Realising Realistic Medicine: Chief Medical Officer for Scotland annual report 2015-2016

Chapter 3: Realistic Medicine: A Multi-professional Endeavour

The messages outlined in last year's report resonated with a range of clinical and care professionals across Scotland and beyond.

Many nurses, pharmacists, psychologists, allied health professionals, social workers, care professionals and healthcare scientists identified with the issues raised and - importantly for realising widespread provision of 'realistic care' across Scotland - recognised ways in which their professions and services have already been making the changes that will be needed if Realistic Medicine is to become the norm across Scotland in the future.

I asked my colleagues from the other main clinical and care professions within Scotland to share their reflections with me on what realising Realistic Medicine might mean for their profession and, crucially if we are to maximise our collective will, ideas and expertise, what this could mean for the ways we all work together to make the changes that people want to see.

People want to be independent, to do as much as they can when they are able to, have a decent quality of life, goals, objectives and dreams and to be at home and safe in their community. People expect high quality, responsive and flexible services to be there when they need them - and at an early stage so that difficulties and challenges can be resolved quickly. System reform, processes and structures are of course important in improving how we deliver care and support and improvements that will help deliver the ethos set out in Realistic Medicine are already happening at pace across Scotland through health and social care integration and other national policy developments.

Changing Professional Systems of Care

Many strategic commitments across the professions have been made in ways that resonate with the growing movement of Realistic Medicine enthusiasts and change agents across all the professions in Scotland's health and care delivery systems. For example, the 'Oral Health Plan for Scotland' ¹² has emphasised the need to modernise an outdated and complex system to improve oral health and related inequalities. Just as with medicine and medical care systems, the dental care system has evolved as a result of an historical need which must change given the current profile of health and care need.

"We must return the mouth to the body and integrate oral health with general health."
Margie Taylor, Chief Dental Officer for Scotland

The Chief Dental Officer has stated that adults tend to be 'treated in a system that pays dentists for doing things to teeth', suggesting a more realistic approach to the future delivery of adult dental care might be to support a greater focus on oral health improvement. This would encourage dentists to work with their primary care colleagues to raise awareness in people of any risk to their oral health. As an example, when a person is diagnosed by their doctor as being at risk of, or suffering from, diabetes they will be given dietary advice and referred to have their blood, eyes ,feet and weight checked on a regular basis. In addition to these checks the patient should be made aware of the importance of attending the dentist regularly for specific advice and treatment in order to avoid future periodontal (gum) disease and tooth loss. This approach could further empower people to self-manage all the potential consequences of their long-term condition at an earlier stage following diagnosis.

Changes to professional systems of care are already happening in Scotland and provide a strong foundation for all the clinical and care professions to work together on new innovative, more efficient approaches that are more in tune with what matters most to people - approaches that will lead to further increases in the already high satisfaction levels across Scotland and provide positive opportunities for professional development and improved approaches to meeting people's health and care needs.

For example, over the last four years the national Musculoskeletal Programme has used an improvement approach to support roll out of self-referral, telephone triage and digitally enabled, supported self-management and rehabilitation. The Musculoskeletal Advice and Triage Service ( MATS) is operated by NHS 24 and is operational in nine NHS Boards (covering
70% of the population).

People with musculoskeletal problems or pain are taken through risk stratification questions to determine their clinical need for: self-management advice ( e.g. exercises, footwear); supported self-management; (an Allied Health Professional ( AHP) call back for instance a physiotherapist or podiatrist); AHP referral for treatment; secondary care referral, e.g. to trauma or orthopaedics and occasionally immediate A&E attendance. This leads to a higher quality and reduced number of referrals to orthopaedics with people on the right pathway for an optimal outcome.

"We need fully utilise the skills and capabilities of allied health professionals to support transformation in community provision across prevention, early intervention and enablement approaches - working in partnership with the people, in communities and with organisations."
Jacqui Lunday Johnstone, Chief Allied Health Professions Officer for Scotland

Nursing colleagues have been leading work to trial new models of healthcare delivery developed around fostering holistic human connections, enablement and self-management - with less of an emphasis on traditional management and professional hierarchies. The Buurtzorg approach from the Netherlands has attracted international attention for its innovative use of independent nurse teams in delivering high quality relatively low-cost care in the community. This model has the potential to identify and inform ways in which realising realistic medicine and care could be organised within new professional structures and processes.

