NHS Scotland Chief Executive's Annual Report 2017/18

Chapter 2 - Improving Quality of Care

‘… there needs to be compassionate collaboration and equal partnerships between the people who are accessing services and supports, their families and carers, and those delivering those services.’

You will see in this chapter how measures taken across a wide range of areas are having a positive impact on the care people receive and the outcomes they experience. Key to this are our Quality Ambitions which continue to guide our approach to improving the quality of care.

Our Quality Ambitions

Through our Healthcare Quality Strategy for Scotland^[28], we have set ourselves three clearly articulated and widely accepted Quality Ambitions based on what people have told us they want from their NHS: care which is person-centred, safe and effective.

Person-centred – mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

Safe – there will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Effective – the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit and wasteful or harmful variation will be eradicated.

Person-centred Care

The person-centred approach extends across health and social care, enabling people to live well, with the right care and support, in communities across Scotland. For care and support to be reliably person-centred, there needs to be compassionate collaboration and equal partnerships between the people who are accessing services and supports, their families and carers, and those delivering those services. It also requires a person-centred system that has the same fundamental principles of compassion, collaboration and partnership at the heart of organisational culture.

What Matters To You?

Scotland continues to be at the forefront of a growing international movement working to improve health and social care by gaining a better understanding of what really matters to people receiving care or support. Almost 700 individuals and teams from across Scotland joined colleagues from around the globe on 6 June 2017 to take part in Scotland’s ‘What Matters To You?’ Day. Members of the ‘What Matters To You?’ working group visited teams working in a wide range of settings across Scotland, including mental health units, acute wards and community services, to observe and take part in local activities. They built on what they learned to plan ‘What Matters To You?’ Day 2018, which included visits by Scottish Ministers to see how staff are ‘asking what matters, listening to what matters, doing what matters’ in settings including a specialist dementia unit and the A&E Department at the Royal Infirmary of Edinburgh.

The ‘What Matters To You?’ approach supports staff to focus on what’s important to the people they are caring for and supporting. It is based on the principle that, by talking to people about what’s important to them, listening deeply to the answers and taking action on what we hear, we can provide the care and support that people really need and want. In line with the principles of Realistic Medicine, the ambition is that conversations about what matters become a core part of how health and social care services are delivered across Scotland, every day.

Person-centred Visiting

Creating the conditions for person-centred care also involves paying attention to the question, ‘Who Matters To You?’. There is a growing recognition across the NHS of how important it is to develop a family-friendly culture that encourages and supports people to remain connected with family and loved ones while they are in hospital.

In August 2017, NHS Grampian launched its ‘Welcoming Ward’ initiative. This person-centred approach to hospital visiting recognises the important role that families, carers and friends can have in a person’s recovery. Across NHS Grampian, family, friends and carers are welcome to visit the ward as much as their family member

or friend would like, to participate in care planning and delivery, and to share their knowledge and experience with staff. NHS Lanarkshire has also adopted a person-centred visiting policy across its acute hospitals, while the new Dumfries and Galloway Royal Infirmary opened in December 2017 with fully flexible visiting.

The Scottish Government is supporting this growing movement in the NHS with a commitment in the Programme for Government 2018/19 to have flexible visiting in place across NHS Scotland by 2020, so that anyone can be with the important people in their lives while in hospital.

Volunteering

It is not only family, friends and loved ones who complement the work of care teams to support people while they are in hospital. Every day across Scotland, volunteers in health settings give their time and energy to help make a difference to the lives of people receiving care. It is estimated that there are around 6,500 directly engaged volunteers in NHS Scotland at any given time.

In September 2017, the national intermediary and network for voluntary health organisations in Scotland, Voluntary Health Scotland, hosted a conference, ‘Volunteering: the Golden Thread in Health’. The conference brought delegates together to discuss volunteering by third sector organisations in NHS settings, and to explore how the NHS, the third sector and other health and social care partners can collaborate to maximise the benefits of volunteering for people receiving care, for NHS staff, and for volunteers themselves.

NHS Inform

The provision of good-quality information about health and healthcare services remained an important theme in 2017/18. NHS Inform, Scotland’s national health information website, has seen its monthly user numbers rise from 40,000 when it re-launched in 2016 to nearly 1.9 million by March 2018^[29]. The website – which provides quality-assured information to support Scotland’s citizens to self-manage their own health and care, or for someone they care for – continues to increase its self-management content, which now includes a range of interactive self-help guides plus a new nation-wide directory of local health and care support services. Phase One of the directory is focused on developing an up-to-date database of quality-assured services in the following NHS Board areas: Greater Glasgow and Clyde, Lanarkshire, Ayrshire and Arran, Grampian and Shetland.

A range of new content was developed across the site in 2017/18, including campaigns on a wide range of topics from Baby Boxes to the ‘Take it Right Outside’ campaign, along with interactive tools such as the Falls Telecare Assessment Tool and Smoking Cessation Quit Plan. Plans for the coming year include work to make British Sign Language (BSL) content available where possible, and to make mental health-related content available across NHS Inform and the Breathing Space site.

InS:PIRE

InS:PIRE (Intensive Care Syndrome: Promoting Independence and Return to Employment) is a five-week programme for people who have been discharged from intensive care units, aimed at helping them recover and return to work. Each week, participants in the programme who have been discharged recently from Intensive Care Units (ICU) receive support from healthcare professionals to help accelerate their recovery. During the five-week programme, participants create their own personal goals, and are given a ‘social prescription’ that is facilitated by third sector organisations which provide sources of support in their community. Along with their families and carers, they also receive psychological support to build their coping skills.

First trialled at Glasgow Royal Infirmary in 2014, InS:PIRE was tested further during 2017/18 by NHS Lanarkshire at Wishaw General and Monklands General Hospitals, at the Golden Jubilee National Hospital, by NHS Fife at Victoria Hospital, and by NHS Ayrshire & Arran at Crosshouse Hospital. This ‘scaling-up’ work has demonstrated that the model can be reproduced in different settings, and the learning from the process offers insights for other integrated teams attempting innovation to address complex problems.

Driving Change Through Third Sector Partnerships

Our third sector partners continued to work with us to drive change and improvement at national and local level in 2017/18.

