A National Clinical Strategy for Scotland

1. Executive Summary

1. This Strategy sets out a framework for the development of health services across Scotland for the next 15 years. It does not give prescriptive details of exactly what developments are required - it is designed to give an evidence-based, high-level perspective of why change is needed and what direction that change should take. It is intended that the National Clinical Strategy will provide a unifying direction to the range of service reviews currently underway, so that the complex whole that is healthcare across the country can progress to a coherent, comprehensive and sustainable high quality service. The Strategy also provides an outline of how the NHS in Scotland will change - describing change that will be required to help the service adapt to changing circumstances.

2. The National Health Service in Scotland is a success story. It provides comprehensive and universal healthcare, free at the point of need. It has successfully made progress against many of the challenges to our nation's health and healthcare. This is evidenced by steady falls in mortality from the "Big Three" - cancer, heart disease and stroke - and life expectancy is steadily increasing. More treatment is provided each year, and waiting times have shown significant improvement over the last 10 years despite increases in demand and activity.

3. The health of the population of Scotland is poorer than in many other European countries, but will continue to improve with national initiatives to support healthier lifestyle choices, to support mental wellbeing, as well as addressing socio-economic, educational, employment and environmental issues that contribute to poor health. While these initiatives will remain crucial to improving the health of the population, the National Clinical Strategy is confined to the delivery of healthcare services to meet assessed needs. This is not to suggest that such initiatives to improve the health of the population are not important - they are essential, and must be progressed with determination.

4. Despite the success of the National Health Service in Scotland, there are challenges that need to be addressed if we are to meet our aim of providing a world-class health service for the future. We know that the fact that we all, on average, tend to live longer will result in an increasing number of older people. While many older people will enjoy better health than their predecessors did at an equivalent age, they will still have significant health needs, and the overall impact will be a steadily increasing demand for health (and social) care. Much of this need will relate to long-term conditions - such as diabetes, hypertension, cancer, sensory impairment, dementia and impairment of mobility. It is clear that for the next 15-20 years, demand for health and care services will increase.

5. We continue to have an unacceptable degree of health inequality across Scotland, which can mean that a person who is amongst the most disadvantaged section of our society can expect to live at least 10 years less than those in the least disadvantaged. This inequality is multifactorial. The solutions do not lie solely with(in) healthcare but evidence indicates that effective healthcare services, particularly in primary and community care, can significantly reduce the impact of these inequalities.

6. We also know that the NHS in Scotland is at present challenged by a number of factors. We have one of the most skilled workforces in the world, and a proud tradition of education and training. Overall the numbers of doctors, dentists and nurses have increased, but we know that in many specialties there are challenges in employing the numbers of highly skilled staff required to deliver sustainable healthcare services. We know that many of the current experienced staff in the service will retire in the next 10 years. While we anticipate that the biggest challenge will be in medical staff in general practice, and in hospital doctors, we know that there are also pressures in a range of other professions. We rely on a range of highly skilled staff that are crucial to the sustainable delivery of health services. We will face challenges to replace these experienced people, particularly because of the time that it can take to train experts - and we recognise that the increased demand from an older population will require more staff and/or innovative technological solutions.

7. As a result of the financial challenges being faced around the world, there will be constraints on what can be achieved with anticipated future resources. World comparisons show that increasing expenditure on health services does not always bring about proportionate improvements in health: more and more resource input may lead to more and more marginal improvements in health. This strategy proposes that a continuous drive to deliver services of the highest quality and value is a more important and appropriate way of managing resources than an isolated focus on finance.

8. There are concerns shared across developed countries that modern medicine, while providing enormous benefit to populations, can also cause harm to individuals. There is also concern that on occasion medical practice can result in overdiagnosis, overtreatment and waste. We know that this overtreatment probably co-exists with undertreatment. If we are to continue to provide our world-class health service we must find a way of addressing these issues. While the commitment to year on year increases in investment is important, this strategy sets out the need for a new clinical paradigm that will ensure that healthcare delivery is proportionate and relevant to individual patient's needs and uses minimally disruptive interventions (including lifestyle changes) wherever possible. In other words the emphasis is on maximising patient value from the available resources.

