Better Health, Better Care: Action Plan

SECTION THREE: ENSURING BETTER, LOCAL AND FASTER ACCESS TO HEALTH CARE

3.1 IMPROVING QUALITY

This section sets out actions to:

• Enable and support patients to be partners in their care
• Make health care in Scotland safer still and a world leader in this area
• Make access to primary care more flexible through re-designing services
• Spread best practice in care for people with long term conditions
• Bring a more systematic approach to clinical effectiveness, for example by reducing variation in practice
• Modernise the NHS through better use of technology
• Deliver the quickest treatment ever available in Scotland's NHS

By virtually any measure, the NHS in Scotland is improving. Waiting times are shorter and mortality from the major killer diseases is reducing. Therefore, this is exactly the right time to seek to accelerate the pace of that improvement. The Scottish people need and deserve care that is safer, more reliable, more anticipatory and more integrated, as well as being quicker still. The key to improving quality will be to meet all of those public requirements.

In its seminal report "Crossing the Quality Chasm" (2001), the Institute of Medicine identified that a health care system that achieved major gains in six dimensions of quality would be far better at meeting patient needs. The six dimensions are as follows:

Patient centred	providing care that is responsive to individual patient preferences, needs and values and assuring that patient values guide all clinical decisions
Safe	avoiding injuries to patients from care that is intended to help them
Effective	providing services based on scientific knowledge
Efficient	avoiding waste, including waste of equipment, supplies, ideas, and energy
Equitable	providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status
Timely	reducing waits and sometimes harmful delays for both those who receive care and those who give care

This section details actions to improve each of these aspects of quality.

3.2 PATIENTS AT THE CENTRE

Introduction

NHSScotland should deliver patient centred care which is respectful, compassionate and responsive to individual patient preferences, needs and values. Throughout the national discussion we heard first hand experiences - good and bad - which challenged us to think about what really matters to patients and design and deliver services that meet their needs and expectations. Patients and carers are after all, the real experts in what it feels like to receive care from NHSScotland. Our task is to listen to them, think afresh about the ways in which we involve and engage them in shaping their care and work in new and different ways which challenge traditional boundaries both within and between organisations.

Improving Your Experience of Care

Better Together, our programme to improve patient experience will involve work with patients and staff across Scotland to find out what is really important to them in the delivery of a good quality health service. It uses surveys, focus groups, interviews and analysis of the complaints we receive to tap into real life experiences and use them as the basis for a programme of continuous improvement to deliver high quality, safe and effective patient centred care. We will implement the programme with an initial focus on inpatient care, GP services and long term conditions. Preliminary improvement work is being carried out to improve the experiences of cancer patients.

Supported Self Management

Supported self management requires support, advice and information to be provided to someone who is managing symptoms that can affect the quality of their everyday life. Of course, everybody self manages to a certain extent, but some people will require a far greater degree of support from care services than others. This might vary over time, as a condition changes through relapses or recoveries, but it might also reflect differences in our ability to learn or manage, or the barriers we face in accessing the information and support that is available.

The Long Term Conditions Alliance Scotland, supported by the Scottish Government, is developing the concept of supported self management and identifying policies and initiatives that might strengthen its role within healthcare in Scotland. Maintaining this 'grass roots' approach is essential in realising the potential of self management to transform the quality of people's lives, reduce pressure on the NHS and change the culture of health and healthcare.

The Alliance suggests there are five key stages where support from professional and voluntary organisations is particularly important:

• at the point of diagnosis
• living for today
• as the condition changes and progresses
• transitions between services, such as between paediatric and adult services or adult and old age care
• end of life.

At each stage along this pathway, our challenge is to ensure that patients and their carers receive accessible, plain, clear, appropriate and timely information. We need to enable patients to ask questions of the professionals they see, provide them with the support and contacts that are most appropriate to their current situation and support them as they think about what they can do for themselves and make the right choices for themselves around treatments, lifestyles and their relationships with those around them.

Self Management Framework

Self management cannot be supported by the NHS alone. Voluntary organisations, Local Authorities, social and community care all provide support to people with long term conditions, their families and carers and have a key part to play in providing and signposting support.

Health and social care professionals need quick access to information and to have the skills to use the knowledge appropriately. Despite good local examples, there is no standard referral system between NHS and non- NHS organisations. A self management framework, based for example on figure 3, is therefore required in each area to identify existing support systems and provide a map for staff and the public. It will include details of the different kinds of support available in a particular area, or for a particular condition at each stage of the patient journey, including details on group activities, condition specific and generic self management programmes, mental health services, motivational coaching; carer and family support and telecare support. This will be supported across Scotland by the launch of a Managed Knowledge Network in April 2008 which will provide resources for patients and carers to help them to self manage their condition.

Figure 3: Self Management Framework for Long Term Conditions

Information for Patients

NHS Boards have developed a range of information for patients and carers about conditions and procedures. Much of this is well presented and of good quality, but it is not necessarily consistent or widely available, and may not, in all cases, meet quality standards or be written from a patient's perspective. There may also be unnecessary duplication with material produced by the voluntary sector.

We are committed to working in partnership with the voluntary sector to ensure that patients, the public and carers get the information they need, when they need it and that this information is clear, accurate, up-to-date and presented in a way which meets their needs. By April 2009 we will introduce a National Health Information and Support Service to provide a single shared health information online resource which brings together quality assured local and national information from the NHS and other sectors, a national health information helpline available and a network of branded health information support centres, embedded in local communities. This will involve:

• a consistent approach to produce high quality patient information across NHSScotland
• information partnerships with key national voluntary organisations to maximise the benefit to patients from the high quality, patient focused information they produce
• clearly signposted access points where people can get support to find the information they need; understand the information provided and develop the skills and confidence to use it effectively in order to become an active partner in their own care
• a particular focus on meeting the needs of those communities and individuals who have traditionally found it harder to engage with health services.

Carers

Under the Community Care and Health (Scotland) Act 2002, NHS Boards are required to develop and implement Carer Information Strategies. These strategies, in place since May 2007, should improve carer identification, information and training to help carers continue in their caring role. The draft Scottish Budget identified a total of £9 million over the next three years to support NHS Boards in implementing these strategies and the Scottish Government is also investing a further £280,000 over two years to pilot carer training and help carers, particular new carers, to gain the knowledge and skills they need to care effectively while looking after their own health.

Our approach to young carers aims to ensure that their interests are addressed in mainstream support. This is particularly appropriate for supporting children living in drug misusing households who almost inevitably have some caring responsibilities. Such carers are often hidden from the services designed to help them, and their mental, physical and emotional health suffers as a result. We are investing £183,000 (spread over two years) in the development of a national young carer forum, which will give young carers a national voice and raise their profile within Scottish society. If this initial event is successful, funding will continue to make this forum an annual event.

Palliative Care

End of life, or palliative care, is an integral part of the care delivered by any health or social care professional to those living with and dying from any advanced, progressive or incurable disease. It is not just about care in the last months, days and hours of a person's life but includes support to enable someone to live with a life threatening condition and maintain, as far as possible, a decent quality of life for their families and themselves.

