subsequently admitted, transferred or discharged within four hours. In 2015/16 Scotland saw the best performance throughout the UK for the first time since records began. Scotland's core A&E Departments have been the best performing in the UK since March 2015.

The launch of the new improvement focused approach in May 2015, based on six fundamental actions developed in partnership with the Academy of Royal Colleges, has supported the progress seen in Scotland. The Six Essential Actions ^[65] are:

• Clinically-focused and empowered hospital management;
• Realignment of hospital capacity and patient flow;
• Patient rather than bed management - operational performance;
• Medical and surgical processes arranged to take patients from A&E through the acute system;
• Seven-day services targeted to increase weekend and earlier-in-the-day discharges; and
• Ensuring patients are cared for in their own homes or a homely setting.

Over the last year, the implementation of the Six Essential Actions has primarily focused on what was required in the acute sector, sharing good practice and embedding changes and focusing on those sites with the biggest challenges. While work will continue to build upon this success, it is recognised that to maintain progress, there is a need to increase the focus on the whole system, and engagement and alignment of primary, secondary, voluntary and third sector organisations. This is vital if the system is to change to one that allows each organisation to link seamlessly together and support our ambition of person-centred, safe and effective care for generations to come.

Nearly £10 million has been invested this year to progress this approach. It is multi-disciplinary in nature and has commitment from partners across every part of the health and social care system. A number of key actions have been put in place to ensure progress. The national team, which consists of a number of experts with a range of professional expertise, has been enhanced, and with central funding, local teams are now dedicated to implementing the Six Essential Actions. This has allowed the Scottish Government and NHS Boards to work closely to make steady and significant improvements, particularly in the case of sites experiencing the biggest challenges.

Improving Delayed Discharge Performance

The impact on delayed discharge performance of new integrated ways of working is starting to be seen already. Bed days associated with delayed discharges have been on an overall downward trend throughout the year, running at 9 per cent below the level in 2014/15 ^[66] . Many local Health and Social Care Partnerships have now almost eradicated delays from the system. Others are making substantial progress. Health and Social Care Partnerships are adopting reablement approaches to help older people regain their independence, allowing them to live in their own homes for longer, as well as investing in new technology enabled care. These actions should help prevent avoidable admission to hospital as well as facilitating timely discharge where treatment in hospital has been necessary.

Transforming Outpatients

The Delivering Outpatient Integration Together Programme ( DOIT) was launched on 10 August 2015 by the Cabinet Secretary for Health and Sport. Demand in Outpatients is increasing and new ways of managing patients and improving their experience is core to the ambitions of the DOIT Programme. Four key improvement elements have been found to have most success in ensuring the patient is seen by the right clinician first time, whilst ensuring greater efficiency in outpatient services. Each NHS Board is expected to implement the 'Improvement Bundle'.

Enhancing Elective Capacity

Some £200 million is being invested to create five new elective centres across Scotland as well as a further expansion of the Golden Jubilee National Hospital. This investment is intended to enhance elective capacity to meet the needs of a growing - and ageing - population. The new capacity will be part of a wider programme to put in place a comprehensive national elective strategy for Scotland, which will deliver diagnostic and treatment facilities which meet the aims of the National Clinical Strategy for Scotland ^[67] and the principles of Realistic Medicine, as set out in the Chief Medical Officer's Annual Report 2014-15: Realistic Medicine ^[68] .

This programme will also enable creative redesign of services to ensure that all elective capacity is operating at optimum efficiency, reflecting 'best in class' practices from across the world and ensuring timely access for all patients across Scotland. In June this year, the programme was launched at a national event at the Golden Jubilee National Hospital and NHS Boards are now working with their partners to plan the size, role and scope of the new centres - with initial business cases due for submission to the Scottish Government at the end of the 2016/17 financial year.

The Golden Jubilee is also working to bring forward part of the expansion of its elective centre from 2018/19 to this year. The investment in MRI scanners will enable delivery of an additional 10,000 scans per annum on a recurring basis from Quarter 4 2016/17 and help build resilience. It also plans to move its ophthalmology suite into a state-of-the-art modular theatre and to create additional theatre capacity that will provide capacity for 2,100 routine general surgery procedures per annum when operating at full capacity, which will take around 12 months.

