Better Health, Better Care: Action Plan

SECTION ONE: TOWARDS A MUTUAL NHS

1.1 TOWARDS A MUTUAL NHS

This section sets out actions to:

• Strengthen public ownership of the NHS by improving rights to participate
• Embed patient experience information in the performance management of the NHS
• Further strengthen the collaborative and integrated approach to service improvement that is the hallmark of Scotland's NHS

Mutual organisations are designed to serve their members. They are designed to gather people around a common sense of purpose. They are designed to bring the organisation together in what people often call "co-production". The concept of the mutual organisation sits extremely comfortably with the Scottish Government's commitments to stronger public involvement, improving the patient experience, clearer patient rights, enhanced local democracy - for example through direct elections to NHS Boards - and independent scrutiny of proposals for major service change. It also underpins the Government's commitment to partnership working, better staff governance and improving the NHS as a place to work.

For these reasons we intend to ensure that NHSScotland is based on a mutual ethos. This will not involve changes to the financial arrangements of the NHS. Nor will it require change to the overall structure of the NHS. On the contrary, it is entirely consistent with our existing approach of integrated care, based on the values of co-operation and collaboration delivered through unified Boards.

However, moving towards a mutual NHS will require new ways of thinking about health and health care. We need to move, over time, to a more inclusive relationship with the Scottish people; a relationship where patients and the public are affirmed as partners rather than recipients of care. We need to move towards an NHS that is truly publicly owned. We need to move towards an NHS where ownership and accountability is shared with the Scottish people and with the staff of the NHS. We need to move towards an NHS where we think of the people of Scotland not just as consumers - with only rights - but as owners - with both rights and responsibilities.

This is a process of evolution. A mutual NHS will require shifts in control, status and participation that cannot be achieved overnight. This strategy and Action Plan, however, sets out to embed the mutual philosophy in the way in which NHSScotland helps Scottish citizens to sustain and improve their health and takes action to improve the quality of health care services. It identifies a series of practical actions that will help bring the concept of mutuality to life for the citizens of Scotland and signal a new phase in the delivery of health care in our nation.

1.2 A SERVICE FOR THE PUBLIC

Introduction

NHSScotland is a public service, a service that is used for, and paid for, by the public. The Better Health, Better Care discussion process demonstrated both the willingness of patients and the general public to get involved in the design and delivery of health services, and the value that can be added by such participation. A mutual NHS gives the people we serve a greater say in their service and a chance for those working in health care to harness their knowledge and enthusiasm on a daily basis, as we make decisions about the shape and structure of services across Scotland.

Patient Focus and Public involvement

Community Health Partnerships ( CHPs) have established Public Partnership Forums, which have made good progress in involving local communities in the design and delivery of health services. These forums played a significant role in shaping this strategy and we will work with them to produce a set of specific proposals during summer 2008 for strengthening their role still further. This will improve the way in which we engage with children, young people and the people who care for them and ensure greater involvement of the most vulnerable and seldom heard groups. Third Sector organisations have well established networks and connections across these communities and can play a vital role as partners in ensuring that our health services are fair for all.

Patient Experience

From 2008, Better Together - Scotland's new Patient Experience Programme - will encourage and empower patients, carers and health care staff in Scotland to work together in partnership to provide patient centred care and improve NHS services for the benefit of all. It will identify opportunities for improving patients' experience and enable patients, carers and staff to work together to redesign services and ensure that changes are implemented effectively. The programme will focus on redesigning the whole experience of care, rather than just internal systems and processes within NHS Boards. In doing so, the programme will make NHSScotland a world leader in involving patients in the design of health care services.

Patient Rights

A public consultation on the possible content of a Patients' Rights Bill will be launched by May 2008. A mutual NHS provides the context for a legal framework that sets out what patients have a right to expect from their service, including individual waiting time guarantees appropriate to individual needs.
It will give us the opportunity to develop a charter of mutual rights - a charter that provides a clear statement of rights and responsibilities from the perspective of Government, staff and the public. It will provide patients with quick and efficient redress where problems occur, without the need for unnecessary and inappropriate legal action and litigation. It will also set out the right of patients to be treated as partners in their care and challenge all those who work for NHSScotland to respect the expertise of patients and their carers and improve the way in which we communicate and involve them in the decisions that affect them.

