Chief Medical Officer - annual report: 2022

Improving and Innovating for a More Sustainable System

Introduction

Innovation and improvement are key to delivering value-based health and care. Medical science does not stand still nor does the world in which we practise.

Research has the power to transform and save lives, improve outcomes for the people we care for and drive a modern, innovative health and care system. From observational studies through to trials of the newest treatments and technologies across all disease areas; the opportunity for researchers, healthcare teams, patients, and the public to come together to drive advances in healthcare has never been greater. The importance of research and novel treatment has been brought into sharp focus by the pandemic.

The measures needed to keep our NHS staff safe – single-use PPE for example – have contributed to significant waste across our health and care system . We are amidst a climate emergency and as our largest employer, NHS Scotland has a key role in helping Scotland achieve net zero. We must find new ways of working and a more sustainable way of doing things.

In this chapter I highlight just some of the work of Scotland’s Chief Scientist’s Office, now in its 50th year, as well as some of the work that aims to deliver a greener, more sustainable health and care system.

COVID-19 research response

The last two years have demonstrated how vital research has been in understanding, treating and vaccinating against COVID-19. The response of Scotland’s research community was rapid, joining the world effort to combat the pandemic and save lives.

Research shows the value of national and international collaboration with health and academic partners. The remarkable efforts have enabled world-leading research into understanding the risk factors for COVID-19 (ISARIC and GENOMICC trials); therapeutics such as dexamethasone and tocilizumab (RECOVERY trial); and vitally, brought about the approval of COVID-19 vaccines which are a key part of our recovery.

Case Study 7: Genomicc

Led by the University of Edinburgh, GENOMICC is the world’s largest study of the genetics of critical COVID-19, involving more than 57,000 people. Latest research (March 2022) has identified some 16 new genetic variants associated with severe COVID-19, including some related to blood clotting, immune response, and intensity of inflammation. These findings will act as a roadmap for future efforts, opening new fields of research focused on potential new therapies and diagnostics with pinpoint accuracy.

Reaching this stage would never have been possible without the enduring professionalism, ambition, and energy of our dynamic research community. And whilst the COVID-19 pandemic has been unprecedented, it provides important lessons for the future of research.

The value of research

People are more aware of research than ever before. Almost all NHS boards in Scotland are research-active, and in the last year alone over 43,000 people in Scotland^[25] have taken part in research.

Embedding clinical research at the heart of care is vital. Benefits include:

• better health outcomes: earlier diagnosis, novel treatments and prevention of illness.
• “research-active” hospitals have lower mortality rates, not limited to research participants.
• £1 invested in medical research delivers an annual return of around 25p.^[26]

Medical research in Scotland creates jobs, income and savings for the NHS, international competitiveness, and economic growth.^[27] Scotland already has one of the largest life science clusters in Europe with over 200 medical technologies companies, 150 pharma services companies and 750 organisations, together employing over 40,000 people.^[28] With an ambition to become the fastest growing health innovation life science cluster in Europe, the role of NHS Scotland as a powerful driver of research, development and innovation cannot be overstated.

Recovery and redesign

We are at a significant moment in global healthcare. Data and analytics, cutting-edge technologies, and treatments, including precision medicine, immunotherapy, genetics and artificial intelligence, are transforming the way we treat the people we care for.

Restoring Scotland’s diverse portfolio of research across all research phases, treatment types, and conditions is vital as we recover from the COVID-19 pandemic and look to redesign and improve services. Research helps create the conditions for a modern health and social care service that is focused on providing the evidence we need to deliver value-based health and care.

Work continues to enable further trials of the most advanced healthcare treatments, diagnostics and medical technologies and bring them to people faster. Research is also being used to help understand what doesn’t work (lower-value care), so we can improve best practice and focus our precious resources on providing healthcare that people really value and will benefit from.