Elective waiting times have been transformed over the last 10 years despite growth in demand, however we recognise that sustaining elective waiting times is a challenge. In 2015/16, diagnostic waiting times statistics showed that 94.6 per cent of elective patients had been waiting six weeks or less at the end of March 2016 ^[69] . Almost 300,000 or 94.4 per cent of elective inpatient and day case patients were treated within 12 weeks in 2015/16, while 88.0 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2016 ^[70] .

Improving Cancer Outcomes

New Cancer Strategy

In March 2016, a new cancer strategy Beating Cancer: Ambition and Action ^[71] was published. It sets out a direction of travel for cancer and related services for the next five to ten years, including prevention, early detection, diagnosis, treatment, care after treatment, quality, workforce and research.

The Strategy supports a new and significant initiative. Established in May 2015, the Innovative Healthcare Delivery Programme ^[72] is focusing on new and innovative ways of both accessing and using cancer data to improve services and patient outcomes. Up to £2 million is being invested as part of the Cancer Strategy to develop a Scottish Cancer Intelligence Framework, with the programme based at the Farr Institute in Edinburgh. Performance of NHS Boards is monitored against Quality Performance Indicators ( QPIs) by the National Cancer Quality Steering Group with reviews undertaken by Healthcare Improvement Scotland. A process of regular revision is in place to ensure that the QPIs keep pace with changes in the international evidence base and clinical practice.

Detect Cancer Early

The Scottish Government launched the Detect Cancer Early ( DCE) Programme ^[73] in February 2012 to address the poor quality of life and poor survival rates resulting from late diagnosis. Early detection offers people the best chance of cure and possibly an opportunity to join clinical trials. Even in cases of advanced or incurable disease, early detection increases the chances of being able to offer treatment that prolongs life or allows more time to manage symptoms better and improve quality of life.

In the combined calendar years of 2014 and 2015, 25.1 per cent of lung, breast and colorectal cancers were diagnosed at the earliest stage, an increase of 8.0 per cent on the baseline combined calendar years of 2010 and 2011. The largest increase in Stage I diagnoses was in the most deprived ( SIMD 1) which was a 16.3 per cent increase from baseline. There has also been particular improvements in the proportion of lung cancers being diagnosed at stage I (35.6 per cent increase from baseline) ^[74] .

During 2015/16, the DCE Programme has successfully carried out social marketing campaigns on bowel cancer screening, lung cancer and breast screening. A new strand of activity was introduced into the DCE programme in 2015 called the wee c ^[75] . In partnership with Cancer Research UK, the wee c aims to change perceptions and attitudes to cancer in Scotland in a bid to reduce fear around the disease and encourage earlier presentation. This was accompanied by a generic awareness raising campaign #getchecked.

To support GPs to refer patients with suspected cancer as early as possible, a mobile app was launched in February 2016 for the Scottish Referral Guidelines for Suspected Cancer ^[76] .

DCE has funded a pilot study in NHS Tayside looking at the use of faecal immunochemical testing ( qFIT) in Primary Care for symptomatic patients who may or may not have bowel cancer. This pilot enables GPs to identify those patients who warrant urgent 'straight to test' referral, and to reassure those for whom a policy of watch and wait would be the optimal choice.

If this pilot is successful, it could transform the management of patients with colorectal symptoms so that many would be spared unnecessary invasive investigation and those who need it would have appropriate further tests more promptly. As a consequence of the use of qFIT in routine use in Primary Care, this may also lead to reduced waiting times. This pilot will be evaluated on completion.

Cancer Waiting Times

For the financial year 2015/16, 90.8 per cent of patients began cancer treatment within 62 days of urgent referral with suspicion of cancer. The 31-day standard was met overall in the 2015/16 financial year at 95.7 per cent ^[77] .

These standards have been set to encourage NHS Boards, where clinically appropriate, to adopt efficient cancer pathways and reduce avoidable delays between appointments.