Independent Scrutiny

Independent scrutiny of proposals for major NHS service change provides local communities with the confidence that the available evidence has been assessed rigorously, all viable options considered and that their views have been sought appropriately and their interests taken fully into account. We have established independent scrutiny panels to consider proposals for service change in Lanarkshire, Ayrshire and Arran, and in the Clyde area and launched a consultation on options for embedding scrutiny in the future. This includes the potential to provide scrutiny through a decision conference, an independent body such as a local authority or an expert panel. We will respond to this consultation by April 2008, setting out a future model for independent scrutiny within the framework of a mutual NHS.

Elections to NHS Boards

Our consultation on the content of a Local Healthcare Bill will include consideration of direct elections to NHS Boards. The national discussion around Better Health, Better Care has identified the need to consider this
issue alongside the functions of existing
non-Executive directors, the role of independent scrutiny and other mechanisms for increasing accountability, including partnership working with Local Authorities and elected members at Board and community level. The Bill, which will be introduced in summer 2008, will address these concerns within the context of a mutual NHS.

Participation Standard

At present, the majority of public involvement exercises are evaluated against a set of criteria devised by the Scottish Health Council. This is extremely valuable, but we now need to integrate the level and quality of participation into our overall approach to quality improvement and the performance management framework for NHSScotland to ensure that patient focus and public involvement are core drivers of decision making and not an afterthought or side issue. We will therefore work with NHS Quality Improvement Scotland, the Scottish Health Council, Public Partnership Forums and other groups, including staff representatives, to agree a participation standard for all NHS Boards covering future involvement of patients, staff and the public more generally. This standard will reflect the needs of Scotland's diverse population. Boards will be asked to conduct an audit against this standard in order to collect systematic, comparable information on good practice and inform the future development of our approach to participation. We will include a target for performance against this standard amongst the key measures for NHS Boards by 2009.

Ownership Report

Our commitment to the concept of mutuality will be embodied in an annual ownership report. Distributed free of charge to all Scottish households, this will set out information on the rights and responsibilities of patients and their carers, alongside useful information about how to access local services, raise issues or complaints and get more involved in the design and delivery of local health services.

We will:

• Produce proposals in Summer 2008 to strengthen Public Partnership Forums
• Launch a public consultation on a Patient Bill of Rights by May 2008, including the right of patients to be treated as partners in their care
• Consult on the development of an NHS charter of mutual rights - a clear statement of duties and rights from the perspective of Government, staff and the public
• Produce proposals for independent scrutiny of major NHS service change proposals by April 2008 following a public consultation
• Introduce a Local Health Care Bill in Summer 2008
• Develop a Participation Standard for NHS Boards which reflects the needs of Scotland's diverse population
• Incorporate assessment of performance against the participation standard into NHSScotland's performance management system by 2009
• Produce and distribute an annual "Ownership Report" to all Scottish households

1.3 DELIVERING TOGETHER

Introduction

A mutual NHS requires us to clarify roles and responsibilities across the organisation and translate this into a clear set of expectations and ways of working. This begins with an explicit commitment to working with partners, at all levels, in the interests of the people of Scotland. It also requires a reappraisal of internal working practices and relationships. National NHS Boards should add value to the work of local Boards, help the organisation as a whole to avoid excessive costs and enable effective decision making at a local level. In turn, NHS Boards need to support the strategic direction of travel set out in this document and look for opportunities to collaborate with each other where this makes sense for patients and NHSScotland as a whole.

Performance Management

We recognise that targets that are poorly designed are an unnecessary distraction and can drive the wrong kind of behaviours and actions. However, all major organisations require clear targets and objectives to provide a sense of purpose, drive continuous improvement and focus the decisions they make.

The HEAT performance management system sets out the targets and measures against which NHS Boards are publicly monitored and evaluated. To support the delivery of our agenda, we will develop this system so that it:

• identifies and drives the contribution of NHSScotland to the overall strategic objectives of the Scottish Government
• links closely with the new accountability and performance arrangements that apply for local government and enables joint roles, responsibilities and actions to be agreed at local level through Community Planning arrangements
• demonstrates clear alignment between short term operational targets and the longer term strategic direction set out in this document.