As an obstetrician I have seen first-hand how maternity teams have a long history of working in partnership to ensure that women and babies have appropriate intervention for their individual needs, and with care delivered by the most appropriate professional. Scotland's current model of care aims to optimise normal processes and avoid unnecessary intervention; whilst insuring that women with additional needs have the appropriate care and services.

Working Effectively Across Clinical and Care Professions

I was very struck by the reflections of our Chief Social Work Adviser, Alan Baird on my Annual Report last year. Alan welcomed the real opportunities for us to be joined up in respect of the questions I posed through 'Realistic Medicine' - questions and challenges that he recognised as being the same ones facing Scotland's social care and wider social services.

"The objectives set out in 'Realistic Medicine' will be very familiar to those working in Scotland's social services who have already been on a similar journey and who have considerable experience of shared decision making, co-producing outcomes for individuals using services, delivering personalised care and supporting and managing risk in order to empower individuals yet afford sufficient protection."
Alan Baird, Scottish Government's Chief Social Work Adviser

People need to feel valued, supported, have the right values and behaviours, be appropriately skilled and be able to utilise their skills as well as develop new ones. I would welcome an increasing role for the involvement of social work, social care and care professionals in multi-professional training, pathway development, care and support planning - this will deliver more realistic approaches to care delivery across the country.

Social workers are a key part of the decision-making processes that influence safe, effective and person-centred care across the country. They have skills in working with individuals in ways that are collaborative and outcome-focused. Social work, social care and health workers inhabit a shared arena in which links are already there with clinical colleagues - but more can be done locally and nationally to support the coming together of these services and those who provide them. This way the principles of Realistic Medicine can shape and influence the new and innovative service models within Scotland's Health and Social Care Partnerships.

Allied Health Professionals also often work across clinical and care professional groups to enable people to live well and avoid dependency on health and care professionals, including delaying or avoiding unnecessary admission to hospital. The strengths and assets-based approaches used by AHPs have foundations in shared decision-making, are informed by the social determinants of health and shaped by the principles of co-production. AHPs are experts in rehabilitation and increasingly the evidence that their work enables people to live independently, supports self-management, empowers people to return to work and avoids dependency on clinical and care systems, will inform the development of multi-professional pathways of care.

Case Study

The INSPIRE team at the BMJ Awards Ceremony

The InSPIRE Project - An Example of Innovative Multi-Professional Working to Improve Care Quality and Outcomes

The INSPIRE Project is an innovative project around intensive care unit ( ICU) recovery which pre-dates Realistic Medicine but closely resonates with its message. People who require an ICU stay are released into diverse environments and ICU-specific follow-up is not always clear. The evidence base shows that people's quality of life post- ICU is poor and many have ongoing cognitive, physical, social and psychological problems. This affects both people and carers. InSPIRE is an innovation between nursing, medicine, allied health professions and pharmacy. It takes a self-management approach where shared decision-making and personalised care are key, focusing on what happens to people after their ICU stay. In this respect it is a prototype of the sorts of multi-professional working that realising Realistic Medicine will support in the future.

People undergo a five-week rehabilitation programme which is constantly being refined using Quality Improvement techniques and - crucially - input from previous people we care for and support. As well as medicine, nursing, social work, clinical psychology and third sector based care professionals are involved. A patient advisory council also exists in ICU where 12-14 former-patients and family return to ICU and are asked simply 'how to make things better'. Changes have ranged from basic signage to complex care packages.

The project won a prestigious BMJ Award for 'Innovation into Practice Team of the Year' in May 2016 and is now being scaled up to other Health Boards including NHS Fife and NHS Lanarkshire. Each is able to take an individual approach in order to make INSPIRE suit the local community.

Nurses across Scotland are developing a national system to better support the identification of people's needs in a consistent way for everyone, every time - determining what matters, who matters, what information people want, involving people with discussions and decisions about care and enduring adaptation of service responses to personal needs.