We are rightly proud of our history of pioneering medical innovation and must build upon this to deliver a more sustainable health and care system for the people of Scotland. Saving and Improving Lives – The Future of UK Clinical Research Delivery – sets out an ambitious vision to realise the true potential of clinical research. It builds on our proven ability to work together, across the research community, across nations and across sectors in pursuit of a common goal – to create a clinical research delivery ecosystem which will shape the future of healthcare and improve people’s lives for years to come.

I want to take this opportunity to recognise the difference Scotland’s CSO has made to our lives over the last 50 years. We are a nation living with high levels of complex disease. We must continue to invest in vital research to find treatments that can transform the lives of the people we care for, not only in Scotland but also around the world.

We must build on our achievements thus far and utilise our research environment – a single unified health system, nationwide research infrastructure, some of the best medical experts and high-quality electronic health data to innovate and improve and transform the outlook for Scotland.

A sustainable health and care system

In my last annual report I began a conversation on the need to improve the environmental impact of the way we provide care. There is an urgent need to act to address the climate emergency and loss of biodiversity. In line with the rest of society, NHS Scotland needs to accelerate efforts to cut greenhouse gas emissions and become environmentally sustainable, and Scotland’s target date for achieving net-zero emissions has now been brought forward from 2045 to 2040.

I recognise the importance of environmental sustainability and climate action to many of you and how this is integral to our work and personal lives. I share this commitment to ensuring we deliver a more sustainable way of working and living. We must find a way to better focus our adaptation and innovation to address this emergent challenge.

Many of the actions needed in response to the climate emergency and the environmental crisis have positive health impacts. Cutting emissions and restoring biodiversity improves air quality and can reduce the incidence of or improve outcomes in diseases such as asthma, heart attacks and stroke. Eliminating pharmaceutical residues from wastewater prevents harm to biodiversity and limits the growth in antimicrobial resistant bacteria.

NHS Scotland has shown throughout the COVID-19 pandemic that it can act quickly in a crisis. Now, more than ever, there needs to be a focus on ensuring our health and care services are used equitably and sustainably in order to meet the needs of the people of Scotland – as well as those of our future generations.

A new NHS sustainability strategy will be published later this year. It will set out the approach and actions which will be taken by NHS Scotland, with support from the Scottish Government and working in partnership with others, to respond to the climate emergency. Its focus is on improving the environmental sustainability of the NHS, while also recognising the role that the NHS has in relation to helping achive the UN Sustainable Development Goals relating to social and economic development.

Where and how

The way we provide care can have a major impact on both our communities and our environment, and can support our transition to a net-zero health service. By transforming where and how we deliver services, we can empower people to have more control over their health and wellbeing and deliver care which is environmentally sustainable, which increases our contribution to supporting good health and helps to reduce health inequalities.

Our NHS should act for the benefit of the local communities we serve and recognise that we can positively contribute to local areas in many ways beyond providing healthcare. As anchor organisations, NHS bodies have an unrivalled opportunity to model the sustainability goals around fair employment, gender equality and sustainable communities.

Our approaches should make a difference to local people including staff. By working in partnership with our local communities, we can design and use our buildings and spaces for social benefit. This includes providing access to better, greener outdoor space, and opportunities for recreation and physical activity, as well as reducing environmental impact.

NHS Scotland has already made significant progress in creating a sustainable health service but more needs to be done. We need to build on the good work that’s underway, and make sure sustainability becomes everyone’s responsibility.

Case Study 8: NHS Greater Glasgow and Clyde

NHS GGC has invested in excess of £1million for a variety of greenspace and biodiversity projects to improve people’s care experience and staff wellbeing. The Board recognises that our experiences over the last two years mean that this has never been more important. The Board’s approach involves close collaboration with key partners:

• NHS GGC have signed up to the Sustainable Glasgow Green Economy Hub Charter. A commitment by leading employers in Glasgow to take action within their own organisations and sectors to contribute to a green recovery and radically reduce the city’s carbon emissions.
• Climate-Ready Clyde: a cross-sector initiative funded by 15 member organisations and supported by the Scottish Government to create a shared vision, strategy and action plan for an adapting Glasgow City Region.
• Glasgow Caledonian University’s School of Built Environment for undergraduate and postgraduate development in technical areas of expertise required to meet this challenge.
• Clinical institutions: working with clinical colleagues to embrace change, given they are the biggest users of resources and producers of waste.
• National Agencies: working with regulatory bodies.