The HEAT targets which will be addressed by NHS Boards in their local delivery plans for 2008/09 are listed in Annex A. They reflect a rebalancing of previous approaches to performance management, with a greater emphasis on health improvement, mental health, efficiency and anticipatory care, with a corresponding reduction in the number of access targets. From 2009, the new targets will embed evidence on the patient experience within the performance management framework of NHSScotland for the first time. This will provide greater impetus to efforts to extend the use of patient experience information in clinical as well as organisational performance management.

Our commitment to an NHS that is accountable and patient focused requires us to ensure that our approach to performance assessment and monitoring is strong and effective. We will therefore develop our arrangements for performance assessment and scrutiny in health in line with the five guiding principles set out in the Report of the Independent Review of Regulation, Audit, Inspection and Complaints Handling of Public Services in Scotland (2007). These are: public focus, independence, proportionality, transparency and accountability.

Community Health Partnerships

Community Health Partnerships ( CHPs) offer the opportunity for NHSScotland and its partners to work together to tackle health inequalities, enhance anticipatory and preventative care, shift resources to community settings and provide a wider variety of services at local level. Our key priorities for health care require the drive towards locally provided services. The successful implementation of the waiting time target of 18 weeks from GP referral to treatment will, for example, require us to increase the availability of local diagnostic services which, in turn, requires development and investment plans for community hospitals and other facilities, including shared or joint premises wherever practicable.

Community Health Partnerships will increasingly be expected to shift the balance of care; improve access, manage demand, reduce unnecessary referrals to specialist services and provide better community care services. But in order to do this effectively they need to have a broader range of delegated resources and greater flexibility of decision making. We will therefore work with them to introduce an "integrated resource framework" which will build on the progress that has been made so far in devolving budgets to local levels and extend the responsibility and accountability of CHPs for delivering better outcomes by ensuring that resources follow the patient or client. This framework will support strategic joint commissioning and collaborative contracts to deliver local shifts in the balance of care.

Work is underway through the Strategic Partnership Group to develop a transparent resource framework that can be used locally to support the delivery of new service and care models. The approach may include the development of collaborative contracts, programme budgets and transitional funding as enablers of change.

Special Health Boards

Special Health Boards offer a unique resource for NHSScotland. They allow local Boards to concentrate resources and attention on front line treatment and care and deliver those services that can be offered more effectively and efficiently on a national basis. They have the additional potential to offer their services and expertise across the wider public sector as part of Efficient Government. To ensure that we make the most of this opportunity, we will work with them to ensure that their purpose, objectives and ways of working demonstrate the value they add in improving services, improving health, achieving economies of scale and minimising unnecessary duplication of investment and effort.

Service Planning

It has become clear during the discussion process that we need clearer health care planning arrangements across NHSScotland. Service planning needs to happen at three levels:

• National: To set the strategic direction for NHSScotland, performance manage NHS Boards on the basis of a focused set of targets and plan the delivery of specialist national services, where these are required, in order to provide sustainable services throughout Scotland
• Regional: To develop plans where NHS Boards have decided that their local population would benefit from a collaborative approach to planning and commissioning services
• Local: To plan and commission the vast majority of healthcare services as an integral part of local community planning processes.

We are committed to improving NHSScotland's healthcare planning system through the development of an agreed planning framework and by clarifying roles and responsibilities at each level, by the end of 2008. This will integrate previously distinct approaches to service, workforce and financial planning and will be supported by annual planning guidance and a co-ordinated timetable for planning across the service.

Implementing Better Health, Better Care

The revised set of HEAT targets and measures, has immediate consequences for the way in which we will manage the implementation of this programme as a whole. Wherever possible, we will use existing accountability arrangements and organisations to drive and support delivery across Scotland. This has the huge advantage of demonstrating that Better Health, Better Care is about the mainstream delivery of services and support, and not an additional project that can, in some way, be ring-fenced or isolated from the heart of our agenda. Any additional reporting on implementation will be streamlined and proportionate.