"Registered nurses work as part of a multi-disciplinary and multi-agency team within the context of integrated services. There are core values, skills and competencies expected at all levels of community and primary care nursing as well as hospital based nursing such as comprehensive holistic assessment, person-centred care, risk assessment and recognising vulnerability. Working across the NHS, third and independent sectors nursing teams support delivery of a range of health and care outcomes."
Fiona McQueen, Chief Nursing Officer for Scotland

The context of Realistic Medicine is one that is embraced by the nursing profession when supporting people to take charge of their own health and decisions around treatment paths to optimise and improve health and wellbeing outcomes.

This is achieved through:

• Empowering people to take charge of their own health and wellbeing to remain healthier for longer
• Development of self-help programmes and anticipatory care plans to support people with long- term conditions to take charge of their health and maintain their independence for as long as possible
• Utilising technology to monitor each individual's condition enabling additional support to be provided rapidly where required reducing the need for hospital admission or emergency department attendance
• Caring for more people with complex needs at home or in a homely setting
• Providing high quality nursing care to individuals and their families at end of life.

The healthcare science workforce contributes to 80% of all clinical decisions that are made in the NHS. The year-on-year increase in diagnostic testing activities and associated costs that has been observed and the sevenfold variation in requesting rates for some diagnostic tests further underlines the need for a broader range of professions within NHSScotland to identify innovative ways of examining any unwarranted or harmful variation. Approximately 25% of diagnostic tests that are undertaken are not appropriate or necessary.

Case Study

National Falls Programme

Falls are the single biggest reason for people over 65 to present to the Scottish Ambulance Service ( SAS), with over 80% being transferred to hospital, often because other arrangements for care could not easily be put in place.

This has a range of unhelpful, and sometimes serious, unintended consequences for both the individual and for the services involved. There is significant variation in the use of alternative pathways to admission across Scotland and the current situation is not a productive use of resources for any of the agencies involved across health and social care. The Chief Health Professions Office, as the Scottish Government policy lead for falls prevention and rehabilitation, commissioned a National Falls Programme to lead improvement in primary prevention of falls.

In November 2016 it established a national multi-agency collaborative involving all 31 of the Integrated Joint Boards and Scottish Ambulance Service ( SAS) to support implementation of the SAS Falls Pathway 'once for Scotland'.

Work undertaken in various parts of Scotland has shown that through implementing a falls pathway, it is possible to reduce transfer to hospital by up to 50%. Similarly, a targeted mini collaborative improvement programme within 45 care homes across Scotland, as a partnership with the Care Inspectorate and Scottish Care, was able to deliver up to a 50% reduction in avoidable falls and also a subsequent reduction in transfer.

Our Healthcare Science Delivery Plan is tackling this and I expect to see the work to realise Realistic Medicine support this further through ensuring that the right test happens at the right time in the right way - as it is only through this work that we will start to have an approach to testing that is more closely based on pathways and preferences than professionals ordering tests 'just in case' or because of a personal professional interest.

"Working collaboratively within a distributed model of leadership and as part of multi-disciplinary teams, scientists can play a key leadership role in optimising patient pathways".
Karen Stewart, Healthcare Science Officer,
Scottish Government

Multi-professional working will increasingly need to support work that ensures that people can access the right health or care professional at the right time - delivering more person-centred but also more efficient care. For example, the impressive work on developing care pathways for musculoskeletal problems has had a significant positive impact on managing demands, reducing the need for medical consultant appointments. The development of new roles for nurses, radiographers and pharmacists have supported a more efficient approach to meeting the needs of people who may previously have had to be seen by a medical practitioner.

The exploration of how diagnostic tests are used in pathways shows noticeable variation in the way the test is being offered, used or interpreted across the NHS Boards. For example B-type natriuretic peptide ( BNP) can be appropriately utilised to triage breathless pepole for echocardiography. Pilots have been initiated which have produced data that highlights a saving of approximately 10-11 weeks from GP appointment to the person commencing treatment. Prior to to the test of change a person would have to wait approximately 14 weeks for treatment, while the new model of delivery is 2-3 weeks.These models have also approximately reduced echocardiograms by 50% and outpatient appointments by 50% with projected annual financial impact of around £30k (via cost avoidance).