9. The strategy describes the rationale for an increased diversion of resources to primary and community care. Stronger primary care across Scotland should and will be delivered by increasingly multidisciplinary teams, with stronger integration (and where possible, co-location) with local authority (social) services, as well as independent and third sector providers. The aim of an expanded health and social care team will be to provide all current services, but also to:

i) support self-management and independence for everyone by supporting patients to fully understand and manage their problems, promoting a focus on prevention, rehabilitation and independence

ii) to provide care that is person centred rather than condition focussed, based on long-term relationships between patients and the relevant clinical team(s)

iii) understand that the problems of multiple long-term conditions and the resulting loss of independence result in complex needs - many of which are best addressed by social interventions. We must not provide an overall system that defaults to medical solutions (such as admission to hospital) when the needs are predominantly social

iv) provide evidence-based interventions that reduce the risk of admission to hospital, especially for the elderly

v) provide more community-based services to replace some that have previously been provided in hospital

vi) provide sensitive end of life care in the setting that the patient wishes.

10. There are a range of changes that will support transformation of primary/community care, such as the move to integrated health and social care from April 2016, and the new GP contract in April 2017. We will build a greater capacity in primary care, centred around practices, by enhancing the recruitment of doctors to general practice, by increasing the adaptation of technological solutions to increase access and improve decision making, and by developing newer, extended, professional roles within primary care, such as Advanced Nurse Practitioners, Pharmacists and Allied Health Professionals. This will provide the range of skills needed to meet the changing and complex needs of communities. With the advent of integration, and closer working between social work staff and healthcare staff, there will be effective and proportionate responses to health and social care needs. The planning and organisation of care delivery for individuals and communities will be based around practices, with GPs increasingly taking on a role in dealing with complex cases, and providing expert assessments of new cases. Transformation of the outdated and complex dental system will meet the needs of younger people (who need to maintain a preventive focus) whilst ensuring that the treatment needs of the older population are met. An eDental programme will improve the assurance, governance, efficiency and information on quality of services. We will consider the mix of secondary/primary care dental provision to ensure the most appropriate use can be made of each.

11. The emphasis on primary care supports the ambition of the Scottish Government's "2020 vision" to provide the majority of care locally and to ensure "We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management." There is evidence from around the world that systems with a strong primary care service tend to produce better overall outcomes for people, a better experience of managing with illness and disability, and a lower and more proportionate use of resources. The potential of prevention is seen, for example, by developments from the extended vaccination programme now being provided by primary care, with, for example, dramatic reductions in gastroenteritis amongst children following immunisations against rotavirus. Primary care will be supported by evolving IT solutions to improve efficiency and safety of the care delivered, as well as enhancing patient access to services and participation in their own care.

12. This strategy also describes a number of changes that need to take place in secondary care settings. The first set of changes revolve around processes. Acute hospital care can be highly complex and involves multiple processes. Despite considerable recent focus on processes within hospitals, we know there is still much that can be done to ensure that we use available resources as effectively as possible, and improve outcomes for patients. The two aims are not mutually exclusive. Across health and social care for example, we need to ensure that patients experience timely discharge without delay, supported when they return to their communities by responsive health and care services. We know that this helps promote a prompt return to previous levels of independence. As another example, we intend to reduce the number of times patients are recalled to review outpatient appointments where this can be avoided. We can provide better alternative arrangements, using modern technology to best effect, that will provide people with faster access to results, see them more rapidly when they are unwell, and disrupt their lives less.

