Chief Medical Officer - annual report: 2022

Personalising Care through Understanding

Introduction

The challenges facing our health and social care system are substantial. COVID-19 has impacted on the delivery of routine care for longer than first anticipated and as a consequence some longstanding conditions now require more urgent management. Our services, and our staff, have been under unprecedented pressure for prolonged periods and we must ensure a more sustainable way of providing high-quality care.

We know that if people are fully involved in decisions about their care, they are far more likely to value the treatment they choose. This further reduces waste and potential harm. Therefore Realistic Medicine provides us with a clear, forward-looking vision to deliver value-based health and care that is rooted in careful and kind personalised care.

If we are to deliver careful and kind care to our patients, we must also show kindness and compassion for the people we care for and for each other. Compassion and kindness have the profound power to enhance our wellbeing, help us make connections, build trusting relationships and increase empathy.

As healthcare professionals, it is our decisions that commit our precious healthcare resources. By practising Realistic Medicine, we can foster a new culture of stewardship – where we are mindful of the resources we use and deliver better value care, for the people we care for and for our system.

Over the past two years we have found some innovative ways to help ensure people can access careful and kind care that they value. In this chapter, I highlight a few approaches that are transforming access to services and delivering better value care for people who are vulnerable, and those living with multiple long terms conditions – the people who need our help the most.

Multi-disciplinary teams

During the last two years, as a consequence of the pandemic, the ways in which people could access treatment and care had to change to protect public health. I understand why some may feel frustrated at not being able to access care in the way they expected. Colleagues across our health and care system recognised this too. I’ve been extremely encouraged by their willingness and determination to overcome these challenges and how they have continued to innovate to find new ways of making sure people can access the care and support they need, when they need it.

There have been real benefits for people accessing services remotely – some are saving on travel and time away from work and education, or have been able to be joined by people close to them via shared video link. As we continue to recover and redesign health and care services, we must also continue to innovate and improve to ensure people can access care based on their needs and what is important to them, rather than the needs of the system. In doing so, we can achieve greater equity and more timely care.

To deliver the right care at the right time we continue to expand community multi-disciplinary teams (MDTs) across Scotland. This evolves the model of care from the doctor often being the first contact, to a model where patients will benefit from the range of expert advice from the whole MDT.

MDTs work to ensure people get the right care from the right healthcare professional first time, led by their GP, supported by the practice team. This means less time spent referring people between services. It also means more time is made available to support people with complex medical needs. Through the expansion of these MDTs and this renewed focus on the role of the GP as an expert medical generalist, the sustainability of general practice teams will also improve. The changes in approach to the way care is delivered have included:

• vaccinations – change in model for delivery of immunisation programmes to free practice nurse time for long-term condition management;
• pharmacotherapy – more efficient processing of repeat prescriptions and medication reviews;
• community treatment and care services – providing nursing and healthcare assistant support for bloods, wounds, ear irrigation and chronic disease monitoring;
• urgent care services – mainly Advanced Nurse Practitioner (ANP) support in areas such as same-day care, home visits, care homes; and
• additional professional clinical and non-clinical services including physiotherapy services, community mental health services and community link worker services.

The scale and value of this work cannot be underestimated. Over the past four years, the multi-disciplinary primary care workforce has expanded significantly, increasing the number of MDT staff per practice from 0.3 Whole Time equivalent (WTE) in 2018 to 2.69 WTE by March 2021, by which time 2,463 WTE multi-disciplinary staff have been recruited.^[12]

Enhancing General Practice capacity indirectly and directly

Making the most of the MDT ensures time is used more effectively, reduces multiple appointments for the same issue, and frees up time for longer appointments, where required. Evaluation of MDT contribution (where MDT members are prescribers) in Edinburgh^[13] has resulted in the following expectations emerging:

• One WTE practice-embedded Physio can augment workload capacity by the equivalent of five GP sessions (half days) per week;
• One WTE practice-embedded Community Link Worker can augment workload capacity by the equivalent of one GP session per week;
• One WTE practice-embedded Advanced Nurse Practitioner can augment workload capacity by the equivalent of six GP sessions per week;
• One WTE practice-embedded Mental Health Nurse can augment workload capacity by the equivalent of five GP sessions per week;
• One WTE practice-embedded pharmacotherapy team member can augment workload capacity by the equivalent of three GP sessions per week (average across a skill-mixed team); and
• One WTE practice-embedded qualified pharmacist would augment workload capacity by more than three sessions, and make indirect impact on workload through prescribing system improvement.