Recognising the evidence around midwifery-led labour and birth which seeks to avoid unnecessary intervention, NHS Boards already provide some services related to home birth, freestanding midwifery units alongside midwifery units and obstetric units. This focus on personalised care, optimising processes and providing services which avoid unnecessary intervention has been strengthened in the recent 'National Review of Maternity and Neonatal Service in Scotland' ¹³ .

It will be important to ensure that the learning for the education, innovation and multi-professional working required across other services is captured and informs the way that collectively we realise Realistic Medicine and care in the future.

Pharmacists are trained as experts in medicines and increasing numbers now practice as independent prescribers. More pharmacists and pharmacy technicians are now being appointed in General Practice settings, supported by new competency frameworks that enhance the mix of skills available to address medicine-related issues in this setting and across the interface with secondary care.

The pharmacy profession interacts with people on a daily basis with the aim of ensuring medicines and other interventions meet their healthcare needs. Community pharmacies are located in the heart of communities and research suggests that they are accessed daily by 600,000 people in Scotland to obtain medicines and seek health promotion and harm prevention advice.

Pharmacy practice has been evolving to ensure that people are supported in understanding what to expect from their medication - central to this role is an acknowledgement that people want to be active partners in treatment options and to be supported through consideration of their expectations, preferences and evidence-based advice. For truly shared decision-making there needs to be a shift towards participative care, meaning that there is an acceptance by professionals of a situation where people may choose something different from what has been traditionally offered - collaboration across professions to support personalisation of care planning will be vital to making this work safely, efficiently and effectively.

The pharmacy profession is already playing its part in helping to realise Realistic Medicine through the provision of pharmaceutical care. It has been adapting to meet the challenges of changing demographics, advances in medicines technology and evolving perspectives on the benefits of medicines. The pharmacy profession has embraced it as a mechanism to modernise practice through innovation, participation and collaboration to improve the health of the population.

Case Study

Social Prescribing community meeting at Heathery Wood Gypsy Traveller site in Fife

Practicing Realistic Medicine with Specific Communities

In NHS Fife, a specific programme addressing the needs of Gypsy Travellers has been implemented. The evidence base for this was a previous needs assessment for the four Traveller sites in Fife - a mixture of public and private sites. Those living on Traveller sites have limited access to health services and research was undertaken looking at Travellers' experience of health and expectations of services. Access was found to be hindered by poor literacy and poor understanding of what services were available.

An innovative social prescribing model was developed to identify priorities for these communities and staff were supported to learn more about this group via an e-learning module. Regular community meetings were commenced on-site to help establish person-centred approaches to care.

For example, the community identified priority areas beyond healthcare, such as fire safety, and so the fire brigade became involved to give advice in this area. Travellers were able to communicate with a community nurse who visited regularly and was able to refer and signpost to appropriate services.

The initiative identified areas that Travellers do use to obtain information, and after consulting with the groups and undertaking a survey they will now upload information to the Fife Council website which is often used by Travellers. Nurses on-site will continue to undertake work on healthy eating, physical activity and mental health - with a new mental health nursing liaison link.

This initiative is an example of taking person-centred care out of the hospital or clinic room and delivering it where it is most meaningful - in this case within communities themselves.

"Pharmaceutical care for people involves the responsible provision of drug therapy to achieve agreed outcomes that improve a person's quality of life. From pharmacy this requires a person-centred approach that supports shared decision-making with people, often with their carers, and the wider clinical and care team."
Rose Marie Parr, Chief Pharmaceutical Officer for Scotland

I am delighted to have the support of my colleagues across the clinical and care professions. They have helped identify areas for collaboration, as well as questions for us to consider more widely as part of our collective commitment to supporting the delivery of transformational changes in health and social care in Scotland. We will be working closely together to consider some of the specific areas where we can support improved ways of working, shared learning across professions and enhanced support for the co-ordination of professional knowledge and skills to better deliver Realistic Medicine and care. We all want to support more effective multi-professional working to contribute to improved outcomes and reductions in harm or unwarranted variation - this shared commitment across Scotland's clinical and care professions will support both the changing approaches required within professions as well as the delivery of more effective multi-professional working across care pathways, services and sectors.