We are committed to the delivery of high quality palliative care to everyone in Scotland who needs it, on the basis of clinical need not diagnosis, and according to established principles of equity and personal dignity.

By March 2008 we will therefore publish a plan setting out how we will implement the recommendations of the Scottish Partnership for Palliative Care's report: Palliative and End of Life Care in Scotland: the Case for a Cohesive Approach. For the first time, this will bring a single, comprehensive approach to the provision of palliative care across Scotland.

As part of this approach we will expand the use of the high quality generalist palliative care standards in all care settings, so that more people can live and die well in the places they choose and encourage a uniform approach to achieving the goals of the Liverpool Integrated Care Pathway for the Dying Patient in all care settings. We will support Community Health Partnerships ( CHPs) and Managed Clinical Networks to better integrate specialist palliative and primary healthcare teams in order to enable patients to remain at home during the terminal stages of their illness should they wish to, and if it is possible for them to do so. We will ensure that we integrate statutory services with ideas and initiatives from the voluntary sector where they are valued by patients and have demonstrated their effectiveness and sustainability.

Tayside Ambulance Pilot NHS Tayside, Marie Curie Cancer Care and the Scottish Ambulance Service have launched a dedicated ambulance, specially designed to transport people with life-limiting illness across Tayside. The Scottish Ambulance Service is operating the service as part of a two year pilot, with funding from Marie Curie Cancer Care as part of its Delivering Choice Programme. The ambulance's first priority is to deliver a quick response for patients nearing the end of their lives and transport them to their preferred place of care - which is usually their home. The ambulance is specifically designed for palliative care patients and is fitted out with specialist equipment and other features to help patients feel relaxed and comfortable during their journey. It is operated by two trained ambulance care assistants who can deal with the specialist needs of palliative care patients. Healthcare professionals can refer their patients to the service by calling a dedicated phone line.

Transport

Many participants in the national discussion, particularly those in remote and rural areas, identified transport as a key factor in their overall experience of the care we provide. NHS Boards have a responsibility to ensure that transport issues are taken into account in designing and delivering health services and are required to deliver operational travel plans by April 2008. Travel Plan Co-ordinators are increasingly being appointed by Boards to take on this responsibility and ensure that patients are provided with appropriate advice and support if required to travel to receive care. All plans must reflect local and regional travel strategies and incorporate sustainable travel policies which address the demand as well as the supply for travel, providing greater encouragement to the use of public transport, cycling and walking wherever possible.

We are committed to establishing a national approach to travel management to realise the potential patient benefits and operating efficiencies that can come from greater co-ordination between local NHS Boards, the Scottish Ambulance Service and the logistical capabilities of NHS National Services for Scotland. As part of this national approach, we will strengthen our engagement with Regional Transport Partnerships to ensure our patients benefit from the statutory obligation on such Partnerships to develop regional transport strategies which address access to health care facilities.

Hospital Evening Visitor Scheme Discussions with communities across Glasgow identified a range of concerns about transport to and from the city's key hospitals, including difficulties in reaching our sites by public transport and fears about travelling at night. These were particular issues for older people, disabled people, parents with young children and people on low incomes. In response to these concerns, NHS Greater Glasgow and Clyde, Community Transport Glasgow, the City's five Community Transport Operators, Glasgow City Council and Strathclyde Partnership for Transport got together to launch a dedicated Evening Visitor Scheme in October 2006. This offers partners, families and friends the opportunity of reaching six Adult Acute Hospitals within the city via a dedicated evening, door-to-door transport system five days a week. In November 2007 the service was expanded outside the city boundaries, with the inclusion of new partners in East Dunbartonshire Council, East Renfrewshire Council, East Renfrewshire CHP, South Lanarkshire CHP and two further Community Transport Providers. The service has now carried over 4500 visitors to hospital and covered more than 30,000 miles.

We will:

• Implement the Patient Experience Programme with an initial focus on inpatient care, GP surgeries and long term conditions
• Ensure that a self management framework is available in every CHP by end 2008
• Launch a Managed Knowledge Network in April 2008 to provide patients and carers with resources to support self management
• Develop an integrated National Health Information and Support Service by
  April 2009
• Invest a total of £9 million over the next three years to support Carer Information Strategies
• Introduce a national young carer forum in 2008
• Publish delivery plans for implementation of recommendations of Scottish Partnership for Palliative Care's report by March 2008
• Extend the use of high quality generalist palliative care standards in all care settings
• Develop a national approach to travel management and ensure that NHS Boards publish operational transport plans by April 2008

3.3 PATIENT SAFETY

Introduction

The NHS in Scotland is safe by UK and international standards, but our priority is to make it safer still. Improving safety standards and ensuring a safety culture within NHSScotland requires us to remain at the forefront of international action on this issue. It demands action by a range of stakeholders and the deployment of tested, evidence based interventions across Scotland.

Considerable concern was expressed throughout our discussions about the risks of MRSA and other hospital acquired infections. We heard examples of patients discovering poor and unacceptable standards of cleanliness and cleaning practice in our main hospitals and a widespread demand for greater accountability for safety within care settings, allied to a willingness on the part of patients and the public to play their part.

Scottish Patient Safety Alliance

The Scottish Patient Safety Alliance brings together the Scottish Government, NHSScotland, the Royal Colleges and other professional bodies, the Scottish Consumer Council and the Institute of Healthcare Improvement in a partnership to achieve:

• significant reductions in healthcare associated infections; adverse surgical incidents, and adverse drug events
• demonstrable improvements in critical care outcomes, care on hospital wards and organisational culture through leadership which is focused on patient safety.

The Alliance will build upon the success of the current Safer Patients Initiative which is already improving safety standards in NHS Ayrshire and Arran, NHS Dumfries and Galloway and NHS Tayside. With evidence suggesting that one in 10 patients admitted to Scottish hospitals will be unintentionally harmed and that 50% of these incidents are avoidable, the significance and importance of this work is obvious. The Alliance's task is to extend the learning and success achieved in these NHS Boards to every NHS Board in Scotland. Front line staff will be empowered to ensure focused improvements are made wherever they interact with patients, be that at the bedside, the operating theatre or clinic, whilst the systematic application of key interventions will support effective multidisciplinary learning across NHSScotland.

Medication Safety: NHS Tayside Ensuring every patient gets the correct medicine in hospital can be a complicated process. When individuals are admitted with a range of medical conditions, a variety of treatments may be involved. This issue can be further complicated when patients are admitted to hospital without their individual list of medicines - until now. NHS Tayside has introduced, as part of the hospital patient safety programme, a matching process for all medications for each patient. This process of medicine reconciliation (matching) involves making a list of medications on admission and referring to that list (in addition to the prescription chart) for all changes and transfers within the patient journey. Reconciliation is undertaken on admission, during all transfers, and on discharge home. The list is also consulted when any change to the medicine regime is undertaken. The introduction of this process has improved medicine safety by 85% in the first two years of the programme. As part of the Scottish Patient Safety Alliance early in 2008 this process will be introduced to every participating site across NHSScotland.