The House of Care^[30] approach supports and enables people with long term conditions to articulate their needs and decide on their own priorities through a process of joint decision-making, goal-setting and action-planning known as Care and Support Planning. In 2017/18, the Health and Social Care Alliance Scotland (the ALLIANCE) continued to work with Year of Care Partnerships, the British Heart Foundation, the Royal College of General Practitioners (Scotland), NHS Boards, the Scottish Government and other partners to support the development of this approach in General Practice across Scotland. Over the course of the year, 32 GP practices have implemented care and support planning using the House of Care approach.

The ALLIANCE is funded by the Scottish Government to deliver A Local Information System for Scotland (ALISS). This web-based resource continues to map community assets and to connect people with local sources of support that will enable them to manage their own health conditions more effectively.

ALISS was co-produced by working with disabled people, people living with long term conditions, unpaid carers, health and social care professionals and technology professionals. In 2017/18, the ALLIANCE developed a new version of the website to make it easier to keep information content up-to-date and to improve the relevance and accuracy of searches. In 2017/18, the number of users who accessed ALISS totalled 164,851 and 3,777 services were added to the system^[31].

Individuals and community organisations championing self management – an approach that supports and encourages people with long term conditions to be in the driving seat of their care and to live well, and on their own terms, with whatever condition they have – were celebrated at the 2017 Self Management Awards, which took place at the Scottish Parliament in October 2017.

The ALLIANCE administers the £2 million per year Self Management Fund for Scotland on behalf of the Scottish Government. This fund, which was established as a key recommendation of “Gaun Yersel”: The Self Management Strategy for Long Term Conditions in Scotland,^[32] provides an opportunity for community and voluntary organisations and partnerships to develop and strengthen new ideas, as well as existing approaches, to self management. To date, the Fund has supported over 240 projects across Scotland.

Improving Health Literacy

The case for action to improve health literacy has been made in Making it Easy: a Health Literacy Action Plan for Scotland.^[33]The plan, published in 2014, set out our ambition, and the means, for Scotland to be a health literate society that enables all of us to have the confidence, knowledge, understanding and skills to maintain good health.

In November 2017, Making it Easier^[34] was published to international acclaim. This builds on what has been learned so far about health literacy and sets out actions to share the learning from Making it Easy across Scotland, embed ways to improve health literacy in policy and practice, develop more health literacy responsive organisations and communities, and design supports and services to better meet people’s health literacy levels.

Welcoming Feedback and Using it for Improvement

The Patient Rights (Scotland) Act 2011^[35] introduced the right for people to give feedback, make comments, raise concerns and make complaints about the services they receive from NHS Scotland, and it places a duty on the NHS to actively encourage, monitor, take action and share learning from the views it receives.

Care Opinion

The Scottish Government continues to support NHS Scotland to engage with the independent website Care Opinion^[36], which provides an online route for people to share their experiences of care – whether good or bad – directly with those providing NHS services, and to engage in constructive dialogue with them about how those services could be improved. With over 12,000 stories now posted about people’s experience of care in Scotland, Care Opinion has become a valuable source of information about what really matters to people about health and social care services across Scotland, what they think works well and what could be better. By listening to the stories, staff at all levels can take action to provide the care and support people really want.

There were 3,200 stories shared about health and social care services in Scotland during 2017/18 and these have been viewed more than 1.7 million times. Over 67 per cent of the stories were considered positive and 66 have led to changes to services being made or planned. There are currently over 1,200 staff at NHS Boards in Scotland reading and responding to stories, and 10 of Scotland’s NHS Boards fall within the top 15 organisations across the UK with the highest numbers of staff listening.^[37]

Scotland is the first country in the world to have such a system in place at national level and is attracting international interest as a result of this bold and innovative approach.

The NHS Scotland Model Complaints Handling Procedure

The new NHS Complaints Handling Procedure (CHP) was introduced across Scotland from 1 April 2017. The revised procedure is intended to support a more consistently person-centred approach to complaints-handling across NHS Scotland. It brings a much sharper focus to the early, local resolution of complaints, wherever that is appropriate, and brings the NHS into line with other public service sectors by introducing a distinct, five working-day stage for early, local resolution, ahead of the 20 working-day stage for complaint investigations. Where people remain dissatisfied with the way their complaint has been handled, they have recourse to the Scottish Public Services Ombudsman.

The CHP reflects the broader ambition for the NHS in Scotland to be an open, learning organisation that listens to and acts on feedback, including when unintended harm is caused. The procedure complements the Duty of Candour Procedure (Scotland) Regulations 2018^[38], which came into force on 1 April 2018. It is also complemented by the Apologies (Scotland) Act 2016^[39], which is intended to encourage apologies to be made, by making it clear that apologising is not the same as admitting liability.

It is important to make people more aware of their right to complain, so information about how to make a complaint is widely publicised and made available in all areas of service provision as well as online. NHS bodies are required to take into account the needs of those who, for example, may be deaf or hard of hearing, visually impaired, have a learning disability, or be a non-English speaker. Where appropriate, suitable arrangements are made for the specific needs of anyone who wishes to complain, including the provision of interpreting services and information in a variety of formats and languages, made available at suitable venues and at suitable times.

The Patient Rights (Scotland) Act 2011 provided for the establishment of the Patient Advice and Support Service (PASS), which is jointly-funded by the Scottish Government and NHS Boards. The primary objective of the PASS service, delivered by Citizens Advice Scotland, is to raise awareness and understanding of patients’ rights and responsibilities and to provide free, confidential, impartial and independent advice and support to patients, carers and anyone else wishing to provide feedback, make comments, raise concerns, or make complaints about NHS services in Scotland. It also signposts people to other information, services and support, such as alternative dispute resolution services (mediation) and independent advocacy. In 2017/18, the PASS service assisted over 3,000 clients and dealt with just under 8,000 enquiries^[40].

In accordance with The Patient Rights (Feedback, Comments, Concerns and Complaints) (Scotland) Directions 2017^[41], NHS bodies are required to publish annual reports showing where lessons have been learned and describing actions taken to improve services as a direct result of feedback, comments, concerns and complaints. The 2017/18 Feedback and Complaints reports covering the first year of the new CHP in operation are published by NHS Boards on their websites. Early indications are that there is a positive increase in the volume of complaints being handled at the early resolution stage. Further work will be undertaken in the autumn to analyse these reports and evaluate the full impact of the new procedure. NHS Complaints national statistics with links to each NHS Board’s annual report will be published on the ISD website by late 2018.