Beating Cancer: Ambition and Action highlights the challenging position for NHS Boards and their ability to achieve these cancer waiting times standards. Specifically, the strategy highlights six actions which will support improvement in cancer waiting times performance:

• Invest an additional £2 million per annum in a new Diagnostics Fund to support swift access to diagnostics for people with a suspected cancer diagnosis;
• Invest an additional £1 million per annum in additional scope capacity, which will see an additional 2,000 scopes per annum on a sustainable basis;
• Invest £7.5 million over the next five years to support improvements in surgical treatments, including urological cancer surgery;
• Invest a further £2 million of capital to support our nationwide programme which will see two further robots for prostate cancer surgery in place - one in Glasgow and one in Edinburgh;
• Invest a further £39 million in radiotherapy equipment over five years. This includes an £8 million investment in 2016/17; and
• Examine whether additional targets for treatment or diagnosis would improve outcomes for people with cancer.

Improving Outcomes Through Whole System Orthopaedic Service Redesign

Whole system redesign of orthopaedic services, using clinical evidence and a focus on improved patient outcomes, is helping to ensure that patients get on the right pathway - starting in the community. A model that uses NHS 24 and NHS inform for early advice and self-management support with end-to-end pathways from community to secondary care is now being implemented across all NHS Boards. A further focus on ensuring that patients are seen by the most appropriate professional the first time they are seen, along with standardised decision-making to ensure they receive the most appropriate treatment, is leading to significant benefits to patients, while reducing the demand for Orthopaedic outpatient assessments and procedures. Where hospital treatment is required, work is focused on achieving efficient throughput in theatres, ensuring that this important resource is fully utilised.

Significant improvements have been seen in the quality of care for hip fracture patients with more people returning home quickly. There has been an increase from 50 per cent to 59 per cent of people returning home or to their original place of residence between 2013 and 2016 ^[78] . This has been achieved through a focus on a pathway of evidence-based interventions, with input from occupational therapy, physiotherapy and geriatrics speciality, so that patients recover quickly and are able to leave hospital without delay. Further improvements in the pathway for patients will be pursued through an enhanced multi-disciplinary focus and social care integration.

An intensive focus on the Enhanced Recovery Pathway ^[79] is also leading to improved outcomes for patients following hip and knee replacement surgery, with patients spending significantly less time in hospital (14,000 fewer post-operative bed days per annum than in 2010 ^[80] ). Variation exists, however, in the benefits being realised from this approach and further work is being undertaken to ensure best practice is embedded to achieve improved patient recovery, reduce length of stay and release capacity in the acute system.

Enhancing the Role of Primary Care

General Practice

In December 2015, the Cabinet Secretary for Health and Sport announced that the Scottish Government had reached agreement with the BMA Scotland, to remove all remaining Quality Outcome Framework ( QOF) points from the Scottish GP contract from April 2016. This means that Scotland is the first in the UK to abolish this bureaucratic system of GP payments. All funding associated with the QOF system will transfer to the core payment, ensuring no reduction in the amount of money GP practices receive. This will significantly reduce the bureaucratic burden on GPs - reducing workload and freeing up GP time to spend with patients.

There will also be transitional arrangements for quality assurance, ahead of a new Scottish GP contract coming into force in 2017. These transitional arrangements include the introduction of 'cluster working' which will allow practices to work more closely together to the benefit of patients. This is a move towards a system of values-driven governance that reflects, and is sensitive to, the needs of different communities across Scotland, and will focus on closer working with other parts of the wider primary, secondary and social care systems.

A £20 million package for GPs was announced in March 2015 by the Cabinet Secretary to ease pressures on the workforce over the next year, while negotiations towards putting General Practice on a long-term, sustainable footing continue. The package includes:

• £11 million to uplift GP pay by 1 per cent and uplift GP expenses by 1.5 per cent, and funding to cover the costs of population growth in 2015/16;
• £5 million to fund a GP from every practice in Scotland to take part in fortnightly sessions on cluster working;
• £2 million funding to improve or upgrade IT infrastructure in GP practices; and
• £2 million on specific measures called for by the BMA's Scottish General Practitioners' Committee: funding a new rate for backfill cover for GPs taking maternity, paternity or adoption leave; developing occupational health services for Primary Care staff; and supplying GP practices with oxygen cylinders for emergency use.