NHS Boards will be charged with ensuring that all acute hospitals take action to:

• ensure early interventions for deteriorating patients through, for example, rapid response teams
• deliver reliable, evidence based care for acute myocardial infarction to prevent deaths from heart attack
• prevent adverse drug events by implementing medication reconciliation
• prevent central line infections by implementing a series of interdependent, scientifically grounded steps
• prevent surgical site infections by delivering the correct perioperative antibiotics at the proper time
• prevent ventilator associated pneumonia by implementing a series of interdependent, scientifically grounded steps
• prevent pressure ulcers by reliably using science based guidelines for their prevention
• reduce staphylococcus aureus ( MRSA plus MSSA) infection by implementing scientifically proven infection control practices reliably
• prevent harm from high alert medications, beginning with a focus on anticoagulants, sedatives, narcotics, and insulin
• reduce surgical complications by reliably implementing a range of surgical safety approaches
• deliver reliable, evidence based care for congestive heart failure to reduce readmissions
• drive a change in the safety culture in NHS organisations by engaging NHS Board members, senior clinicians and managers.

By March 2010 we will:

• see significant, measurable improvement in outcomes at all major NHS hospitals in Scotland through the implementation of these specific evidence based interventions
• ensure, through NHS Quality Improvement Scotland and the Institute for Health Improvement, that robust quality improvement methodologies are widely implemented in major NHS hospitals
• develop and build a quality improvement and patient safety culture in our hospitals underpinned by the capability and capacity required to sustain this culture over the long term.

Healthcare Associated Infection

We will introduce new measures to tackle Healthcare Associated Infection ( HAI) from 2008/09 and provide over £50 million to support their implementation through the HAI Task Force. The Task Force will be responsible for ensuring that NHS Boards have the right tools at their disposal, follow all the correct nationally recognised procedures and are better equipped to deal with situations where infection is a serious risk. This will support the work of NHS Boards in meeting their target of reducing all staphylococcus aureus bacteraemia, including MRSA, by 30% by 2010.

Priorities for action include new work to:

• target skin and soft tissue infections
• develop and implement evidence based 'care bundles' aimed at Clostridium difficile, central and peripheral vascular catheters; ventilator associated pneumonia; surgical site infections; hand hygiene and urinary catheterisation
• renew hospital cleaning standards
• introduce a pilot MRSA screening programme in 2008/09 and a national programme from 2009/10
• reduce bloodstream infections
• ensure that additional surveillance information is gathered and put to practical use in the targeted areas of general medicine and the care of the elderly.

We will:

• Support the Scottish Patient Safety Alliance to deliver significant improvements to safety in all major NHS hospitals in Scotland
• Introduce new measures to tackle hospital infection and provide £54 million for them and a national MRSA Screening Programme from 2009/10

3.4 EFFECTIVENESS

Introduction

Scotland's healthcare challenges require us to continue to shift the balance of care towards community based services which enable ongoing, continuous care to be delivered at home or within the local community. It requires a greater emphasis on anticipatory rather than reactive care and action to develop the services offered in primary care and community hospitals. It also requires more flexible opening hours among GP practices and provision of walk-in access to a wider range of services through community pharmacies.

Improving Access to Primary Care

At present, the General Medical Services ( GMS) contract defines opening hours for GP practices as 8 am to 6.30 pm, Monday to Friday. Typically, routine appointments are scheduled for between 9 am and 5.30 pm. Only very few GP practices offer evening, early morning or lunchtime appointments. Whilst this pattern suits those who do not have work commitments, many participants in the national discussion told us that they wanted general practice opening hours to reflect the demands of their day to day lives. There is no substantial demand for GP services to be available 24/7, but many patients, especially those who commute, would prefer to attend on Saturday mornings or before or after work. Early morning, evening or weekend sessions would be particularly popular for routine, planned or ongoing care. We must also, as we make clear later in this document, ensure that primary care resources are targeted in a way that reflects levels of need.

We will work with the Scottish General Practitioners Committee of the BMA, the Royal College of General Practitioners, NHS Boards and individual GP practices to provide an accessible service which fits in with the day to day lives of their patients. This will mean:

• guaranteed access to see a member of the GP practice team within 48 hours
• advanced booking arrangements that allow patients to book ahead with a GP of their choice
• as appropriate, early morning (from 8 am) and later (up to 6.30 pm) appointments, with premises remaining open throughout the day and throughout the week
• discussions with the GP profession about an enhanced service to extend the opening period of practices in weekday evenings or at weekends
• innovative methods of increasing access to services including more effective use of telephone consultations and email communication (within the guidelines on patient confidentiality and consent) to allow for the differing commitments of patients
• through the national Improving Patient Experience Programme and the framework for GP practice based patient experience surveys, develop a robust evidence base to support the drive to improve access and patient experience.

Community Pharmacy

Community pharmacies offer convenient access to primary care in busy high streets and other community settings. The new Community Pharmacy contract provides opportunities to build further on the role of the community pharmacist and work has begun on pilot projects in five NHS Boards ( NHS Grampian, NHS Greater Glasgow & Clyde, NHS Lanarkshire, NHS Lothian and NHS Tayside) that will test and evaluate walk-in access to a wider range of services through selected community pharmacies. The pilots will offer a different mix of services in suitable locations, such as major shopping areas and main commuter points, or where there is an identified local need. They will also open at more convenient times, such as early evening and at weekends. Over time, the services provided will include, for example, nurse-led minor injury treatments, sexual health screening, simple diagnostic tests, and some adult immunisations. The pilot sites are expected to be up and running by the end of March 2008 and their work will be fully evaluated with a view to the wider development and spread of walk-in services.

Long Term Conditions

There are many good local examples of integrated case or care management approaches delivering holistic care and real benefits to those with long term conditions. Our aim is to make such approaches more consistent and widespread across Scotland and to balance this professional care, on the basis of need, with the enhanced support for self management described earlier in this document. The implementation of our long term conditions strategy is being overseen by a steering group led by the Chief Medical Officer for Scotland and we are determined to ensure that, as it does so, it is driven by the experiences of those who live with these conditions either directly or in a caring role. A delivery plan for the next stage of this work will be published in 2008. The Long Term Conditions Alliance Scotland and the individual organisations it represents have led the development of our approach to date and we are committed to supporting the organisation in the future and, in particular, to enabling them to develop the concept of a long term conditions 'hub', which can act as a valuable resource for smaller member organisations.

The Scottish Patients at Risk of Readmission and Admission ( SPARRA) risk-prediction tool offers NHS Boards the opportunity to identify those people who are at greatest risk of emergency admission or readmission to hospital. At present it concentrates on people aged 65 and over, but we will extend its scope to encompass all high risk people by June 2008 and have commissioned work to develop a separate predictive tool for mental health patients. By the end of 2008, SPARRA will be extended further to identify those judged to be of medium risk of emergency admission and who have yet to enter the cycle of repeat emergency admissions. This will allow NHS Boards, and their partners locally, to support these people with preventive models of care and support that can help avoid unnecessary and potentially traumatic admissions to acute hospitals. All Boards will be required to use SPARRA unless they can demonstrate that they have a more effective predictive tool available.