Satisfaction with NHS Scotland

Satisfaction with NHS Scotland amongst people who use its services is high. Our care experience surveys tell us about the quality of health and social care services from the perspective of those using them.

The Inpatient Experience Survey^[42] asks people about their experience of a recent overnight hospital stay. Results published in August 2018 show that people are continuing to experience high levels of care during their stay in hospital, in particular their experiences with hospital staff. Eighty-six per cent of people rated their full inpatient experience between 7 and 10 on a scale of 0 to 10, where 0 is ‘very poor’ and 10 is ‘very good’. Thirty-six per cent said that their overall care was ‘10 out of 10’.

The 2017/18 Health and Care Experience Survey^[43] asks about people’s experiences of: accessing and using their GP practice and other local healthcare services; receiving care, support and help with everyday living; and caring responsibilities. It found that the majority of GP patients and social care users report a positive experience of their care, with 83 per cent of people rating the overall care provided by their GP practice positively. However, an overarching finding was that respondents were slightly less positive than in previous surveys, in particular about accessing GP services and support for carers.

The Maternity Care Survey^[44] asks women about their recent experience of maternity care services. This survey has recently been conducted for the third time, with results due to be published early in 2019. The results of this survey will be a vital piece of evidence to support the evaluation of the Scottish Government’s Best^[45] Start policy on maternity and neonatal services in Scotland. The latest published results, from the 2015 survey, showed a positive picture of women’s experiences of maternity care services, with over 90 per cent of women rating the overall care they received during pregnancy, labour and birth, and at home following the birth, positively.

The Scottish Cancer Patient Experience Survey^[46] asks individuals about their experience of cancer care from diagnosis through to support after treatment. This survey was first run in 2015 and found that 94 per cent of individuals rated their cancer care positively. The results also highlighted some areas of care which required improvement, particularly around helping individuals to access support for their wider emotional, financial and practical needs. Planning for the second iteration of this survey is ongoing, with results to be published in April 2019. Results for this survey will inform a range of actions being taken forward under the Scottish Government’s cancer strategy, Beating Cancer: Ambition and Action^[47], which is supported by investment of £100 million. They will also be used by Macmillan Cancer Support who will work with their local networks to highlight where things are working well and identify areas for service improvement.

The Our Voice Citizens’ Panel

The Our Voice Citizens’ Panel^[48], which is made up of around 1,200 members of the public, is one of the ways in which organisations with an interest in the delivery of a healthier Scotland can gather demographically representative views of the Scottish public to inform their work.

In 2017/18, the Panel offered insight into a range of topics, including the use of digital technology for healthcare improvement, loneliness and isolation, access to medical professionals other than the GP, and shared decision-making. The results have fed into policy-making on a range of levels, including informing the development of the new digital health and care strategy Scotland’s Digital Health and Care Strategy: Enabling, Connecting and Empowering^[49].

Ensuring People Have a Voice

The Scottish Government recognises that being able to communicate and having freedom of expression is a basic human right – one which is essential to our physical and mental health and our social wellbeing. This is why legislation was introduced to place a duty on NHS Boards to provide communication equipment and the support to use it – often referred to as Augmentative and Alternative Communication (AAC) – free of charge^[50]. This duty relates to people of all ages and from all care groups who cannot speak or who have difficulty speaking.

Throughout 2017/18, the Scottish Government engaged with a network of AAC lead officers across NHS Boards to understand the implementation progress. This network has a key role within a multi-agency AAC National Advisory Group because they bring local knowledge and influence, as well as specialist expertise, to this work.

The legislation is one part of a wider programme of work that is developing guidance on the vision, the principles and future pathways as well as the definition of AAC. All stakeholders are also being encouraged to innovate and share good practice. In the coming year, work will continue with partners to support the ongoing delivery of the duty and to improve AAC provision where needed.

Duty of Candour

The Duty of Candour (Scotland) Regulations 2018^[51] came into force on 1 April 2018. The legislation places a statutory duty on organisations that provide health, care and social work services to be open and honest when an unintended or unexpected incident occurs that results in death or harm. The introduction of the Duty of Candour Procedure provisions in the 2016 Act reflects the Scottish Government’s commitment to place people at the heart of health and social care services in Scotland. The Regulations implement the provisions in the Act.

Health and Social Care Standards

There is an important relationship between health and social care. These two areas must work together in order to improve people’s outcomes and provide person-centred care. The Health and Social Care Standards^[52] were published in June 2017 and introduced on 1 April 2018. The Standards are underpinned by five principles:

• Dignity and respect;
• Compassion;
• Be included;
• Responsive care and support; and
• Wellbeing.

They aim to provide better health and social care outcomes for everyone and to ensure that our basic entitlement to human rights are met.

Importantly, the Standards are applicable across the whole of health and social care. They are relevant to those involved in care delivery and to those responsible for the planning and commissioning of health, care and social work services. The Care Inspectorate and Healthcare Improvement Scotland are incorporating the Standards into their inspection and quality assurance activities.

Over the course of 2017/18, the Scottish Government, along with these and other key partners, has collaborated to ensure that the Standards are promoted, understood and implemented across health and social care. The implementation of the Standards will help show a commitment to the delivery of person-centred, flexible care and support that meets people’s needs.

Supporting People in their Caring Role

There are an estimated 788,000 unpaid carers in Scotland, including 44,000 under 18 years of age^[53]. Carers UK estimates that carers save the Scottish economy £10.8 billion per year^[54].

During 2017/18, the Scottish Government worked with people and organisations across Scotland to prepare for implementation of the Carers (Scotland) Act 2016, which took effect on 1 April 2018^[55]. The Act puts in place a system of carers’ rights which is designed to improve the consistency of support for individuals and protect carers’ health and wellbeing. This will help sustain caring relationships and provide support that is reflective of individuals’ wishes. Key actions included development of:

• A Carers’ Charter, summarising carers’ rights under the Carers Act^[56];
• Regulations and statutory guidance for public bodies with duties under the Act, with input from them as well as from carers and carer organisations^[57]; and
• Information to help carers understand their rights for support. This resource is co-produced with carers by carer organisations and Young Scot.

The Young Carers Festival in August 2017 gave young carers a break and the chance to have their say. Decision-makers heard their views on local and national policy developments which affect them. A Carers Act guidance co-production workshop was also held in August. The workshop helped ensure the statutory guidance reflects the views of carers and organisations working to support them. This also included the views of Local Authorities, NHS Boards and Health and Social Care Partnerships with duties under the Carers Act.