13. The other changes needed are in relation to the structures within secondary care. There is now an overwhelming amount of evidence that suggests that some complex, and many less complex, operations are best performed in more specialist settings. There is increasing evidence that teams more specialised in doing complex operations frequently get better outcomes for patients, who tend to have fewer side effects, and typically spend less time in hospital. This strategy sets out the evidence that some services should be planned at a national, regional or local level on a population rather than geographical boundary basis. This would mean that, for some services, there would be fewer specialist inpatient units within a region. However, in order to ensure that services are provided as locally as possible (where clinically appropriate) the strategy proposes that most services would continue to deliver outpatient, diagnostic and day-case surgery at most hospitals, as at present. By developing networks of hospital services it will be possible to deliver first class outcomes from more specialist centres/services where evidence supports interventions concentrated in such a way. However, within a specific specialty, not all interventions are complex, therefore by developing a planned delivery network, local access to all other services within that specialty would be maintained. These changes will be complex, but they are based on evidence of benefit and have considerable potential to improve outcomes for patients while at the same time maximising resources and clinical skills. The commitment to an investment of £200 million for elective diagnostic and treatment centres will support the changes in capacity that will be required as a result of an increase in surgical procedures - especially those that are significantly age-related (such as cataract extraction, and knee and hip replacements).

14. It is essential to take forward planning and delivery locally, regionally and nationally. As noted above, planning in this way is not new but how this is achieved will need to change to meet future needs. Planning and delivery with geographical and/or other boundaries will no longer deliver what is needed; planning and delivering services for and across populations, regardless of locality, is key. We must increase the collaborative working that is the hallmark of the NHS in Scotland. It will also be necessary to adopt a performance management framework that supports service planning at the most appropriate level.

15. The strategy describes the advances that can be made by harnessing technology - with particular emphasis on digital technology, both for clinicians and patients. It has enormous potential to provide training and clinical decision support, to support standardisation of processes where they should be standardised, and to improve safety and self-management. It has the potential to address some of the barriers to access inherent in living in a remote community, by enabling specialist input to augment local care via teleconsultations.

16. The NHS will increasingly become an organisation that is driven by information. Currently a great deal of data is generated, and use is made of it to support service improvement and performance management. However as we become more able to draw conclusions from "big data", we should be able to:

• make more informed decisions and provide better coordinated and more personalised care
• predict risk for individuals and thus focus interventions more effectively/proactively
• collect and use more information on outcomes, especially those that matter most to patients, rather than clinical data such as biochemical or other surrogate markers
• assess outcomes from medications, and multiple medications, in different patient groups, thus developing greater understanding of complex polypharmacy
• understand degrees of variation in interventions across regions so that any inappropriate clinician driven variation is minimised
• predict future needs more accurately
• continue to drive continuous service improvement.

17. Acknowledging that the quality of services is related to the quality of our workforce, the strategy describes the development of increasingly skilled staff, working effectively in multidisciplinary and multi-organisational settings to deliver excellence in care.

18. The strategy ends with discussion about a new clinical paradigm. This will be a longer-term cultural and clinical change programme that will need strong national clinical leadership. At its heart will be a desire to provide proportionate and realistic care to fully informed patients, who are encouraged to understand options and choose treatment according to their preferences. It will support an approach that uses lifestyle modification first before more significant intervention. It will support self-management where appropriate, and encourage empathetic resilience building rather than dependency. This clinical paradigm will identify interventions that are of limited value or may cause harm, and reduce their use. It will address waste and variation in clinical practice. We know that patients when fully informed tend to choose less interventional healthcare. As is the case at present, we have a duty to ensure that everyone is provided with enough information to equip them to become confident partners in decision making. Technology will play a key role in realising this change.

19. Over the next 10-15 years there will be scientific advances which have not been anticipated at present, and these will change the way that we deliver healthcare. There will also be advances that are beginning to make an impact now. The most obvious example of this is the increasing understanding of genomics and its potential. Already we have developments that mean drug treatment can be tailored to individuals - so that fewer patients may need treatment. It is hoped that genomics will, in the foreseeable future, help stratify patients into low and high risk, thereby reducing treatment for some patients and focusing it more effectively for others. This may help some of the challenges created by high-cost but effective medications - we may be able to use them more wisely, with greater certainty of benefit.

20. In summary, the clinical strategy sets out the case for:

• planning and delivery of primary care services around individuals and their communities
• planning hospital networks at a national, regional, or local level based on a population paradigm
• providing high value, proportionate, effective and sustainable healthcare
• transformational change supported by investment in e-health and technological advances.