Case Study 3: The frailty multi-disciplinary team — Coatbridge

Multi-Disciplinary Teams also provide a context to work across sectors to improve the health of complex and vulnerable people. In North Lanarkshire an MDT is providing comprehensive assessment of older people with increasing frailty on a proactive basis.

The MDT includes a local voluntary sector advocacy organisation (Equals Advocacy), doctors from primary and secondary care, community nursing, rehabilitation team, older peoples’ mental health team, care at home, link worker and pharmacy.

Escalating frailty is identified by MDT members discussing people they have dealt with or by the electronic Frailty Index identifying high-risk patients. Patients are offered a facilitated home self-assessment supported by Equals Advocacy which focuses on a ‘What Matters to Me’ conversation, including anticipatory care planning as well as a comprehensive frailty and carers assessment. This is brought to the virtual MDT meeting with the advocacy worker acting on the service users behalf, ensuring they are at the centre of their care.

The MDT formalises a diagnosis of frailty, allocating a key worker and organising a polypharmacy review. At the MDT a range of additional interventions and referrals are made, such as carers assessment or falls risk assessment tailored to the person’s priorities and values.

• In a snapshot of 56 patients who had medication reviews there were 28 new items started and four increased but also 66 items stopped and 37 doses reduced to give more appropriate prescribing plans.
• Those changes resulted in a 31% reduction in anticholinergic drugs — drugs that increase the risk of, or worsen confusion.
• It was also associated with a saving of £92 per person per year showing that more personalised care offers better outcomes and value.
• In terms of capturing the patient’s wishes, the practices have improved a high baseline level of electronic Key Information Summary, with 87.5% of those discussed having an active record and an increase in the number of severely frail patients with an Anticipatory Care Plan from 10% to 25%.
• Up to 8% of those discussed benefitted from an increase in their care at home package to support their independence.

Feedback from both service users, carers and members of the MDT has been positive.

“It’s so positive… this new way of working – how everybody is coming together… and I think it’s the best thing” – (Carer)

Moving care closer to patients

People living with long-term conditions often have an abundance of knowledge about living with their conditions and can benefit from sharing experience. Clackmannanshire and Stirling HSCP supports patients with vitamin B12 deficiency to self-administer their treatment – this approach enabled 50% of patients to self-administer their own B12 injections and is now offered to the 4,000 people the service supports. This previously accounted for 16,000 appointments annually.^[13]

Appointments, especially in secondary care often involve travelling from home, taking time away from work or education. In Forth Valley MDT working has allowed 9% more patients to be managed in their community by a physiotherapist embedded in their practice.

Advance practice physiotherapists embedded in GP practices now offer around 3,000 direct access appointments per month. Less than 1% of patients require follow up with a GP and less than 2% referred to secondary care. Rolling out the service, 26 practices with a physiotherapist saw a 9% reduction in patients requiring secondary care whilst 24 practices without a physiotherapist saw a 13% increase in referrals.

At a system level this equates to at least 700 fewer referrals to hospitals each year. In addition, the Primary Care Mental Health Nurse service is delivering more than 4,000 appointments each month, meaning far more direct contact with mental health services and less than 2% of people being referred back to GP care. The service is also offering 15 and 30 minute appointments, allowing for longer conversations to truly personalise care, and reducing the likelihood of secondary care referral.

Tools to access care

Care Navigation is a process to signpost people to the best-skilled person to deal with their needs. There are now more ways of consulting with patients including telephone consultations, video consultations, group consultations (shared medical appointments), virtual group consultations and digital interfaces such as DACs (Digital Asynchronous Consulting) alongside traditional face-to-face consultations.

DACs describes a range of general practice digital tools that support clinical triage and remote consultations where the clinician and patient are not necessarily present at the same time. These tools should be used to deliver care in the way best suited to the person being consulted.

Digital consulting: Near Me

Video-based consultation via the Near Me service, provides virtual access to care. Near Me allows people and those closest to them to access the care that they need remotely from a setting that suits them. Some benefits include:

• reduced need for travel (an estimated 50 million miles of travel have been saved since January 2020);
• reduced time away from work and education;
• allowing multiple family members to join consultations;
• consulting geographically remote specialists or members of the MDT; and
• reduced exposure to hhealthcare-acquired infection.

The benefits of remote consulting are particularly important in rural communities.