Glasgow’s approach is delivering more sustainable buildings and greener environment. The £71 million North East Hub will be NHS GGC’s first net zero building for heating and power through a range of measures including the use of air source heat pumps and electricity generated by solar panels. The Hub has a courtyard designed to make better use of green space to support wellbeing.

Clydebank Health And Care Centre, which is nearing completion, has also been designed to utilise the district heating system using heat from the River Clyde harnessed by water-source heat-pumps.

Sustainable care

Achieving Scotland's climate goals and Realistic Medicine fit naturally together. To become a sustainable and greener healthcare provider, we must deliver safe, effective, personalised care, and reduce harm and waste through improvement and innovation. Realistic Medicine promotes a culture of stewardship of finite NHS resources, where we take responsibility, individually and collectively, to use our healthcare resources wisely.

Healthcare professionals are the stewards of the resources we use in the care we provide. The NHS in the UK has experienced growth in demand^[29] for healthcare services of around 4.5% per annum and almost two thirds of it is generated by increases in the volume of activity, or innovation.^[30]

If we wish to see a more sustainable health and care system, we must focus our efforts on reducing the waste and potential harm caused by both under treatment and over investigation.

Value-based health and care

Realistic Medicine asks us to respond to the twin threats of harm and waste by focusing on the concept of value. When there is only enough resource to make interventions available to a few people, those interventions are offered to people who have most to gain and who are more willing to accept the risk of potential harm – in these circumstances, we are delivering high-value healthcare. However, as investment and resources increase, interventions are offered to people who are less severely affected, so the maximum benefit that this person can expect is less but the probability and magnitude of harm remains the same. By being mindful of the dangers of going beyond the “point of optimality” – we can maintain the best balance of benefit to harm to the people we are for.

Value-based health and care can help relieve some of the pressures we are experiencing across health and care. It presents us with an incredible opportunity to provide more equitable, better-value care for the people we care for and for our system.

Let me be clear: value-based health and care is not primarily about saving money, or delivering efficiencies. It’s about us, working with the people we care for, to consider whether a treatment or an investigation is going to be of value to them. By discussing the evidence, the risk and the benefits of available test and treatment options, we will be able to optimise the use of our precious healthcare resources and reduce harm and waste. In doing so we can relieve some of the workload pressures we are experiencing day in, day out, make better use of the resources at our disposal, increase job satisfaction and provide care that people, and those closest to them, really value.

As we remobilise and reform services, we must build towards a more sustainable health and care system that delivers the better value care we are looking for.

Conclusion

Scotland has been at the forefront of medical research for five decades and this innovation has brought about real benefits every day for us, our colleagues and the people we care for. We must innovate to deliver value based health and care for the future. Failure to protect the environment around us has direct consequences but also longer-term risks changing patterns of disease and our ability to treat it.

This year’s World Health day was titled ‘Our Planet: Our Health’, noting that “an environmentally sustainable health system would improve, maintain or restore health, while minimising negative impacts on the environment and leveraging opportunities to restore and improve it, to the benefit of the health and well-being of current and future generations.”^[31]

Like many of you, I wish to see a sustainable innovative health and care system in Scotland that secures our future and that of our future generations.

Considerations

• How can you improve and innovate to help deliver a more sustainable system?
• How can you make better use of evidence and research to deliver better-value care?
• Can you change the environmental impact of your work, and better still, improve staff wellbeing?