During 2015/16, the Scottish Government announced an £85 million Primary Care fund. Over three years, this investment will enable work to progress to address immediate workload and recruitment issues, as well as putting in place long-term, sustainable change within Primary Care.

Of this investment, £2.5 million has been allocated towards a GP Recruitment and Retention Fund. This fund is exploring with key stakeholders, the issues surrounding GP recruitment and retention. It will examine and take forward proposals that promote Scottish General Practice as a positive career choice, support medical students to actively choose General Practice, inspire doctors in training to select speciality training in General Practice, and encourage our alumni to stay in or return to Scotland and encourage those wanting to work in rural and economically deprived areas. All NHS Boards and Health and Social Care Partnerships were invited to apply. A number of proposals will be selected for development and will be reported on during 2016/17.

Primary Care Transformation Fund

The creation of the Primary Care Transformation Fund ( PCTF) was announced by the Cabinet Secretary in July 2015. With funding of £20.5 million to be allocated over the next three years, this will support the redesign of Primary Care services across Scotland, building towards a future where Primary Care is delivered by multi-disciplinary community teams in localities. NHS Boards and Health and Social Care Partnerships were invited to submit proposals on how they proposed to use their PCTF allocation. Proposals were received from every NHS Board. The assessment and stakeholder engagement meetings are complete and the majority of NHS Boards have now received their allocations.

Review of Primary Care Out of Hours Services

The National Review of Primary Care Out of Hours Services Report, Pulling together: transforming urgent care for the people of Scotland ^[81] , led by Professor Sir Lewis Ritchie, was published on 30 November 2015. The Review, announced by the Cabinet Secretary for Health and Sport in January 2015, reviewed the current landscape and recommended actions to ensure person-centred, sustainable, high-quality out of hours services for the people of Scotland. By visiting NHS Boards across Scotland, the purpose of the National Engagement Programme 2015 was to provide an opportunity for the range of people involved in delivering health and social care during the out of hours period to their communities to contribute their views on what worked well and what did not.

The Chair advocated that the following guiding principles are adopted in the design and implementation of future urgent care services: person-centred; intelligence led; asset optimised; and outcomes focused. Work is now ongoing on behalf of the Scottish Government to take forward the implementation of the report's recommendations.

Optometry

Glaucoma is a progressive disease, affecting around 50,000 patients in Scotland, and is the second most common cause of blindness in the UK. While it is a difficult disease to diagnose as there are no symptoms in the initial stages, early diagnosis and treatment is the best chance of preventing blindness. On publication of the Scottish Intercollegiate Guidelines Network ( SIGN) Guidelines on Glaucoma Referral and Safe Discharge ^[82] in March 2015, the Scottish Government provided every optometry practice in Scotland with a pachymeter, a handheld device which measures the central corneal thickness of a patient's eye. This measurement needs to be considered when assessing the pressure within a patient's eye, a sign of glaucoma. The pachymeters were provided to every practice in Scotland by March 2016, a first in the UK and helping to deliver the Scottish Government's ambition of shifting more resources into Primary Care.

Pharmacy - Building Clinical Capacity

Work has continued to deliver the three-year programme to invest £16.2 million from the Primary Care Fund to recruit up to 140 whole time equivalent ( WTE) additional pharmacists with advanced clinical skills training to work in Primary Care settings. In the first two years of the funding, NHS Boards have made plans to recruit a total of 121.8 WTE pharmacists and 10.9 WTE pharmacy technicians. In year 1, Boards planned to recruit a total of 40.7 WTE pharmacists, providing support to 141 GP practices. For year 2, plans are in place to recruit a further 81.1 WTE pharmacists and 10.9 WTE technicians. These will provide support to around 283 practices across Scotland. To date, there are 47.8 WTE pharmacists in post. By the end of this Parliament all GP practices will have access to a pharmacist with advanced clinical skills ^[83] .