Case Study 4:

“We live in a remote rural area and have used Near Me in our local surgery before the coronavirus lockdown. It saves us so much time and hassle as we do not need to travel to Inverness for every appointment (80 miles and two hours each way), but still have the ‘face-to-face’ experience. Many of our appointments are mainly talking and we can see the benefits for us and also the hospital from removing the need to travel for every appointment. In addition, we would normally claim travel expenses for a hospital visit which is no longer needed, saving the NHS money. If we have to wait for an appointment when the surgery is running late, this would be much nicer to do in our home rather than in a hospital waiting room with anxiety about our return journey and our dogs sitting outside in the car park. Of course, lockdown has changed everything, and now it is also safer to have video and telephone consultations. The reduction in travel is also good for the environment and indirectly all our wellbeing. Where actual in the room appointments are not needed, this is such a good thing.”

Click here to view Dr Callum Duncan Consultant Neurologist talking about his experiences of Near Me

The Near Me Quick Start Guide for Practice Administration Staff makes it easier for Practice administration staff to offer Near Me appointments by providing step-by-step guidance when speaking to people seeking help. The Near Me system also features an option to “Consult Now”, where healthcare professionals can send a one-time URL link to a person’s phone or e-mail. This function allows both professionals and the people they care for connect instantly via video call. This allows for rapid conversion from phone to video, which can reduce the need for in-person follow-up.

Group consultations

Group consultations have gained popularity over several years. Shared medical appointments give the flexibility to deliver high-quality routine care to improve outcomes for the people we care for.

They are recognised as being effective and efficient use of clinicians’ time.^[14] More importantly, they provide a safe environment where people can gain mutual support from others as part of their self-management.^[15] People also often find it easier to complete a course of group sessions online, saving them time when they do not have to travel to attend.

Many in-person groups ceased during the pandemic and a video group solution that was safe and simple to use for both patients and clinicians was requested. In response, a Group Consulting feature was launched in November. This allows up to 30 participants to take part in a patient-friendly and secure video meeting. Current users of group video sessions include Dietetics, Clinical Psychology, and Psychiatry, and they have enabled people to remain connected with their healthcare team as well as access peer-to-peer support and shared decision making.

I’d encourage you to take a look at the resources available to support professionals to set up and run Near Me Group Consultations

Transforming access to care for people who have suffered sexual assault

Work to transform and personalise care for people who have suffered rape and sexual assault is an outstanding example of collaboration and change, driven by a shared desire to help people in an extremely vulnerable moment.

Case Study 5

In 2019, 19-year-old Katie was drugged and raped. She reported it to the police who made arrangements for her to attend a new Sexual Assault Response Coordination Service (SARCS), provided by her local health board. The SARCS staff looked after her immediate health and wellbeing needs, such as checking if she was at risk of pregnancy and testing for sexually transmitted infection. As the assault was within the previous seven days, she also had a Forensic Medical Examination (FME).

The SARCS provided a quiet and friendly healthcare environment, in contrast to the police station, which was the former location for FME in that health board area. Nonetheless, when Katie arrived, she felt scared and unsure of what was going to happen and just wanted go home to her own bed where she felt safe.

A nurse at the SARCS offered Katie a hot drink and something to eat, and sat with her while they waited for the FME to begin. This was a comfort to Katie, and helped to make her feel safer. Katie was also comforted by the support provided by the nurse during the FME, who ensured that she was always aware of what was going to happen next and why.

After the FME, Katie was offered longer-term support from a designated nurse called Barbara. Barbara coordinated Katie’s ongoing health and wellbeing support, including a referral for specialist counselling, and support to obtain a certificate to be absent from work, meaning Katie didn’t have to arrange these herself. Katie also had access to a family service, meaning her mum also got the support she needed.

Over time, Katie and her mum began to feel like they were more able to manage day to day. When Katie was contacted by Barbara after 12 weeks, she said she felt much better. She was receiving advocacy support from Rape Crisis Scotland and was due to start her counselling. Barbara reassured Katie that while she would not contact her proactively, she could get in touch with her at any time.

When reflecting on her experience recently, Katie told Barbara that the care she received during this difficult time was invaluable. She said she felt listened to and respected by the SARCS staff at a highly traumatic time in her life. The SARCS was a peaceful space and the nurse gave her time to comprehend what had happened and made her feel able to get the tests that she needed. Katie felt that she was able to speak and be heard without feeling judged.

Katie said that this support has enabled her to find the courage and strength to go forward and live a full life and that such support can help someone to survive the trauma that a rape or sexual assault can cause.