A new, dedicated, Long Term Conditions Collaborative, is being developed to support NHSScotland deliver sustainable improvements in patient centred services. The three year national programme will engage all 14 territorial NHS Boards and have work streams on self care, specialist care and complex care. The focus will be on clinical systems improvement to improve access, reliability, safety and patient experience. There will be a regional management infrastructure to support the use of technical and behavioural management tools and techniques. These teams will work closely with other improvement programme teams for the Mental Health Collaborative and 18 weeks Referral to Treatment Time programmes and others including Rehabilitation Co-ordinators.

As we develop integrated case and care management across Scotland, we will enhance the level of emotional support provided to patients and carers within their package of care and rehabilitation. This will be achieved by:

• ensuring that people with long term conditions are treated as people, not a collection of symptoms
• making sure that they are made aware of the full range of information and support available to them, especially around the time of diagnosis, especially the contribution that the voluntary sector can make
• recognising the psychological dimension to long term conditions management by providing better psychological support through counselling and techniques to raise self-esteem.

Nairn Anticipatory Care Project In Nairn, the Anticipatory Care Project has led to the development of Anticipatory Care Plans for around 300 people who are assessed as being at greatest risk of admission to hospital or who currently enjoy Residential and Nursing care. Case Managers seek out these patients and ask a series of questions about their carer or cared for status, preferences for treatment, progression of disease, referred place of care and resuscitation status. The team is also looking at general health status and action that might be taken on issues such as nutrition, financial matters and help with the demands of daily living. This has seen it take action to ensure that paths are gritted, working with the local authority to ensure that the elderly person is exempt from taking the bins to the gate and reduce the risk of falls. Such interventions improve the quality of life of some of our most vulnerable people and have a direct impact on the number of days that people have to spend in hospital. In Nairn for example, with less than 3% of the list receiving a more managed approach to their care they are on target for a 15% reduction in occupied bed days, based on last year.

New patterns of consultation in primary care need to be developed continuously to support a person centred approach, enabled by relevant systemic change. This could, for example, offer people with more than one long term condition different types of appointments, such as "one stop clinics", which could improve both efficiency and the patient experience. Such an arrangement could include the consultation, any necessary investigations, interventions from a range of appropriate health care professionals and advice on health improvement and health protection in order that their total needs can be assessed and managed in the round.

Rehabilitation

Rehabilitation is a process of enablement geared to supporting individuals in achieving personal autonomy. The emphasis is on aspects of daily life considered important by the patient or service user and their family and carers. Access to rehabilitation can be a key determinant of an independent life, lived to the full, including being economically active. The Delivery Framework for Adult Rehabilitation (2007) sets out a model for how such services can be delivered across health, social care and the voluntary sector. This enabling approach will support older people and those with long term conditions to remain active and independent within their communities. It will also be key to avoiding unnecessary admissions to hospital and supporting people to return home after a period of ill health.

Community Care

Community care outcomes are often delivered jointly between the NHS and local authorities, and other partners - particularly the third sector - and form a key component of shifting the balance of care. For example, effective community care increases the number of people with complex care needs who can be cared for at home, reduces dependency on hospital based services, and enhances the quality of life of the people who depend on these services.

Over the last 15 years, there have been very significant increases in the number of older people, and adults with learning disabilities and mental health problems, living at home or in community settings rather than acute hospitals. Partnership working and investment of around £30 million per year has reduced the number of patients inappropriately delayed in hospital for more than six weeks by over 80% in the last six years. The introduction of Free Personal and Nursing Care has enabled many older people to access care services free of charge, and the extensive investment in care home fees has enabled vulnerable people to access better quality care services. Recent legislation has also strengthened support for adults at risk of harm.

The draft budget builds on these achievements and links them to an agreement via the Concordat with local authorities in respect of care home quality, free personal care and respite for carers. We have made significant new investment in housing and tackling poverty and deprivation, and are committed to sustaining and developing joint working between local authorities and NHSScotland, to secure further improvements in key areas including user satisfaction, faster access, better support for carers, the quality of assessment and care planning, identifying those at risk of admissions, and moving services closer to users/patients.

Community care aims to enable everyone in the community to enjoy sustained health and wellbeing, especially those in disadvantaged communities. We are therefore committed to supporting carers to look after their own health, including working with local government to develop local agreements to make progress towards delivering 10,000 more respite weeks annually and to ensure the effective implementation of Carers Information Strategies. We will enhance the delivery and sustainability of Free Personal and Nursing Care by supporting Lord Sutherland's Review and up rating levels of payment. Standards will be raised through effective regulation; we will implement our commitments in All our Futures; and we aim to reduce delayed discharges to nil by the end of March 2008, and to sustain this achievement thereafter.

The Single Shared Assessment remains a key part of these plans. We have heard concerns about its implementation during the national discussion. We are developing new standards, with stakeholders, for users' and carers' assessment and for care plan reviews and will revise the National Standards to set standards for the time to make an assessment and the time between assessment and service delivery. By 2009, we will also ensure that every partnership has the capability to share information electronically, based on the Single Shared Assessment. We are also committed to providing greater inclusion for people with learning difficulties, autistic spectrum disorders and sensory impairment.

Health in Care Homes

Care home residents have the same rights to access primary care services, such as doctors, dentists, chiropodists and opticians, as anyone else in the community. Due to the complexity of their needs, many older people in care homes also need access to specialists such as a Consultant in Old Age Psychiatry.

However, the Care Commission has raised concerns that the contribution of doctors, other professionals and specialist services for older people can be limited in some care homes. Alzheimer Scotland has concluded that a significant number of older people in care homes with dementia may not have received a diagnosis and may not, therefore, be receiving access to appropriate treatments.

Access to effective primary care and specialist health care services for people in care homes, including the frail elderly, can assist in reducing inappropriate hospital admissions and help maintain people in the community.

As part of our commitment to shift the balance of care and to providing more personalised and integrated care services, we will work with care providers and NHS professionals to ensure that people in care homes have appropriate access to both primary and specialist health care services.

National Clinical Priorities

The national discussion served to reconfirm the continuing importance of identifying cancer, coronary heart disease ( CHD), stroke and mental health as the national clinical priorities. The success we have enjoyed in recent years in the treatment of cancer and in reducing premature mortality from coronary heart disease and stroke suggests the benefits of this approach, but we agree with those people in the discussion who argued that there is no room for complacency. Scottish mortality rates for CHD and stroke remain high by western European standards and there are still unacceptable disparities due to health inequalities. We are therefore committed to revising our national strategies for each condition, to put greater emphasis on prevention and tackling those issues that have hitherto been neglected such as inherited cardiac conditions. Updated strategies will be published in Summer 2008.

From 2008, dementia will be regarded as a national priority. This will be reflected in a new target from 2009 which will focus NHS Boards on this condition and allow us to build national approaches based on new standards for an integrated care pathway for dementia that will be published by NHS Quality Improvement Scotland in December 2007. We are committed to developing guidance and support tools to help make all primary care buildings dementia friendly, identifying and building upon examples of good practice across Scotland and developing a competency framework to support training and development of mental health nursing for older people.