Dentistry

A pilot commenced in four Territorial NHS Boards on 1 April 2015 to use existing data and quality indicators to identify at an early stage practices or dentists that are experiencing difficulties. Ten indicators are being used to ensure that NHS Boards are able to offer support as early as possible to avoid the practice or dentist getting into further difficulty. The 10 indicators are: practice inspection; out of hours arrangements; patient complaints; drug prescribing pattern; Childsmile fluoride varnish applications; clinical quality; clinical audit; probity; patient view; and NHS Board concerns.

Improving Motor Neurone Disease Care

Significant progress has been made towards achieving the Ministerial commitment to improve support for people with Motor Neurone Disease ( MND) by doubling the number of Motor Neurone Disease Clinical Nurse Specialists and increasing the number of specialist nurses across Scotland. Over £2.4 million has been invested by the Scottish Government on a recurring basis to improve access to specialist Motor Neurone Disease ( MND) nursing and care. Patients in NHS Fife, NHS Forth Valley, NHS Orkney and NHS Shetland now have specialist nursing support available in their local areas - made possible through cross NHS Board collaboration. This is just one area of specialist nursing that has benefited from NHS Board investment. Other specialist nursing services to have benefited from investment include cancer, epilepsy, Parkinson's disease, multiple sclerosis and learning disability - increasing the number of nurses in all parts of Scotland.

Saving Lives at Risk from Cardiac Arrest

Scotland's Out-of-Hospital Cardiac Arrest ( OHCA) Strategy ^[84] is being implemented by a wide range of stakeholders. This is pivotal to its success which is now starting to be evidenced through increased survival from cardiac arrest, innovative ways of delivering emergency response to cardiac arrest to the public, and effective collaboration between organisations. Collaboration is already making a difference. This includes: third sector and emergency services working together to provide cardiopulmonary resuscitation ( CPR) training for school children; Scottish Fire and Rescue Service and the British Heart Foundation making CPR training kits available for community use across all fire stations; and a co-responding trial between Scottish Fire and Rescue and the Scottish Ambulance Service in several parts of Scotland.

The Save a Life for Scotland ^[85] campaign was launched in October 2015 aimed at increasing numbers with CPR skills. Over 1,400 people learned basic life-saving CPR skills on that day alone ^[86] . In November 2015, Out-of-Hospital Cardiac Arrest: A Strategy for Scotland won the policy development award at the Scottish Public Service Awards.

Improving Mental Health Services

A New Mental Health Strategy for Scotland

In late 2015 and early 2016, a first round of engagement was carried out to help shape and develop the new Mental Health Strategy. Following that first round of engagement, views were sought in a paper Mental Health in Scotland - a 10 Year Vision ^[87] on: our priorities for transforming mental health in Scotland; the early actions proposed to deliver this transformation; and how success should be measured over the 10-year period. The engagement closed on 16 September. The analysis of the consultation and the new Mental Health Strategy will be published in late 2016.

Mental Health Primary Care Transformation

In February 2016, the Cabinet Secretary for Health and Sport launched the Mental Health Primary Care Transformation Fund, totalling £10 million over two years. This is part of the wider Primary Care Transformation Fund. This money will support innovative tests of change which will result in the redesign of mental health services and support at primary and community care level so that people receive the most appropriate support, as fast as possible, in the most appropriate setting. NHS Boards and Health and Social Care Partnerships submitted proposals on how they proposed to use their funding. Proposals were received from all Boards. Assessment and stakeholder engagement meetings are now complete and funding has been allocated so the tests of change can begin.

Psychological Therapies and Child and Adolescent Mental Health Services

Waiting times for access to Psychological Therapies and to Child and Adolescent Mental Health Services ( CAMHS) and performance on the mental health access standards continues to show a considerable rise in the number of people starting treatment ^[88] . The total number of people starting treatment for Psychological Therapies in the first quarter of 2016 has increased 2.5 per cent on the last quarter of 2015, and 15 per cent on the same period last year, with over 1,700 more people starting treatment. It is welcome to see the increase in the number of children and young people seen within the target time has increased on the previous quarter, with 84.2 per cent of people being seen within 18 weeks during the first quarter of 2016 (see Table 1). In addition, a total of eight NHS Boards are meeting the standard in the first quarter of 2016, up from five at the end of 2015.