Carers make up a large and valued part of Scotland’s workforce. For this reason, the Scottish Government continues to promote the Carer Positive^[58] scheme with Carers Scotland. The scheme encourages employers in Scotland to understand the business case for supporting carers in the workplace – helping to retain experienced staff and improve productivity through flexible employment policies. In March 2018, Young Scot became the 100^th Carer Positive employer.

Social Care that Works for You

Scotland is moving towards social care shaped around what matters to the supported person and their family. This is called Self-directed Support^[59] and is based on the understanding that having greater control of your life and decision-making leads to improved health and wellbeing. Self-directed Support should include a discussion and agreement around the personal outcomes that will be the focus of the social care work. Where someone is eligible for social care, they can make decisions about how much control they want over their support.

The Scottish Government reviewed the support that was available to people who are exploring choices about their social care^[60]. The findings from this review will help to inform decisions about future funding of such projects. It found supported people were very positive about the quality of support received from the voluntary sector funded by the Scottish Government. This fund is called Support in the Right Direction^[61]. Eight out of ten respondents said it had made a substantial difference. They said that self-directed support had a positive impact on health and wellbeing. Lastly, the review found that supported people felt a positive outcome was probably only achieved because of the support received. Because of the results of this review, the Scottish Government will provide a further three years of funding for Support in the Right Direction projects to 2021.

Social Work Scotland carried out a study in 2017 into best practice and Local Authority progress in Self-directed Support, on behalf of the Scottish Government^[62]. The study found a positive shift to personal outcomes and relationship-based work. This change has been achieved through investment in training. Local Authorities are taking steps to personalise care and to increase individuals’ choice and control. However, the research acknowledges that Self-directed Support represents a significant leadership challenge both in Local Authorities and in communities, and requires further investment in workforce training. In areas of strong leadership and collaboration across services and functions, far swifter progress in implementation has been possible. The Scottish Government has provided a further £3.52 million to Local Authorities during this year to support the transformative change required by this agenda.

It is known from the Social Care Survey 2017^[63] that 70 per cent of people made choices using the Self-directed Support options about the help they received in 2016/17. This relates to the group of people in Scotland in that year who had an assessment and were found to be eligible.

To ensure that people of all ages are treated equally, the Scottish Government also committed to extend the provision of free personal care to all age groups from April 2019.

Improving Palliative and End of Life Care

The Strategic Framework for Action on Palliative and End of Life Care^[64], published by the Scottish Government in December 2015, sets out a vision that by 2021 everyone in Scotland who needs palliative care will have access to it. This commitment was reaffirmed in the Health and Social Care Delivery Plan.^[65] Both make clear the importance of delivering palliative and end of life care and support that is holistic, multi-disciplinary and personalised. Getting this right is a vital aspect of the role of Health and Social Care Partnerships in planning, commissioning and delivery.

Work has also been taken forward to support professionals in having timely, appropriate conversations when time becomes short. This will enable the planning of a person’s care and support in line with their and their families’ wishes. The Extending Community Health Outcomes approach, which is used in Highland Hospice, encourages the use of tele-mentoring to share expertise relating to palliative and end of life care. In this way, colleagues working in various settings, including within hospitals, pharmacies, primary care settings and care homes, can be involved. In spring 2018, the Scottish Government provided funding to support further training in this innovative approach, which connects professionals across health and social care, and helps build the skills required to support people at the end of life and improve the quality of their care.

Support Services for Adult Survivors of Child Abuse

The Scottish Government funds organisations helping survivors through a dedicated Survivor Support Innovation and Development Fund and other routes. Future Pathways (previously the In Care Survivor Support Fund) has invested £13.5 million to expand and enhance existing support for survivors of in-care abuse over five years. Future Pathways offers help and support to people who were abused and neglected as children while they were living in care in Scotland. This is a direct response to the InterAction dialogue led by the Scottish Human Rights Commission^[66].

Achieving Better Outcomes for People with Dementia, their Families and Carers

While dementia is a debilitating and progressive condition for which there is currently no cure, people can nevertheless live satisfying and constructive lives with the right help and support. Our shared vision, as described in Scotland’s third three-year National Dementia Strategy^[67], is of a Scotland where people with dementia and those who care for them have the right to access timely, skilled and well-co-ordinated support from diagnosis to end of life. The Strategy is designed to support the progress that has already been made in modernising and reshaping services. This includes Scotland’s post-diagnostic support offer, and more and better integrated home care. At the heart of this approach is close national and local engagement with people with dementia, their families and carers.

Workforce education, training and development, and implementation of the Standards of Care for Dementia in Scotland^[68] across the care pathway and in hospitals remains at the centre of this work. The Scottish Government has a continuing national commitment to fund this activity through the implementation of Promoting Excellence: A Framework for all Health and Social Services Staff Working with People with Dementia, their Families and Carers^[69] and the newer dementia skills framework for allied health professionals, Connecting People, Connecting Support^[70], published in 2017.

The second round of national performance data for the dementia post-diagnostic Local Delivery Plan Standard was published in February 2018, relating to performance during the period 2015/16. It showed that the equivalent of 42 per cent of people estimated to be diagnosed with dementia in that period were offered post-diagnostic support. Of those offered the post-diagnostic service, 85 per cent completed the service^[71].

Supporting People with Autism and Learning Disabilities

The Scottish Government remains committed to transforming the lives of people with autism and people with learning disabilities, specifically addressing the inequalities they face in accessing health, education, work and active participation in society. The Scottish Strategy for Autism^[72] has been refreshed with the publication of The Scottish Strategy for Autism Outcomes and Priorities 2018–2021^[73] published in March 2018. Together with a refresh of The Keys to Life^[74], the aim is to focus on specific priorities for the next three years to achieve the four strategic outcomes intended to ensure people with autism and those with learning disabilities live healthier lives, have choice and control over the services they use, and are supported to be independent and active citizens.

Aligning these aims with the wider ambitions for A Fairer Scotland Action Plan^[75] will truly improve and transform people’s lives so they feel valued, included and accepted by society. Only then can the Scottish Government say we all live in a fairer Scotland – a more equal Scotland – a Scotland for everyone.