Forth Valley Dementia Project The Forth Valley Dementia Project is an improvement programme run by the Dementia Service Development Centre with funding from the Scottish Government. It aims to identify the needs of people with dementia in the Forth Valley area, establish what services are available and identify practical ways to improve the care of people with dementia. The programme began in April 2007 and has delivered an extensive programme of training for nursing staff to help raise their understanding of dementia and offer problem solving advice for coping with difficult situations involving patients. Training has also been provided to police officers given that they come into contact with people with dementia in a variety of everyday situations. The programme has also produced an information booklet, Memory Loss: Finding your Way Through the Maze which provides information on dementia services in the Falkirk area.

Mental Health Services

The new Government is fully committed to the successful implementation of the action plan, Delivering for Mental Health (2006). NHS Quality Improvement Scotland has developed a set of standards for depression, dementia, schizophrenia, bi-polar and borderline personality disorder, which will provide the framework around which mental health services, particularly in primary care will operate and in January 2008. We will also publish guidance on the physical health needs of people with severe and enduring mental health problems covering both primary and secondary care. In April 2008, we will launch the Mental Health Collaborative to share good practice and drive the delivery of new and emerging commitments on antidepressant prescribing, readmissions and dementia.

The Scottish Recovery Indicator provides a method of assessing the extent to which practice in mental health services is focused around factors which are known to promote recovery. This focuses on 'strengths' rather than looking for negative aspects of an individual's illness. The tool is currently being piloted in four NHS Boards to test its validity and evaluate its impact on changing practice, promoting the concept of recovery and improving the quality of life of those who suffer from mental illness. Our aim is to roll out the use of this tool across all mental health services in Scotland by 2010.

We know that it will take time to grow the numbers of staff we will need to be able to deliver the range of psychological interventions that are required but we believe that such an investment of time and resources is worth it. Working with local NHS Boards and NHS Education for Scotland we will work to enhance the skills of current professionals in this area and train new staff in different interventions, whilst ensuring that they all have the appropriate supervision to practice safely and effectively. At the same time we will be funding a national mental health improvement programme that will work for the next three years with NHS Boards, Local Authorities and users and carers to drive forward the delivery of our mental health targets and change the way in which we care and treat individuals. An early output will be to work with NHS24 to explore and pilot telephone based Cognitive Behavioural Therapy in 2008.

Organ Donation and Transplantation

Organ transplantation is one of medicine's great success stories, but there is an acute, and growing, shortage of donor organs for transplantation. Although 29% of our population now have their names on the NHS Organ Donor Register, our donation rate is one of the lowest in the EU. We believe that organ donation should be regarded as a usual, not an unusual, event and that discussions about donation should be a normal part of end-of-life care for appropriate patients. We fully support the work of the UK wide Organ Donation Task Force and will ensure that Scotland plays its part in contributing to the 50% increase in organ donation which the Task Force believes is possible over the next
five years. We will also encourage a wide public debate on the issue of presumed consent for organ donation.

Dental Services

A number of steps are underway to improve access to dentistry in Scotland, including:

• grants and allowances are in place to attract practitioners to Scotland and to encourage existing practitioners to expand their practices
• an undergraduate bursary scheme where students commit to work in NHS dentistry for up to five years following qualification
• funding under the Primary and Community Care Premises Modernisation Programme to provide new or substantially improved premises to support the delivery of NHS dentistry in areas with gaps in provision.

Furthermore, we have signalled our intention to open a third dental school in Scotland by expanding the Aberdeen Dental Institute. It is intended that the first group of students will enter the dental school in October 2008.

We will:

• Work with Health Boards and GP practices to provide an accessible service which fits in with the day to day lives of their patients
• Establish pilots in five NHS Boards to evaluate walk in access to a wider range of services in community pharmacy
• Publish a delivery plan for the next stage of our work on long term conditions in 2008
• Extend the scope of the SPARRA risk prediction tool from identifying those aged over 65 and high risk to all high risk individuals by June 2008; and to medium risk individuals by end 2008
• Launch Long Term Conditions and Mental Health Collaboratives in 2008
• Work with Local Authorities to secure further improvements in community care and enhance their deliverability and sustainability of personal and nursing care
• Roll out the Scottish Recovery Indicator by 2010
• Reduce delayed discharges to nil by the end of March 2008
• Ensure that people in care homes have appropriate access to primary and specialist health care services
• Ensure that all partnerships can share information electronically by 2009 based on the single shared assessment
• Revise our strategies for the national clinical priorities by Summer 2008 and include dementia in these priorities from 2008
• Establish a dental school in Aberdeen, aiming for a first student intake in 2008

3.5 EFFICIENCY

Introduction

A recent Commonwealth Fund report compared the UK health care system to five international examples (Australia, Canada, Germany, New Zealand and the USA) and found that the UK was the most efficient provider of services. The UK system as a whole performed well in terms of the relatively low number of individuals who presented as emergencies with conditions which could have been treated earlier by another health care professional and in areas such as the deployment of multi-disciplinary teams in primary care.

Nevertheless, we all recognise that NHSScotland, as an organisation that accounts for over £10 billion of public money every year, must strive to become ever more efficient in everything it does. In particular, it needs to draw on the expertise of staff and ideas from patients at every level in order to identify and take opportunities to ensure that resources are deployed in the most appropriate way in order to support front line patient care.

NHSScotland Efficiency and Productivity Programme

Over recent years, a range of initiatives and programmes around measuring and improving efficiency and productivity in NHSScotland have emerged. These include national improvement programmes, benchmarking, measurement of output and quality, unit costing/tariffs, programme budgeting and work towards achieving greater integration of finance, workforce and service planning in Boards' Local Delivery Plans.

The NHSScotland Efficiency and Productivity Programme has been established to bring greater coherence to this landscape within NHSScotland. A Steering Group will be established, chaired by a senior figure within the service, which will provide governance, direction and advice on a programme designed to assist Boards in identifying local improvements and efficiency savings. In particular, it will take forward further work on:

• national tariffs that reflect the value of procedures carried out by one NHS Board on behalf of another and act as a spur to greater efficiency
• pay modernisation to better reward and recognise staff, improve recruitment and retention and facilitate service changes that improve patient care
• release and reallocate valuable consultant time in conjunction with the Scottish Association of Medical Directors group
• Whole System Benchmarking to help NHS Boards to track the timing and sources of efficiencies and productivity, safeguard against double counting and improve the transparency of reporting by providing clearer standards against which the public can judge the performance of their local services
• improving the way in which we measure quality and productivity in line with the work of the Atkinson Review (2005) commissioned by the Office for National Statistics
• ensuring that service improvement programmes and the application of Lean principles are fully integrated with NHSScotland's overall approach to efficiency and productivity.

The national discussion and our determination to support the overarching purpose for Government also challenges us to develop a shared agenda around Best Value in conjunction with local authorities and other public sector partners. This needs to cover the nine dimensions of that model, namely:

• sound governance at a strategic and operational level
• responsiveness and consultation
• commitment and leadership
• use of review and option appraisal
• joint working
• sustainable development
• equal opportunities
• sound management of resources
• accountability, including public performance reporting.