In 2017, a CMO taskforce was established by my predecessor, Dr Catherine Calderwood, to lead the improvement of Forensic Medical Examination (FME) services in Scotland to provide person-centred and trauma informed healthcare for people of all ages. A Forensic Medical Examination (FME) is a type of examination for people who have experienced rape or sexual assault and is carried out by a specially trained doctor, who may be able to collect evidence that could help the police.^[16] The taskforce has had wide representation and contribution from across health, justice, social work and the third sector.

Listening to the views of people with lived experience has been pivotal, and has helped transform the way services are delivered. The taskforce has ensured:

• no one has to go to a police station for an examination;
• sexual Assault Response Co-ordination Services (SARCS) now operate in each health board across Scotland*;
• SARCS staff are trained to provide medical, emotional and practical support to people in the days following an assault; and
• people who experience rape or sexual assault are supported and empowered to ask questions before they decide to go ahead with any aspect of care.

Understandably, some people who have experienced rape and sexual assault, may be undecided whether to talk to the police. Having the choice to self-refer for a FME is an important aspect of giving people control at a time when it has been taken away. The Forensic Medical Services (Victims of Sexual Offences) (Scotland) Act 2021, which commenced on 1 April 2022, provides people aged 16 and over the ability to access healthcare and request an FME without first having to make a police report. Any evidence collected during this examination will be securely stored within the SARCS for 26 months, giving people time to decide on whether to make a police report.

A National Strategic Network is being established under the NHS, to provide continued national leadership for the improvement of SARCS and to help ensure the highest standards of patient care.

* NHS Borders SARCS expected to be operational by Summer 2022

Preventing long-term ill health

As well as ensuring access to services people need, we must prioritise the prevention of illness and its complications including obesity and the metabolic disease associated with it. This opens up ways to prevent long-term ill health with benefits to the individual, reduces the need for healthcare, improves quality of life and helps people to continue doing what matters to them.

Case Study 6

David is a taxi driver from Edinburgh, who benefited from the “Counterweight Plus” intervention See his story here

There is also a whole system benefit in reducing the volume of complications and people requiring long term care, ultimately delivering value-based health and care – better value for the people we care for and for our health and care system. In Scotland, two in three adults are living with excess weight. This is even more marked among our least affluent communities.^[17] In addition, the number of people living with type 2 diabetes (T2DM) is increasing. The Scottish Diabetes Survey (2020), shows that 278,239 people are currently living with type 2 diabetes, a 46% increase since 2008.^[18]

It is however possible for people recently diagnosed to achieve remission through intensive weight management programmes.^[19] Remission for people with type 2 diabetes means that blood sugar levels are controlled without the need for any diabetes medication.^[20]

MDT working between clinicians, dietitians and psychology delivers an intervention: Counterweight Plus.^[21] It focuses on supporting people to achieve remission through significant weight loss. Studies have shown that this approach works, with nearly half of the study group achieving remission and for those who lost 15kg or more, up to 86% were in remission at 12 months.

In direct response to the need to support people during the pandemic, Counterweight Plus has been delivered remotely via NHS Near Me, with scales, blood glucose and blood pressure monitors given to people to use at home. This has allowed greater reach, faster access and ensured people received vital support .

Counterweight Plus Outcomes:

• 60% of patients lost >10% of their starting weight
• 40% achieved remission of Type 2 Diabetes

This is value based health and care in action. An approach guided by clinical and cost effectiveness evidence, where people access care they value and are supported to live longer, healthier lives.

Getting it right takes team work. I would encourage healthcare professionals to consider how they can work in partnership with their MDTs to deliver proactive, value-based interventions like this.

Sharing information about things that matter

Providing personalised care based on what matters most to people, is a key tenet of Realistic Medicine. This extends beyond improving care and preventing ill health through to ensuring we know and understand the wishes of those with long-term health conditions.

We must ensure our health services deliver a good quality of life for people as well as ensuring they are able to die with dignity and in comfort. We must create confidence between people and their health professionals that the right care will be provided in the right place, informed by what matters most to the people we care for. Previous Realistic Medicine reports have highlighted the related issues of inappropriate investigation and over-treatment, especially towards the end of life.^[23]

I’ve listened to people expressing frustration at having to repeat their “story” to every new professional they encounter. People expect that those charged with providing their care will share as complete a picture as possible of the person in front of them. In a health emergency that “story” may include vital information, such as a person’s wishes for care and treatment when their health deteriorates, and what really matters to them.