During 2017/18, the Scottish Government has continued to invest in local autism projects throughout Scotland, which have reached more than 6,000 people. Investment has been made in the delivery of local autism services by building capacity and sustainability in third sector organisations. Investment continued in an improvement programme to reduce assessment waiting times by improving diagnostic services and increasing diagnostic capacity across child and adult services. This continues to be a challenge for NHS Boards, especially those covering remote and rural communities. Investment in NES continued during 2017/18 to deliver a work plan of upskilling the NHS workforce in autism using the Autism Training Framework^[76]. As a recommendation of the Scottish Strategy for Autism, The Microsegmentation of the Autism Spectrum Report^[77] was commissioned and published in March 2018. The report highlights the annual economic cost of autism in Scotland as £2.2 billion and makes an economic case for interventions.

As part of the The Keys to Life activity in 2017/18, support continued for the Changing Places toilets campaign^[78] to ensure people with profound and multiple learning disabilities can participate in community life and day-to-day activities that most of us take for granted. There are now 167 Changing Places toilets throughout Scotland, with new ones opening over the course of 2018/19. A review of the building regulations is being considered which will see an increase in Changing Places toilets in certain new large buildings.

During 2017/18, the Scottish Government committed to find ways to reduce by at least half the employment gap between those with disabilities and those without^[79]. Helping more people with learning disabilities into work will be key to achieving this ambition. The Scottish Commission for Learning Disability (SCLD) is a key partner in this work and a short-life task group on employment is supporting the development of the programme of work, including mapping the employability landscape for people with learning disabilities^[80]. Work continues on improving services for parents with learning disabilities across Scotland. Housing also contributes to better health outcomes and getting it right has the potential to narrow inequalities. The SCLD published a report^[81] exploring the experience of housing of people with learning disabilities in Scotland with a focus on the contribution housing can make to improving outcomes for them.

Safe Care

We have set ourselves clear aims to ensure that there will be no avoidable injury or harm to people from the healthcare they receive, and that an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. The internationally acclaimed Scottish Patient Safety Programme (SPSP) continues to drive improvements across a number of key areas of healthcare.

In addition to marking the 70^th Anniversary of the NHS, 2018 marks the 10th Anniversary of the launch of the SPSP. NHS Scotland was the first health service in the world to adopt this unique approach to patient safety, using evidence-based tools and techniques to improve the reliability and safety of everyday healthcare systems and processes. Since the launch of the SPSP in January 2008, the programme has expanded to support improvements in safety across a wide range of care settings, including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and in Medicine safety.

Underpinned by the robust application of quality improvement methodology, the SPSP has brought about significant change in outcomes for people across Scotland. The SPSP is now embedded within Healthcare Improvement Scotland’s Improvement Hub (ihub)^[82], supporting improvements within NHS Boards and recently expanding into Health and Social Care Partnerships. The following are just some examples of the progress being made.

Adults in Acute Care

Supporting reductions in harm and mortality for people being cared for in acute hospitals has been a key area of focus for the SPSP since its launch in January 2008. Many improvements have been supported and one key example is the significant improvements in how deteriorating patients are quickly and effectively identified and cared for. In April 2018, 16 reporting hospitals demonstrated a reduction in cardiac arrests of 27 per cent compared to baseline figures taken in February 2013. This means that on average, 22 fewer people per month experience this harmful and distressing experience^[83]. Further improvements can also be seen in the number of people experiencing pressure ulcers in Scotland, which has reduced by 24 per cent as of April 2018 compared to baseline figures taken in January 2015. This equates to 46 fewer pressure ulcers a month^[84].

Mortality Ratios

Hospital Standardised Mortality Ratios (HSMR) are a key measure of safety and the original aim of the SPSP was to reduce hospital mortality by 15 per cent by December 2012. This was subsequently extended to a 20 per cent reduction by December 2015. In 2016, there was a recognised need to consider the statistical basis for HSMR to ensure it reflected up-to-date information about predicted mortality. In order to support continued improvements in safety across Scotland, a new stretching aim was set to reduce hospital mortality by a further 10 per cent by December 2018.

HSMR at Scotland-level has decreased by 9.2 per cent between January and March 2014 (first quarter after new baseline) and January and March 2018 (most recent quarter), with an increasing number of hospitals having a greater than 10 per cent reduction^[85].

Sepsis

Significant progress has been made with the implementation of the National Early Warning Score (NEWS), which helps those delivering care to recognise and escalate the need for treatment of sick patients. This has helped the sustained 21 per cent reduction in deaths from sepsis since 2012^[86]. NEWS is also now being used to improve the recognition, referral and treatment of deteriorating patients who may have sepsis who first present to a primary care health professional.

Reducing Stillbirth

The death of a baby is devastating for all concerned. Although not all causes of stillbirth are known currently, when pregnant women know the risk factors, the signs to look out for and when to seek help, the rate of stillbirth can be reduced.

The Maternity and Children’s Quality Improvement Collaborative (MCQIC) – part of the SPSP – aims to improve outcomes and reduce unnecessary variation for all women, babies and families in Scotland. One area of focus for the Collaborative has been the development of a package of care designed to reduce stillbirth and harm. This includes the use of a cardiotocograph (CTG) and improving the monitoring of fetal wellbeing. For example, a documented discussion on fetal movement has been introduced to teach women what to look for and who to contact when problems or concerns arise. This work has helped support a reduction of 22.5 per cent in the stillbirth rate in Scotland since 2012^[87].

Supporting Reductions in Postpartum Haemorrhage

Postpartum Haemorrhage (PPH) is Scotland’s leading cause of maternal morbidity. The aim is to reduce PPH by 30 per cent. Although from April 2017 to March 2018 the overall PPH rate remained unchanged, there is evidence of local improvement in some NHS Boards, with NHS Greater Glasgow and Clyde achieving a 47 per cent reduction in their severe PPH rate during the same time period^[88].

Reducing Neonatal Mortality

Neonatal care is the type of care a baby born prematurely or sick receives during the first 28 days of life. The SPSP has been working with NHS Boards for some time to reduce neonatal mortality through learning sessions and events, and by providing and promoting the use of improvement tools and resources. However, data now shows a 17.4 per cent overall reduction in Scotland’s neonatal mortality rate since September 2014, a reduction that has been maintained throughout 2017/18^[89].