We will:

• Ensure that NHSScotland plays a full part in cross Government activity to create a more successful country
• Revise the HEAT performance management framework so that performance targets are better linked to long term strategy and integrated with other approaches to performance management across the public sector
• Embed patient experience data in our targets for the first time
• Develop an integrated resource framework to support joint commissioning and collaborative contracts within Community Health Partnerships
• Review the purpose, objectives and ways of working of Scotland's Special NHS Boards
• Review and improve the planning system within NHSScotland in 2008
• Manage the overall implementation of this programme through existing processes and mechanisms wherever possible

1.4 CO-OPERATION AND COLLABORATION

Introduction

A mutual NHS enshrines our values of co-operation and collaboration in the very fabric of the organisation. We believe that co-operation and collaboration both across NHSScotland and between NHSScotland and its partners, is a more effective means of driving change than internal competition. Our national discussion has confirmed our belief that a public service, particularly one which supports people at some of the most emotionally testing times of their lives, should look to drive and sustain change on the basis of patients' needs and the expertise of our staff, rather than a reliance on market forces.

The values of co-operation and collaboration must be assertive rather than passive values. The challenge of implementation, is to create the structures and processes that support them in making a real difference to our services.

Staff Partnerships

Our staff are the agents of change. We cannot hope to bring about the improvements envisaged by this plan unless the people who will deliver these improvements are protected in their places of work, recognised and rewarded for their contribution to our success and given the opportunities to develop the skills and experiences they require. This commitment applies to staff at all levels and in all roles; from clinicians who work directly with patients, to the range of other professionals who work tirelessly behind the scenes to ensure that NHSScotland runs smoothly and that the public get best value for their annual investment of over £10 billion.

Over the past few years, NHSScotland has benefited greatly from its approach to partnership working with staff and their representative organisations. Partnership is not merely about good employee relations. It is invaluable in shaping and supporting service redesign, developing roles and ways of working and increasing capacity and skills across the service. It demonstrates trust, integrity and openness across all our activities and ensures that our values of co-operation and collaboration are realised in both our strategic direction and in the practical issues that affect people's working lives.

The concept of a mutual NHS reinforces and extends this commitment to partnership working and we will work through the Scottish Partnership Forum to continue the development of this concept at both a strategic and practical level. This will include joint working to incorporate staff involvement in the new participation standard for NHS Boards and to explore new opportunities to work together to support Scottish citizens in making healthy lifestyle choices and reinforce the reputation of NHSScotland as a professional, patient centred organisation.

Managed Clinical Networks

Managed Clinical Networks developed as mechanisms for linking groups of health professionals and organisations in the delivery of high quality services. The coverage of these networks now needs to be expanded. We will continue to encourage spontaneous initiatives from clinicians and the voluntary sector for the development of networks, where there are tangible benefits to patients from doing so, but we will also provide national leadership and resources to ensure the effective implementation of networks for respiratory and neurological conditions. Where appropriate, we will also strengthen the traditional model of Managed Clinical Networks so that they provide effective clinical leadership for action to plan and deliver national services against stretching targets. Such networks will recruit staff to network wide positions and enable us to sustain nationally networked services which balance the need for specialisation and local delivery of services wherever possible. In particular, they will lead the implementation of planned improvements to our specialist children's services, neurosurgery and laboratory services across Scotland.

Workforce Planning

Workforce planning is vital in order to meet the challenges of recruiting and retaining staff, particularly in remote and rural areas, in the face of an ageing population and intense competition for the best people from other sectors of the economy. This needs to draw effectively on the knowledge and experience of front line staff who understand the roles, responsibilities and opportunities that exist.

Over the next three years, a phased approach to workforce planning will support NHS Boards to develop their workforce capability, integrate workforce planning within the new overall planning framework and better integrate workforce planning with health care partners across the public and voluntary sectors. This will see greater collaboration in training provision, developed as part of a shared commitment to Best Value. Our strategic direction for developing workforce planning will be outlined in Better Health, Better Care: Planning Tomorrow's Workforce Today.

New Roles

Over the last 10 years, NHSScotland's workforce has grown by around 18%. The focus must now be on planning for new and extended roles arising from opportunities around the redesign and modernisation of services. This includes roles such as Rehabilitation Co-ordinators to support and enable self care, Physician Assistants and Assistant Practitioners in Child Health.