Table 1: Starting treatment with Psychological Therapies and child and adolescent mental health services, 2015/16

	Psychological Therapies [89]	Child and Adolescent Mental Health Services [90]
March 2015	11,659	4,269
March 2016	13,451	4,436
Difference	+1,792	+167
As a percentage of March 2015	15 per cent (15.4 per cent)	4 per cent (3.9 per cent)

The Scottish Government is committed to supporting NHS Boards to meet their access targets and an improvement programme was included in the comprehensive package of support for mental health services announced by the First Minister in January 2016.

The Improvement Programme will take a phased approach, working intensively in collaboration with NHS Boards to deliver sustained improvements in access. The programme will be delivered by Healthcare Improvement Scotland and will work in partnership with NHS Boards.

Distress Brief Intervention

Distress Brief Intervention ( DBI) is a time-limited, supportive and problem-solving contact with an individual in distress. The intended outcome of the DBI is to better engage and equip people to manage their own health and to offer a systematic and structured approach for staff to use that promotes a medium to long-term reduction in distress in service users. A better response by services to individuals in distress - including by NHSScotland, emergency services, social services and the third sector - is seen as a key component in supporting people at risk of non-fatal self-harm, and of future suicide prevention ^[91] .

Health and Social Care North Lanarkshire and South Lanarkshire Health and Social Care Partnership will host the DBI central team and participate as one of five test sites, with partners Penumbra in Aberdeen, Support in Mind in Inverness, NHS Greater Glasgow and Clyde and its constituent Health and Social Care Partnerships, and NHS Borders Joint Mental Health Service hosting local pilots.

Mental Health and Learning Disability Inpatient Bed Census

The Mental Health Strategy: 2012-2015 ^[92] had a commitment to undertake an audit of who was in hospital on a given date and the reason for their stay, to provide a better understanding of how the inpatient estate was being used. This was carried out in October 2014 and the results provided a range of valuable data on usage of inpatient beds and those patients who were in beds outwith, but paid for by, NHSScotland ^[93] . The outputs proved valuable and it was agreed that this would be repeated on an annual basis. A further census was carried out on 30 March 2016 and the results were published in September 2016 ^[94] . It showed that the trend of shifting resources from hospitals into the community is continuing and that bed occupancy levels met best practice guidelines. For the first time it included data about the physical health of patients which will allow the measurement of progress in improving the physical health of people with mental health problems or learning disabilities.

Reducing Suicide Risk Discussion Framework Tool

Learning from suicide reviews and from national reports on suicide incidence were used to identify key evidence-based, organisational features that reduce suicide. These were pulled together into a discussion framework for mental health teams to use episodically in internal discussions about reducing risk ^[95] .

Ensuring Children Get the Best Start

Prevention and early intervention is fundamental to ensuring the long-term health and wellbeing of our children and making sure they get the best start in life. It is key to achieving our ambition to address inequalities, raise attainment and create equitable economic growth. The Scottish Government is committed to delivering improved outcomes for children, young people and their families. This begins before birth and continues throughout the child's journey to adulthood.

Maternity and Neonatal Services

We launched a review of maternity and neonatal services in 2015 that will report in early 2017. The Review will make recommendations for a Scottish model of care, with a focus on choice, quality and safety of services. It is based on evidence and extensive engagement with staff and service users in every NHS Board area in Scotland across all of the professions involved in delivery of maternity and neonatal services; and also with a wide range of third sector organisations, and professional groups.

Stillbirth

Stillbirth is a dreadful experience for women and their families. Working through the Maternity and Children Quality Improvement Collaborative and a number of initiatives, NHSScotland continues to drive down the rate of stillbirths in Scotland, with preliminary figures showing the lowest ever rate in 2015 of 3.8 stillbirths per 1,000 births ^[96] .