Reductions in Paediatric Ventilated Acquired Pneumonia

Ventilator Acquired Pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. Reducing VAP has been one of the key successes supported by the SPSP with the deployment of a variety of tools, resources and care bundles. Recent national achievements include an 86 per cent reduction in VAP incidents since 2013, and in 2017/18 there were only nine episodes of VAP across the two units in Edinburgh and Glasgow compared to 26 the previous year^[90].

Improving the Care of Deteriorating Children

The SPSP has also worked in collaboration with the paediatric community to create the Paediatric Early Warning Score (PEWS)^[91]. Scotland is the first country in Europe to have national PEWS charts, which enable clinical staff to reliably recognise and manage an unwell child. There are five different charts for five different age ranges. NHS Boards are now working to introduce the national charts to all areas to provide a standardised, safer approach and common language to use when assessing and responding to ill children.

Ensuring Those Using Mental Health Services are Safe

Over the last six years, collaboration and innovation from staff, service users and carers – along with the application of quality improvement and improvement science – has seen a reduction in self-harm of up to 68 per cent, a reduction in violence of up to 80 per cent and a reduction in the rate of restraint of up to 80 per cent across Scotland as of April 2018 compared to August 2012^[92]. At the same time, the Programme continues to advocate the use of a human-rights-based approach to the delivery of all mental health care.

Ensuring Adults at Risk of Harm are Safe, Supported and Protected

In 2017, the Care Inspectorate led the first joint inspection of Adult Support and Protection in Scotland. Local Authorities, NHS Boards and Police Scotland participated in all Adult Support and Protection Partnerships that were the subject of the inspection. As a result of the processes in place, many adults at risk of harm are safe, protected and supported, but it is recognised that there is more to be done.

One of the key themes from the inspection was the need for NHS Boards to further increase their role in adult support and protection. A key message from the inspection was that all of the required partners, particularly police and health professionals, should attend adult protection case conferences. These findings will be relevant for all NHS Boards and their partners in considering whether their arrangements for adult protection require strengthening.

Developing Excellence in Care for Nursing and Midwifery in Scotland

Last year’s NHS Scotland Chief Executive’s Annual Report outlined ambitious plans to develop a national assurance and improvement programme for nursing and midwifery in Scotland. This year has focused on the development of measures which will support assurance and improvement to patient care and these measures are scheduled to go live from April 2019. It will be the first national programme of its kind in the world and the policy framework is being developed in collaboration with all stakeholders. Progress with Excellence in Care is continuing, which will include developing the policy and delivering the four key objectives in a collaborative, open and transparent way:

• Identify and/or develop a small set of nationally agreed and clearly defined key measures/indicators of high-quality nursing and midwifery care;
• Provide a framework document that outlines key principles/guidance to NHS Boards and Health and Social Care Partnerships on development and implementation of Excellence in Care;
• Design and deliver a local and national infrastructure and ‘dashboard’ that enables effective and consistent reporting ‘from Ward to Board’; and
• Design a set of NHS Scotland record-keeping standards and guiding principles that drive shared decision-making and support professional judgement whilst taking a proportionate and appropriate response to risk.

To support the four key deliverables, funding was provided for 30 nurses and midwives to learn quality improvement methodology, tools and skills through the Scottish Improvement Leader (ScIL) course run by NES. The first cohort graduated in December 2017. These nurses and midwives are a valuable resource to NHS Boards to lead, plan and support improvement activity locally to ensure patient care is the best it can be.

Improved Continence Care

Incontinence in care home residents has numerous associated patient risks, as well as a clinical and financial impact. National Procurement, part of NHS National Services Scotland, secured funding from the Health Foundation to address evidence of increasing use of incontinence products. In partnership with NHS Lanarkshire, a Continence Promotion Care Bundle was developed with project pilot care homes. The bundle consisted of five key interventions to promote continence. Data was recorded and improvements implemented over 10 months to August 2017. Results demonstrated that low-cost quality improvement interventions were shown to promote continence in care home residents, improve safety and reduce absorbency pad usage. The pilot reported a 65 per cent reduction in falls, 30 per cent reduction in skin damage and 40 per cent reduction in hospital admissions for falls and urinary tract infections. NHS Scotland Chief Executives have now recommended that the Continence Promotion Care Bundle be rolled out across all NHS Boards.

On 16 November 2017, a debate was held in the Scottish Parliament on Incontinence in Scotland. The Cabinet Secretary for Health and Sport made clear during the debate the importance that she placed on patients seeing the right person, at the right time, to provide them with the support and advice they need to manage their condition. She also reiterated the importance of diagnosing the causes of incontinence and not just treating the symptoms in order that better outcomes are achieved for patients.

Midwifery Supervision and Regulation

The Nursing and Midwifery Council (NMC) and UK Government response to the Morecambe Bay Inquiry^[94] was to separate midwifery supervision from regulation. Scotland is the only UK country to have fully implemented an entirely new employer-led model of supervision for midwives. Following the change in legislation on 31 March 2017, Scotland’s Chief Nursing Officer convened a stakeholder group, in partnership with the Scottish Executive Nurse Directors, to support NHS Boards with the transition to, and implementation of, the employer-led supervision model for midwives.

By the time of going live on 8 January 2018, NHS Boards across Scotland had appointed 149 clinical supervisors who had completed training developed by NES. A toolkit was developed by the stakeholder group and issued in January 2018, which offered NHS Boards nationally-consistent resources produced by NES for local use, and also shared good practice examples from local NHS Board developments. The employer-led model aims to contribute to improved services, safer care and better outcomes for women and families, by supporting midwives to advocate for women’s needs and to reflect on clinical midwifery practice in line with professional accountability and regulation.

Tackling Healthcare Associated Infection and Antimicrobial Resistance

The rapid spread of multi-drug resistant bacteria means that we could be close to reaching a point where we may not be able to prevent or treat everyday infections or diseases. Prudent prescribing and active stewardship of antibiotics has a major role to play in the prevention and control of Healthcare Associated Infections. Scotland’s progress on Antimicrobial Resistance and Healthcare Associated Infection is globally recognised and work continues with stakeholders across the UK to deliver improvement.

Reducing Healthcare Associated Infections and containing Antimicrobial Resistance remain key priorities for the Scottish Government. Since 2007, significant reductions in Healthcare Associated Infections have been achieved. Cases of Methicillin-resistant Staphylococcus aureus (MRSA) have reduced by 91 per cent and cases of Clostridioides (formerly Clostridium) difficile in patients aged 65 years and over have reduced by 88 per cent^[95]. These reductions are in part due to the improved use of antibiotics in both hospital and community settings. The most common organism reported in acute and non-acute care remains E.coli, which we are working proactively with stakeholders in Scotland to reduce.