Emergency care and treatment decisions must be personalised to the individual patient. As healthcare professionals it is crucial we know that the care we provide is what the people in front of us would choose if able; failing to do so runs a significant risk of moral injury to those providing emergency care.

Where people have not had the opportunity to discuss and record their care preferences, or where this information is not immediately accessible to emergency care providers, there is grave risk of doing harm through distressing over-medicalisation. There is an equally grave risk of dangerous under-treatment when rapid emergency treatment decisions are made based on limited or inadequate information.^[24]

Research has repeatedly established that where people have been able to have conversations about their treatment preferences, and these have been recorded in the Key Information Summary, they have been significantly more likely to die out of hospital, at home or in a homely setting.

ReSPECT

The ReSPECT process elevates care planning to a new level. It highlights and supports an intuitive conversation as integral to the process, and its implementation goes hand-in-hand with staff development.

The digital version of the ReSPECT process presents a transformative opportunity to meet that need, with a robustly sharable record, underpinned by a truly person-centred process.

The aim of ReSPECT is to have a single, accessible, shared record for each person, produced with them, centred on what matters to them. This record can evolve as the person’s condition changes and aims to serve as a guide when an emergency does happen.

The ReSPECT process is for everyone, but will have increasing relevance for people who have complex health needs, people who are likely to be nearing the end of their lives, and people who are at risk of sudden deterioration or cardiac arrest. Some people will want to record their care and treatment preferences for reasons personal to them.

I see the future as embedding ReSPECT alongside other care planning tools to help ensure people receive the care that matters to them. They must have the opportunity to share in decisions about their care in a way that they understand and are comfortable with.

Scottish Capsule Programme (ScotCap)

Public Health restrictions during the pandemic have led to some people waiting longer to access services, including diagnostic testing. Innovation is required to help ensure people can access the tests they need, when they need them. The Scottish Capsule Programme seeks to do precisely that, and at the same time significantly reduce the number of people who need endoscopy.

The Scottish Capsule Programme (ScotCap) introduces a new technology, Colon Capsule Endoscopy (CCE), to Scotland.

CCE is a “pill” that contains two cameras, it’s swallowed and as it travels through the gut, it takes 50,000 images of the bowel lining. The capsule wirelessly transmits the pictures it takes to a data recorder, worn by the patient. In addition to this, people wear a detection “vest” which helps localise the position of the capsule as it travels through the body.

CCE offers several benefits to patients and their healthcare team:

• It is far less invasive than optical colonoscopy;
• Can be delivered closer to home; and
• Reduces stigma compared to traditional optical colonoscopy.

In rural and remote areas, e.g NHS Western Isles, the CCE service works with the “Hospital at Home Team” to deliver the procedure at home supported via Near Me, together with nursing staff from a delivery partner.

Feedback has been extremely positive. One person who recently underwent CCE said

"it's a lot easier. It's just swallowing a tablet, the prep is just the same as for a normal colonoscopy and it's a really good option if you're worried about the procedure as it's a lot less invasive. It's painless, it's not uncomfortable at all, it's easy to do and as long as you follow your prep work, it's straight forward, I'd definitely recommend it."

The ScotCap Playbook summarises key information encompassing patient information, bowel preparation, vetting and reporting procedures, data capture from every person participating in the national programme and a summary of the latest evidence base.

Conclusion

Our pandemic response has demonstrated our resilience and ingenuity – our capacity to innovate at speed. Our ability to tap into a wealth of creativity and our determination to find novel solutions to the challenges we face.

Our workforce has adapted and repurposed to confront the unique and sustained demands of COVID-19, and I want us to preserve that agility and strength in depth as we continue.

People must be supported to access the care that is right for them. Our system and indeed our national psyche is focused on care being doctor led, when there is clear evidence that other members of the Multi-Disciplinary Team are better placed to provide the care people need and value.

The work to develop SARCS demonstrates the value of truly personalised care and ensuring people have control over their care even in the most difficult circumstances.

We have a clear ambition. We want people who live or access services in Scotland to have more years in good health, and to reduce health inequalities.

We must promote innovation and adopt new and better ways of working; redesign the system around the people we care for, and what matters to them; and ultimately prioritise prevention, improve population health and reduce inequality.

Considerations

• Does your service support personalised care and ensure people can access the care they need at the right time?
• How can we modernise pathways to deliver careful and kind care in a way that eliminates harm and waste from our system?
• What can we, individually and as a profession, do to ensure people live the longest good quality life possible?