The NHS Efficiency and Productivity Programme will consider how we pursue these dimensions as part of the wider range of work.

Key Targets

The focus of action to improve efficiency and productivity is upon improving outcomes for patients in terms of clinical success, experience of care and, ultimately, quality of life. To achieve such outcomes however, it is essential that we concentrate on the way in which our services are designed and delivered.

The new HEAT performance framework contains a number of new targets aimed specifically at improving efficiency throughout NHSScotland. These include:

• universal utilisation of CHI, the unique patient identification number
• a sickness absence rate of 4% from 31 March 2009
• all employees covered by Agenda for Change to have an agreed personal development plan in line with the Knowledge and Skills Framework by
  March 2009
• delivery of agreed efficiency improvements for first outpatient attendance DNA, non-routine inpatient average length of stay, review to new outpatient attendance ratio and day case rate by March 2011
• NHS Boards operating within agreed revenue resource limits, capital resource limits and their cash requirements
• meeting NHS Board cash efficiency targets
• increase the percentage of new GP outpatient referrals into consultant led secondary care services that are triaged online for clinical priority and appropriate recipient service to 95% from December 2010.

Evidence Based Clinical Practice

Action to tackle significant variations in current practice across NHSScotland will be taken forward on the basis of an explicit commitment to the delivery of evidence based clinical practice which will ensure appropriate decision making and action across clinical and planning communities. It will enable us to ensure that investment is driven by clinical evidence and allow us to target other known variations in practice. In an initial phase this work will focus on:

• variations in referral from GP practices to emergency care
• variation in day surgery rates
• variation in theatre utilisation
• variation in length of stay.

Reducing Our Carbon Footprint

All NHS Boards are required to contribute to an annual national environment report which demonstrates performance in gas omissions, energy usage, water consumption, production of clinical waste and increased levels of recycling. This focuses the whole organisation on building on 38.7% reduction in carbon dioxide emissions we have achieved since 1989/90 and we propose to expand the scope of the report to embrace the wider sustainability agenda. In particular, we are keen to ensure that in designing new facilities, NHS Boards give full consideration to both design quality and the impact of design on the environment. This will be supported through the framework agreement with Architecture and Design Scotland that runs until September 2009.

NHS Grampian: Carbon Management NHS Grampian was identified as a UK pilot in the carbon trusts study into carbon footprint reduction measures. NHS Grampian, recognising the direct and harmful influence of carbon dioxide emissions on climate change and mindful of its responsibility as a large public sector organisation agreed to this pilot study with the Carbon Trust the aim of which is to bring about sustainable reductions in the Board's CO 2 emissions. The Board has set targets of reducing its carbon impact by 2% year on year and by a minimum of 15% over five years. In meeting those targets over 10 years NHS Grampian would save £6.9 million and avoid emissions of 61,000 tonnes of CO 2.

eHealth

High quality information is crucial to the delivery of safe and effective health care. We will build on our work to put in place a modern and efficient information and communications system to ensure that the right information is available at the right time, in the right place, to enable staff to provide the best possible care. We also need to ensure that the benefits which information technology brings to patients and health care professionals, such as improved co-ordination of care, are delivered within a culture which respects, values and keeps secure patients' data.

Significant progress has been made over the past few years in developing eHealth that meets the needs of patients and facilitates efficient and effective working across NHSScotland. The Emergency Care Summary now contains key clinical information for over 5.1 million patients and is currently used around 25,000 times per week, if the patient explicitly consents, by clinicians in Out Of Hours GP services, A&E Departments and NHS24. Use of the Community Health Index ( CHI) number on the 10 key clinical documents for communication between GPs and acute hospitals has increased from 70% in November 2006 to 94% in December 2007 and it now used on 94% of community-held case records, up from 86% in April 2007.

The Scottish Government is determined to build on these achievements and add fresh impetus to our national strategy in order to realise the opportunities that exist for improving the quality of patient care across Scotland. In Spring 2008, we therefore intend to publish a new eHealth strategy that will demonstrate how we intend to bring together existing information and systems throughout a patient's journey of care and spread good practice between areas and clinical functions, whilst ensuring a continuing focus on protecting the confidentiality and security of patient information. The strategy will address the cultural issues we face in implementing new technology and above all will prioritise future investment on IT on the basis of its potential to improve our patient's experience of care.

Key features of the Strategy will be:

• action around the three themes of supporting safe, effective, timely and efficient patient care, contributing to equitable, patient centred care and improving eHealth capacity
• a vision of ever diminishing paper and increasing use by clinicians of secure IT to access the right information in the right place at the right time
• a clear focus on patient safety, safeguarding confidentiality, evidence based care and more efficient management of the patient's journey through care
• a new emphasis on 'Patient eHealth', initially focused on long term conditions, with trials of patient/carer online access to their records along with knowledge to promote self and collaborative care.

We have made progress to date by introducing incremental improvements that produce clear benefits to patients and the service. Our strategy will continue to be built on this approach. We do not plan to produce some large single database of patient information, but will join up systems where there are clear benefits from doing so.

Telehealth

Telehealth offers a range of care options remotely via phones, mobiles and broadband, often involving videoconferencing. Deployed effectively, it can improve the patient's experience of care by reducing the need for travel to major cities and hospitals to receive care and treatment. It has already been used successfully to provide treatment around conditions such as dermatology, cardiology and neurology.

Over the next five years the Scottish Centre for Telehealth will support and guide the development of telehealth for clinical, managerial and educational purposes across Scotland. This involves working across boundaries with industry, Local Authorities and NHS Boards to develop recognised models for redesigning care. The focus will be support for long term conditions (with an initial emphasis on COPD), paediatrics, and unscheduled care and in remote and rural areas. The Centre will provide support and advice to NHS Boards and help evaluate the potential benefits of new technologies, with the aim of making Scotland a recognised global leader in telehealth.

Tele-endoscopy for head and neck cancer assessment The incidence of head and neck cancer is increasing and is particularly noticeable for oral cancer where the age standardised rates have increased by 35% in males and 44% in females over a 10 year period. Tele-endoscopy for head and neck cancer assessment uses remote diagnostic technology to facilitate the examination of an airway with symptoms of tumour growth. The first stage of the pilot involves the delivery of a remote diagnostic service from Aberdeen to Shetland to provide patients with local access to a specialist opinion. Two local doctors and two local nurses have been trained to facilitate the clinical service which now runs every month. Future phases will involve the delivery of a remote diagnostic service from Inverness to Stornoway and a remote review appointment service to a local community hospital for patients who have had surgery, radio or chemotherapy for head and neck tumours.