Effective Care

Many of the areas for improvement that have been prioritised during 2017/18 make a direct contribution to our Quality Ambition for more effective healthcare services. A focus of this activity has been to identify improvements where there is clear and agreed evidence of clinical and cost-effectiveness, and to support the spread of these practices where appropriate to ensure that unexplained and potentially wasteful or harmful variation is reduced.

Unscheduled Care

As outlined earlier, this winter was a challenge for health and social care. In 2017/18, 92.2 per cent of patients were seen, treated and discharged or admitted within four hours in Scotland’s A&E departments. Scotland continues to see the best A&E performance across the UK administrations – and has done so for more than three years^[96].

The Scottish Government invested more than £9 million in 2017/18 to progress the national clinically-led unscheduled care Six Essential Actions to Improve Unscheduled Care programme^[97]. The work supports local health and social care systems, with a strong focus on ensuring that people get back to or remain in their home or community environment, avoiding unnecessary hospital stays. The programme will seek further improvements in 2018/19, including the introduction of a more robust governance and accountability structure to ensure sustainable improvements in the future.

The Six Essential Actions programme has been running since May 2015. NHS Boards continue to be supported to implement new processes that will enhance performance for patients. Alongside working with local hospitals, the remit of the programme has been broadened to ensure closer working with community partners, including Health and Social Care Partnerships and primary care, in recognition that more patients want to be treated in the community and homely settings. This will require a shift in culture and engagement but will yield long-term gains for sustainability and improved quality patient outcomes, which is why there will be a greater focus on the whole system in 2018/19.

Investing in Elective Centres

The proportion of older people in our population will increase over the next 20 years, and with this will come increasing demand for elective procedures such as hip, knee and cataract operations. As part of our strategy to meet this demand and deliver sustainable, high-quality elective care, in 2015, the Scottish Government announced at least £200 million of funding to create a network of new elective care centres. The centres will deliver additional capacity for outpatients, day surgery and short-stay theatre procedures for several specialties as well as relieving pressure on unplanned and emergency treatment services. The first of the new facilities will open at the Golden Jubilee National Hospital in early 2020, with the NHS Highland and NHS Lothian centres opening during 2021 and the NHS Tayside and NHS Grampian elective centres in early 2022.

During 2017/18, the first stage of the expansion of the Golden Jubilee National Hospital was realised with around 10,000 more patients every year benefiting from the introduction of two new Magnetic Resonance Imaging (MRI) scanners. Also during 2017/18, phase one for the new-build ophthalmology unit moved forward with building work scheduled for early 2019.

Scottish Trauma Network

The Scottish Trauma Network has enabled a new level of collaboration between regional trauma teams and the Scottish Ambulance Service. This new and improved approach to treating major trauma patients is estimated to save 40 additional lives each year in Scotland, as well as improved care and outcomes for 2,000 major trauma patients and 4,000 seriously injured patients^[98].

The Scottish Ambulance Service has piloted the use of Advanced Paramedics based in Major Trauma Centres, and has developed and tested a Major Trauma Triage Tool which ambulance crews use to decide where a patient should go, depending on the severity of their injuries. The Trauma Desk, based in the Glasgow Ambulance Control Centre, has improved pre-hospital critical care team ‘tasking’^[99].

Major Trauma Centres (MTCs) in the North and East are progressing, with the opening of centres in Aberdeen on 1 October and Dundee on 19 November 2018. The new centres will help the most severely injured patients and ensure patients have the best chance of a speedy recovery from their injuries. MTCs in the West and South East will follow.

By 2019, all hospitals in Scotland with an emergency department will report trauma patient data via the electronic data system eSTAG (Scottish Trauma Audit Group). This will support continuous improvement across the network by enabling real-time data to be reported against the STN’s key performance indicators. The STN Major Incident with Mass Casualties Group will develop an updated national plan for managing major incidents with mass casualties by the end of October 2018.

Review of Public Holidays

During 2017/18, a review of health services over public holidays was led by Sir Lewis Ritchie. This brought together partners and stakeholders, including patient representatives, from across the whole healthcare system to support people to transfer seamlessly through the system without delay and ensure they are seen in the most appropriate environment.

The Scottish Government invested £8.4 million in 2017/18 to support the implementation of the recommendations from this review, which included:

• Well-co-ordinated, multi-disciplinary urgent health and social care provision across the whole care system;
• Sufficient levels and numbers of senior decision-makers from all sectors rostered;
• NHS 24 providing enhanced support for self-management and direction to the right service where needed;
• Promoting community pharmacies as a source of advice and medicines; and
• Proactive discharge planning in advance of public holidays.

The recommendations from the review provide a platform for NHS Boards and Health and Social Care Partnerships to align existing practices and staffing to support optimum access to services over public holiday periods.

Improving Organisational Resilience

The second edition of the Standards for Organisational Resilience^[100] was published in 2018. These standards have been updated to support continuous improvement in health and social care and also reflect lessons following disruptive events, such as the bad weather in early 2018. NHS Boards have made progress in developing business continuity and major incident plans and work will continue to support them with this. As part of a programme of enhancement, additional funding of £1.76 million was provided to the Scottish Ambulance Service to improve specialist capability assets across Scotland.

Scottish Access Collaborative

The Scottish Access Collaborative was launched in November 2017. This innovative and clinically-led initiative is designed to make the connections between existing services in order to put patients more in control of their care, and to ensure primary and secondary care clinicians and patients are leading on service reform. The programme includes a number of challenges to ensuring that balance between demand and capacity is sustainable across both the short- and longer-term.

Challenge	Rationale
Virtual Attendance	Ensure that the patient is not being moved when we could instead move their clinical information, or provide them or their healthcare providers with the information they need remotely.
Waiting List Validation	Ensure that no-one is waiting unnecessarily on a list due, for example, to changed clinical picture or circumstances, and allow us to fully understand current demand for services.
Active Clinical Referral Triage	Ensure no-one is added to a waiting list who does not need to be, or who should be accessing other pathways of care instead or at the same time. This will also allow full understanding of current demand for services.
Enhanced Recovery After Surgery	Ensure people return to their best possible function as quickly as possible after surgery. This will also maximise capacity in hospital beds and reduce the need to provide follow-up services associated with surgical complications.
Team Job Planning	The development and use of annualised session agreements, split between fixed and flexible, as a basis for whole team job planning, and monitoring of delivered capacity.