Health Visiting

Health professionals, particularly Health Visitors, have a vital role to play in supporting children and families in the early years of a child's life. NHSScotland has been developing the Health Visiting Services over the last year to introduce a consistent enhanced service to all families and grow the workforce. In October 2015, the Scottish Government, in conjunction with Territorial NHS Boards, published the new Universal Health Visiting Pathway in Scotland - Pre Birth to Pre School ^[97] . This outlines a core home visiting programme to be offered to families with pre-school children. It consists of 11 contact points including formal health reviews of the child at 13-15 months, 27-30 months and prior to starting school to assess development and report on any issues or concerns. This provides an opportunity for Health Visitors, children and their parents and carers to review development and act as a gateway to other services when needed.

Early Years Collaborative

NHSScotland is actively involved in the improvements being delivered through the Early Years Collaborative ( EYC) ^[98] . This is strengthening services for children and families and contributing towards the shift to prevention and early intervention in line with Getting It Right For Every Child ( GIRFEC) ^[99] and public sector reform. For example, Health Visitor teams are using the quality improvement methodology adopted through the EYC to improve family uptake of the 27-30 Month Child Health Review and speed up responses for those children who need extra support. Some NHS Boards have utilised the EYC to ensure pregnant mums on low incomes are signposted towards the benefits they are entitled to, with families increasing their income by up to £5,000. This work is closely affiliated to the Maternity and Children Quality Improvement Collaborative ^[100] - an integral part of the Scottish Patient Safety Programme.

In Vitro Fertilisation

Scotland leads the way on In Vitro Fertilisation ( IVF) access in the UK. Eligible couples are provided with two full cycles of IVF treatment, with treatment provided within twelve months of referral for 99.9 per cent of patients in 2015/16 ^[101] . Over the last four years, around £18 million has been invested to reduce waiting times and to improve the outcomes for patients undergoing IVF treatment.

Investing in Cutting-edge Medical Research

Developing precision medicine - the practice of tailoring treatment to individual patients based on knowledge about their genetics and other biology and information from their health records - is being supported through investments by the Scottish Government announced in 2015/16. An investment of £4 million will support the establishment of a Scottish Precision Medicine Ecosystem that will bring together resources across Scotland, coordinated by the Stratified Medicine Scotland Innovation Centre, with an initial focus on precision medicine approaches for pancreatic cancer and multiple sclerosis.

Further investment of £4 million plus £2 million from the Medical Research Council is supporting the Scottish Genomes Partnership ^[102] - a collaboration between the Universities of Edinburgh and Glasgow, NHSScotland and NHS England - to use whole genome sequencing technology for research on rare diseases, cancers, Scottish populations and to work with Genomics England on the diagnosis of patients in Scotland with rare diseases.

Empowering People and Improving Care Through Digital Health

Digital technology has an important role to play in helping to transform services, and to ensure person-centred care is provided in a way that fits with people's lives, particularly in an increasingly digital age. Empowering people to more actively manage their own health is key to our 2020 vision for health and social care that everyone is able to live longer, healthier lives at home, or in a homely setting.

Patient Portal

NHSScotland is working to provide everyone in Scotland with on-line access to an integrated summary of their Electronic Patient Record by 2020, which is an important step in self-management and co-production. Working on behalf of NHSScotland as a whole, a consortium of West of Scotland NHS Boards has defined the content and services that will be available through the national patient portal. Work is now underway to develop a business case to take this forward for development.

'My Diabetes My Way' Patient Portal

The 'My Diabetes My Way' patient portal ^[103] delivers tailored support and information to patients, including access to their own records and two-way secure communication with their care providers. The portal consists of an interactive website which includes electronic Personal Health Record ( ePHR) allowing anyone with diabetes in Scotland access to their records. The website contains a variety of multimedia resources aimed at improving self-management and patients can manually enter home-recorded information (weight, blood pressure, etc.), or automatically upload blood glucose results.

Patients can correspond with their healthcare team using secure messaging, delivering remote guidance between routine appointments. These features enhance the service's value and allow patients to contribute to a genuinely 'shared' record. As at April 2016, 'My Diabetes My Way' had 19,098 registrants (an increase of 6,146 since 2015) who had an interest in participating and 8,358 (44.6 per cent) who were fully enrolled and active on the site. The proportion of registrants transferring to active users has increased by 6.1 per cent in the last year ^[104] .