We will:

• Bring greater coherence to NHSScotland's efficiency and productivity efforts through the NHSScotland Efficiency and Productivity Programme and meet the key efficiency improvements described in the HEAT performance framework
• Target variation across NHSScotland as part of an explicit commitment to evidence based clinical practice
• Further develop the existing Benchmarking Programme to help NHS Boards identify areas for improvement
• Publish the Balanced Scorecard for Mental Health to allow benchmarking of services
• Promote the lessons from the NHS Grampian carbon management pilot study
• Extend the scope of the NHSScotland Environment Report to embrace the wider sustainability agenda
• Publish a new eHealth Strategy in Spring 2008
• Support the Scottish Centre for Telehealth to focus on telehealth applications in the areas of long term conditions, paediatrics, unscheduled care and remote and rural health care

3.6 EQUITY

Introduction

It is important that we understand and respond to the needs of the different groups and communities we serve. It is not enough to provide a uniform service and expect that patients and the public will be able to take advantage of that service equally.

A lot has been achieved in NHSScotland already but it is critical that every part of the service considers whether the services it provides, and the way in which they are provided, support equity.

Remote and Rural Health Care

Building a Health Service: Fit for the Future recognised that a one size fits all approach can not meet the challenges of providing health care in remote and rural areas and established a national steering group to develop a framework for the provision of services in those areas. A further group was established to develop specific training for doctors working in remote and rural areas. Both groups have now reported and we will issue guidance on how we expect their recommendations to be implemented early in 2008.

The proposed framework presents a model for sustainable remote and rural services which maximises the contribution of each member of the health and social care team, and encourages further integration of services. Primary care teams are recognised as the bedrock of the health care system. Recommendations are made to extend, as far as is possible, the range of diagnostic tests and specialist support available to those teams to prevent unnecessary onward referral and travel for patients. The potential to upskill members of those teams to provide more local services - for example through the development of GPs with special interests - is also recognised.

The Framework describes a suite of safe and sustainable core services for Scotland's Rural General Hospitals, supported by a modern staffing model which secures quality of care for patients. Rural General Hospitals will develop formal networks between one another, and with larger hospitals in urban centres, which will include agreed specialist clinical links. The current practice of visiting specialists will be reviewed and extended where appropriate. This will allow local decision making to be informed by access to specialist opinion, peer group support, training and education, the development of shared protocols and pathways across and between different facilities and opportunities for staff rotation that can help maintain and develop necessary skills.

It is clear that we can do much more to exploit the opportunities offered by eHealth and particularly telehealth in remote and rural areas. Travelling to a central point can be avoided through the use of videoconferencing, telephone or email, whilst digital data such as blood tests, ECGs, and images can be transferred from remote sites to other points to enhance diagnosis. This requires protocols and agreed service standards and the Scottish Centre for Telehealth will be a critical source of information and advice for NHS Boards as they start to deploy these technologies more effectively.

The Medical Training Pathways group has applied an understanding of the service requirements within remote and rural areas to develop educational standards for doctors within a multi-disciplinary team, specifically considering Anaesthetists, Physicians, Surgeons and General Practitioners. The report makes recommendations on a competency framework for each of these key medical specialities, adapting the general training curricula for each specialty when required.

Fair for All

Our Fair for All agenda seeks to understand the needs of different communities, eliminate discrimination in the NHS, reduce inequality, protect human rights and build good relations by breaking down barriers that may be preventing people from accessing the care and services that they need. It aims to address inequalities by recognising and valuing diversity, promoting a patient focused approach and involving people in the design and delivery of health care.

A vast amount has been achieved already, with guidance now being available to help staff understand and meet their responsibilities under the Disability Discrimination Act, support NHSScotland in implementing the Gender Equality Duty, assess progress in achieving race equality outcomes and provide information and good practice examples of LGBT people using NHS services. Guidance on religion/belief and issues relating to age are due to be launched shortly. A new Directorate of Equalities and Planning is being created in NHS Health Scotland to bring together this work and to be the focus of support, advice and expertise to NHSScotland in addressing diversity and reaching excluded communities.

We are committed to continuing and further developing our Fair for All approach across NHSScotland. We will therefore ensure that we equality impact assess this action plan throughout its implementation. We will do this, not just because it is a legal requirement. It is right to do so and we believe that it will lead to services that are equitable and fair for all the communities we serve.

Disabilities

NHSScotland has been working in partnership with the Equality and Human Rights Commission through our Fair for All - Disability initiative to raise awareness of disability issues and deliver more responsive services for people with a disability. Fair for All - Disability, which is now housed within NHS Health Scotland, supports NHS Boards directly and with guidance to ensure health services strive for best practice that goes beyond compliance with the law and promotes the rights, independence, choice and inclusion of disabled people as health service users and members of the community. Achieving Fair Access - good practice guidance - has been launched to assist health staff to understand and meet their responsibilities under the Disability Discrimination Act.

We are working to address the barriers which disabled people ⁵ have told us they face, including the need for better information, providing suitable opening and appointment times and improving the accessibility of the buildings, including support for helping finding your way around buildings. Barriers to access can very often be easily remedied by offering simple adaptations to existing services such as making appointments by email, providing treatment information in large print, on tape or in easy read. The use of colour in signs and as guide-lines on walls or floors can help visually impaired people to find their way around large clinics and hospitals. Disability awareness training for NHS staff at all levels of the service is helping to ensure that staff are confident and competent in dealing with a range of impairments and disabilities and are aware of the potential barriers which might prevent disabled people from accessing services.

We recognise that disabled people and carers may need more flexibility with appointment systems and we will continue to work towards the following:

• the opportunity to book longer appointment times
• appointments at a time of day that is best for them, e.g. to fit in with medication routines and carer availability
• provide a written summary of discussion and outcomes from NHS interventions in an accessible format so that patients have a note to take away
• advocacy and communication support, e.g. British Sign Language interpreters available when and where required.

The NHS in Scotland will continue to strive to provide a supportive attitude as well as creating an environment that is both welcoming to, and inclusive of, disabled people. They are significant users of NHS services, and listening and responding to their feedback is an essential mechanism to improve experiences. Monitoring these improvements will be central to 'Better Together' the Scottish Patient Experience Programme.

National Statement and Action Plan on Race Equality

The development of a National Statement and Action Plan was one of the recommendations made following the Executive's comprehensive and wide ranging review of race equality, which reported in November 2005. These will be launched in Spring 2008 following a further period of consultation and will set out the vision, basis and direction for our future work on race equality, and the actions the Scottish Government will take to support ethnic minorities in the labour market, Gypsies/ Travellers, race equality in rural areas, and refugee integration.

We will:

• Publish guidance in early 2008 on the implementation of the Remote and Rural Steering Group's Report
• Establish a Directorate of Equalities and Planning in NHS Health Scotland
• Publish a National Statement and Action Plan on Race Equality by Spring 2008
• Equality impact assess the implementation of this action plan
• Seek to reform the GP contract to better meet the needs of all of our citizens
• Address the barriers young disabled people face in accessing health services

3.7 TIMELINESS

Introduction

From December 2007, all patients will be seen in an outpatient clinic within 18 weeks of being referred by their GP, and if an operation is needed, all inpatients and day cases will be treated within 18 weeks of being placed on a hospital waiting list. By the end of 2007, we will have abolished Availability Status Codes (hidden waiting lists) and delivered against a number of other waiting time targets which will then be embedded as patient access standards.