We want to see a model of nursing in the community that delivers effective nursing support to individuals, families and communities. This, we believe, will support community based services that are proactive, modern, safe and which help people to realise their potential for health and wellbeing. However, during our national discussion, we heard some concerns about the current developments and it is therefore important that we test this new approach of community health nursing to demonstrate what works and to get it right for the future. We will therefore progress with work in four pilot sites and make a final decision about roll out, based on the outcomes of these projects in Spring 2009.

Third Sector

The value added contribution of Scotland's network of voluntary and community organisations is already significant, but more must be done to foster this important partnership. NHS Boards are required to work with local third sector organisations to understand and develop the potential contribution they can make to improving the effectiveness of health improvement and health care planning and delivery. Working together with Volunteer Development Scotland, we will refresh the strategy on NHS Volunteering, recognising the various roles played by the third sector and considering how best to recognise the role played by volunteers. We will then go further and require all NHS Boards to achieve the Investing in Volunteers Standard - the nationally recognised standard which guarantees a quality experience for volunteers.

Leadership Development

Leadership is central to improving performance, redesigning services and securing better outcomes for the people of Scotland. Leadership at all levels, and in all disciplines, can make or break the delivery of this change programme. The Leadership Development Framework for NHSScotland and its subsequent delivery plan (2005) has served NHSScotland well over the past two years, but the plan needs to be reviewed during 2008 to clarify the leadership qualities and behaviours we require to deliver our new priorities.

We will continue to invest in staff skills, training and competencies to help improve services for patients, support team working and enhance Scotland's reputation as a base for leading health care science and research. This includes support for four demonstration projects in different NHS Boards which aim to illustrate the benefits of the National Career Framework in helping staff to plan and progress their careers, whilst at the same time providing NHS Boards with a valuable tool to help them plan workforce development around changing service needs and patient expectations.

Staff Experiences

One of the best ways of demonstrating the value we place on our staff is to invest in their health and wellbeing. We have already made good progress in addressing bullying, harassment and violence towards staff. Partnership Information Network policies have set minimum standards in relation to staff and employment issues. OHSXtra, a case management approach for fast track rehabilitation, including mental health, physiotherapy and Cognitive Behavioural Therapy services, has been piloted successfully in NHS Lanarkshire and NHS Fife and is now being tested in other areas. These initiatives are all encouraging, but we and our partners can do more to provide working environments which minimise the risks to health and encourage and enable staff to take greater responsibility for their own health. This offers a practical demonstration of our commitment to mutuality as we work with staff to make NHSScotland a better place to work and ultimately improve the service we are able to provide for our patients.

Understanding and reacting to the needs of individual staff is, of course, the stuff of good management. Nevertheless, as in many organisations, there is a need to take a regular snapshot of staff satisfaction through a survey and then use its findings to drive change. The next survey takes place in 2008 and we will ensure that each NHS Board works with its local partnership committees to identify problem areas, develop action plans to address problems and to show progress against previous results. Local Staff Governance Committees will be responsible for recommending actions and monitoring progress at a local level.

We will:

• Work with the Scottish Partnership Forum to develop the concept of mutuality as it applies to our staff
• Expand the coverage of Managed Clinical Networks and strengthen them, as appropriate, to implement improvements to neurosurgery, laboratories, and specialist children's services
• Move towards better workforce planning that directly supports the safe delivery of services in a way that is both affordable and sustainable
• Introduce phased improvements to workforce planning to help Boards develop their workforce capabilities and link more effectively with partners outside of NHSScotland
• Assess four pilots of a new model of nursing in the community and make a decision about roll out in Spring 2009
• Support four national demonstration projects around the National Carers Framework
• Refresh NHSScotland's strategy on volunteering
• Review the Leadership Development Framework during 2008
• Support staff in taking greater responsibility for their own health and ensure health protecting and enhancing working environments
• Hold a staff satisfaction survey in 2008 and take action on the results at national and local level

...there is a need for a greater emphasis on joint working in order that NHSScotland, local authorities and partners can deliver on what is undoubtedly a shared agenda "

NATIONAL PROFESSIONAL REPRESENTATIVE ORGANISATION