Information Governance

NHSScotland takes privacy of an individual extremely seriously. Securing people's trust in the safety of their personal data and how it will be used is vital to maximise the opportunities that technology has to offer in supporting the delivery of seamless care and support to people. In July 2015, the NHSScotland Information Security Policy Framework ^[105] was published which sets out the measures that NHS Boards need to put in place. This policy framework includes a number of commitments such as the appointment, for the first time, of Senior Information Risk Owners at NHS Board-level, as well as a 114 different controls that need to be in place in each NHS Board. All NHS Boards are being asked to provide evidence of progress against this standard each year.

Sharing Information to Improve Care

The Scottish Wide Area Network ( SWAN) ^[106] is a single public services network for the use of all public service organisations within Scotland. As the major partner, NHSScotland led the procurement for SWAN. During 2015/16, the SWAN transition to improve broadband services continued apace. With over 3,300 NHS sites in Scotland, this is a major project that directly supports the aims of health and social care integration, making it easier to share information appropriately and securely between NHSScotland and other accredited public sector partners - improving the care that is offered while at the same time increasing efficiency. Work is also underway to upgrade the NHSScotland mail system which also assists in effective information sharing and working practices.

Clinical Decision Support

Clinical Decision Support ( CDS) is a key enabler of healthcare improvement and safe care. NHSScotland has increased its focus on the appropriate use of CDS tools across a range of settings and services. During 2015/16, the CDS programme, part of the implementation of the eHealth Strategy, delivered several successful outcomes.

For example, we know that individuals with diabetes are more likely to develop complications associated with their illness, and appropriate clinical decision support has been shown to lead to earlier identification of potential issues leading to earlier screening and intervention. In a pilot project on context-sensitive decision support ^[107] linked to Scottish Care Information ( SCI) Diabetes in NHS Tayside and NHS Lothian, it was shown that patients provided with evidence-based prompts, alerts and reminders to support lifestyle interventions, prevention and treatment were three to four times more likely to be referred to screening; and patients with decision support also showed a small but significant improvement in glycaemic control ^[108] . The SCI Diabetes team is now exploring options for extending this decision support more widely.

Technology Enabled Care

There is no doubt that technology is increasingly present in people's daily lives. The challenge for health systems is to determine how to make the most of the technology people already own and use. Through the Technology Enabled Care ( TEC) Programme, self-reported outcomes from local areas show we have enabled in excess of 20,000 people to benefit from technology enabled care thanks to funding made available during 2015/16, and laid firm foundations for the further expansion of Technology Enabled Care. This has enabled more people to be supported at home, with fewer admissions to care homes and hospitals and an increased feeling of safety and independence.

Computerised Cognitive Behavioural Therapy

The NHS 24 Scottish Centre for Telehealth and Telecare has compiled significant evidence that computerised cognitive behaviour therapy ( cCBT) works. As part of the three-year MasterMind programme involving a consortium of nine European Union members, the MasterMind team in Scotland has spent its first full year developing, implementing and evaluating its cCBT services across NHS Lanarkshire, NHS Grampian, NHS Fife and NHS Shetland. MasterMind is targeted at people with low to moderate levels of depression and/or anxiety. The service currently utilises the digital software package Beating the Blues, and builds on services originally established in NHS Forth Valley and NHS Tayside in 2005 and 2007 respectively, which continue to offer cCBT as one of their core, mainstream psychological therapies. In 2015/16, there were over 4,000 referrals to the MasterMind cCBT service, with 2,889 patients commencing treatment. Of all referrals made to the service, 80 per cent were made by GPs, with the remaining 20 per cent coming from clinical psychology and other mental health services. Funding has now been made available from the TEC Programme to roll this approach out nationally.

Developing Healthcare Science

The Healthcare Science National Delivery Plan ^[109] has set out service improvement programmes that focus on improving health outcomes for people by reducing inappropriate referrals to Secondary Care and preventing unplanned admissions to hospital or long-term settings. Ongoing work on a national approach to demand optimisation will significantly improve patient outcomes, with each diagnostic test optimised to improve clinical care and ensure efficient use of resources.