Whilst these are significant improvements, there must be no let up in our efforts to reduce waiting times. Shorter waits can:

• lead to earlier diagnosis and better outcomes for many patients
• reduce unnecessary worry and uncertainty for patients
• reduce inequalities by addressing variations in waiting times between NHS Boards or individual hospitals
• save the time, energy and resources that are wasted in the bureaucratic task of managing queues and backlogs for diagnosis and treatment.

18 Weeks Whole Journey Standard

From December 2011, 18 weeks will become the maximum wait for treatment following referral by a GP for non-urgent patients. Most patients will be seen more quickly than this.

The 18 week target is different from previous waiting time targets. It does not focus on a single stage of care, such as the time from referral to first outpatient appointment, or the time from being put on a waiting list until treatment starts. Instead, the 18 week Referral To Treatment ( RTT) standard will address the whole patient care pathway, from receipt of a GP referral, up to the point at which each patient is actually admitted to hospital for treatment. This approach has the added advantage of introducing a single standard for access which is well understood by patients and clinical teams alike. As a milestone towards this goal, we will reduce the longest permitted waits for first outpatient consultations to 15 weeks, diagnostic tests to six weeks and inpatient or day case treatment to 15 weeks by end March 2009.

Achieving an 18 week pathway will challenge NHSScotland to improve patient access to hospital services, and, in so doing, increase the effectiveness of clinical care through faster access to outpatient consultation, diagnosis and treatment. Importantly, this will give added impetus to shifting the balance of care from acute hospitals into locally delivered, primary care diagnosis and treatment services. Where it is needed, extra activity will be commissioned by NHS Boards to achieve this standard, supported with additional investment by the Scottish Government Health Directorates. We will publish our delivery strategy in Spring 2008 setting out our approach to the inter-related elements of:

• planning: action to plan and invest in effective and efficient reduction in patient access times locally, regionally and nationally
• redesign: to make the best use of current capacity, improve efficiency and bring best practice to systems and health care delivery
• information: to develop and use information and technology to support faster access to diagnosis and care
• performance management: to ensure clear targets are set, and service improvement momentum is maintained between 2008 and 2011.

The Scottish Government will support NHSScotland in delivering the 18 week target with an investment of an additional £270 million over three years to improve the range and quality of services for patients across the country. A three year Service Transformation Programme will engage with NHS Boards and their clinical teams, building on best practice both internationally and within NHSScotland and addressing the changes to behaviour that will be required across the service to deliver service transformation of this magnitude. Collaborative work will support NHS Boards to develop quicker access to services whilst improving patient safety and reducing health care inequalities.

Urology services in NHS Tayside Although a one stop service for frank haematuria (blood in urine) was available in Ninewells Hospital in Dundee, it was not provided in Perth Royal Infirmary or Stracathro Hospital in Angus. In Perth Royal Infirmary, patients waited up to 96 days to receive a clinical management decision. A Rapid Improvement Event using Lean methodology was held in February 2007, in which a multidisciplinary team of 16 people examined current processes, spoke to staff and patients about their experiences and developed a four week action plan to improve the journey for frank haematuria patients across NHS Tayside. One stop services for patients in Perth and Stracathro were introduced in March and May respectively. The average waiting time for patients to receive a clinical management decision in Perth now stands at 11 days.

Unscheduled Care

When someone experiences a health emergency or crisis they need to have access to the right response, the right form of emergency care as quickly as possible. A good system of unscheduled care is one that responds promptly when it is called upon, but also one that responds in a way that is appropriate to patient needs.

We will respond to the challenges set out in the Audit Scotland report on primary care out of hours services (2007) and continue to develop a more integrated approach to the delivery of unscheduled care in each local area. We will therefore increase the use of "see and treat paramedics" so that patients can be supported without an unnecessary journey to hospital, extend access to primary care, use joint "rapid response" services, build on recent improvements in the services of NHS24 and ensure that we improve the experiences of patients through whichever route they receive unscheduled care. This approach can be further supported through the wider use of the Scottish Patients at Risk of Readmission and Admission tool to enhance preventative care in local communities, better use of the Emergency Care Summary to ensure joined up care and increasing the use of remote consultation and diagnostics through telemedicine and telecare. Such an approach will enable us to ensure that patients get the services they need, in the places that they need them, whilst also ensuring that we use our emergency care resources as efficiently as possible.

Our overall approach to unscheduled care, also requires us to ensure that we have the infrastructure in place to support crises that might occur for people with mental health problems. Crisis Standards have already been published and other work such as the development of the standards for integrated care pathways, the development of out of hours crisis teams or intensive home support services are also having a positive impact. More, however, requires to be done. In 2008 we will publish a tool, developed in partnership with SAMH and the Mental Health Foundation that will assist NHS Boards and their partners in evaluating and improving current services. This will be further supported by the development of a risk prediction tool to help identify those people who have a mental illness and who are at most risk of being re-admitted to hospital and assist care providers, particularly GPs and other community staff, to offer appropriate support to these individuals.

Improvement and Support

The Improvement and Support Team, working alongside partners such as NHS Quality Improvement Scotland, will support the implementation of Better Health, Better Care by helping NHS Boards to develop an overarching culture and capability for continuous improvement. From 1 April 2008, the National Improvement Programmes will be restructured to reflect the priorities with programmes to support work on achieving the 18 week whole journey time, mental health, long term conditions and implementing proven improvement approaches to new areas such as health improvement and productivity. Performance support programmes will also be developed to help Boards meet the challenges of the refreshed HEAT Performance Framework. This will offer access to improvement education, rapid improvement events and, where Boards need intensive performance support, tailored performance support programmes.

Unscheduled and Out of Hours Care: Integrated Emergency Response This proposed service will bring together the dispatch functionality of NHS24, SAS and the Lanarkshire Out of Hours HUB and will also incorporate a Lanarkshire wide bed bureau. A single team is envisaged with all team members having the ability to access all the clinical and demographic information currently only provided to NHS24 through the Emergency Care Summary. In addition to accessing out of hours services and traditional ambulance services, the service will have access to 'see and treat paramedics' and also outpatient and GP next day slots to prevent A&E attendance and possible hospital admission. The emergency response team should be in operation 24 hours but it is acknowledged that the team will be able to access different levels of resource at different times of the day.

We will:

• Abolish ASC codes (hidden waiting lists) by December 2007 and introduce a new system of defining and measuring waiting times which is more transparent, consistent and fair to patients
• Publish a National Framework for achieving the 18 week Referral To Treatment ( RTT) standard in Spring 2008
• Reduce the longest permitted waiting times for first outpatient consultations
  to 15 weeks, diagnostic tests to six weeks and inpatient or day case treatment to
  15 weeks by end March 2009
• Publish comprehensive performance statistics from 2010 showing our progress towards the 18 week RTT target
• Achieve an 18 week RTT standard across Scotland by end 2011
• Establish a local NHS24 service in every mainland Board area
• Ensure that people can gain access to appropriate care first time by better linking the ambulance service, NHS24 and other health providers
• Continue to expand the Emergency Care Summary in order to ensure that care is joined up