A series of design-led workshop events for each specialty will provide a platform for NHS Boards and other services to come together to learn from each other and test identified areas of good practice in their local areas.

• Cardiology
• Urology
• Gastro-enterology
• Respiratory
• Gynaecology

• Orthopaedics
• Chronic Pain
• Ophthalmology
• General Surgery
• General Medicine

• Neurology
• Ear, Nose and Throat
• Dermatology
• Oral and Maxillofacial Surgery

The Cardiology speciality was the first to report its finding^[101].

Hip Fracture

Hip fracture is the most common, serious orthopaedic injury to affect older people. It is important for these patients to receive swift and effective care. Improvement work has focused on getting patients back to their original place of residence as rapidly as possible, with a level of mobility, function and independence which is acceptable to them, by optimising the pathway of care during their hospital stay.

There are 12 best practice Scottish Standards of Care for Hip Fracture Patients. An audit measures these standards to encourage continuous improvement at each hospital. The audit report of 2017 data shows:

• Over 90 per cent of patients had a cognition assessment within 24 hours of inpatient admission. Elderly care nurses in orthopaedic departments are trained to carry out comprehensive geriatric assessments;
• Over 90 per cent of patients had a physiotherapist assessment within two days and almost 70 per cent had access to support by an occupational therapist by the end of day three post-operatively;
• 86 per cent of patients had an osteoporosis risk assessment prior to leaving hospital; and
• 58 per cent of patients were back home within 30 days after their hip fracture^[102].

Cataract Surgery

Cataract surgery has the ability to transform a patient’s ability to remain independent and to undertake activities of daily living such as driving. Recent forecasting work undertaken by Information Services Division (ISD Scotland) – taking into account age-specific profiling – has shown that the number of cataract surgeries could rise to 52,500 by 2025, an increase of around 10,000 surgeries a year across NHS Scotland^[103]. NHS Tayside and NHS Ayrshire & Arran have been supported to undertake high-volume cataract surgery in

dedicated ring-fenced surgical sessions, as a proof of concept. The number of patients undergoing cataract surgery in these four-hour theatre sessions varied between 10-14 patients – and around 40-50 per cent increase in volume of patients per list.

It is accepted that in order to undertake higher volume cataract surgery, the whole day-case process requires to be examined by the multi-disciplinary team. The changes required to deliver these sessions include:

• Batched arrival of patients to facilitate pre-operative work-up and review;
• Use of Mydriasert dilating agent to allow a single point of distillation;
• Instillation of antiseptic in the pre-operative area to transfer for surgery;
• Additional staff to enable seamless delivery of patient care across the whole pathway, pre-operatively, during surgery and post-operatively;
• Team brief including staff from the day-case unit; and
• Adequate space in the pre- and post-operative areas to facilitate the increase in patient numbers.

A full evaluation is ongoing.

Improving Mental Health Services

Access to Mental Health Services

In April 2017, the Mental Health Strategy 2017-2027^[104] was published by the Scottish Government. The Strategy drew from a wide and comprehensive consultation process and reflected the shared ambition of partners across Scotland to harness the broadest range of opportunities to improve the population’s mental health. The vision for the Mental Health Strategy is of a Scotland where people can get the right help at the right time, expect recovery and fully enjoy their rights, free from discrimination and stigma.

The scale of the challenge is considerable. During 2017/18, performance against the two principle waiting time targets continued to be poorer than required, with 74.1 per cent of children and young people being seen by Child and Adolescent Mental Health Services (CAMHS) within the 18-week target, and 76.5 per cent of people being seen within the Psychological Therapies 18-week target. The demand on services is increasing, with 33,270 referrals to CAMHS during 2017/18 – up from 32,677 the previous year – and an equivalent increase for Psychological Therapies from 109,370 to 136,029^[105].

There has been a substantial increase in workforce over the last decade, and the challenge for the service is to grow specialist NHS services to meet the increasing demand whilst, critically, developing the community-based services that are so vital to early intervention and prevention.

Recognising the importance of ensuring access to treatment and joined-up accessible services, the Mental Health Strategy included an action to

increase the workforce. The focus was to allow access to dedicated mental health professionals in A&E departments, GP practices, police stations and prisons. This action is backed by funding rising to £35 million to deliver 800 additional mental health workers in these key settings by 2021/22.

In June 2018, the Cabinet Secretary for Health and Sport announced a joint Task Force with COSLA on Children and Young People’s Mental Health. The Task Force is to provide recommendations for improvements in provision for children and young people’s mental health in Scotland and, in partnership, develop a programme of sustainable reform of services. The Task Force will work with partners and stakeholders to galvanise action that will improve outcomes for children and young people’s mental health. The Scottish Government and COSLA asked Dr Dame Denise Coia to chair the Task Force. Following an intensive period of early meetings, she gave a preliminary view and initial recommendations for the work of the Task Force in September 2018.

Chart 1: Headcount and Whole-time Equivalent (wte) of CAMHS Staff in NHS Scotland from 30 September 2006 to 31 March 2018

Source: ISD Scotland (CAMHS Publication, June 2018)

Suicide Prevention

The Scottish suicide rate fell by 17 per cent between the periods 2002-2006 and 2012‑2016^[106]. This time period includes the periods covered by the Scottish Government’s decade-long Choose Life strategy^[107], which ran from 2002 to 2013, and the successor Suicide Prevention Strategy 2013-2016^[108]. Suicide rates were significantly higher in the most deprived areas of Scotland than the Scottish average, but this inequality gap has narrowed over recent years^[109].

In March 2018, the Scottish Government published a draft suicide prevention action plan^[110], inviting comments from the public and stakeholders on proposed actions to continue the strong long-term downward trend in the suicide rate in Scotland. Following an extensive engagement process, which included detailed discussion with a wide range of key stakeholders in the NHS, the third sector and academia, Scotland’s Suicide Prevention Action Plan: Every Life Matters^[111] was published in August 2018.

Distress Brief Intervention Pilot Project

The relationship between suicide and self-harm is complex. For that reason, the scope of the Suicide Prevention Strategy 2013–2016 was limited to suicide and suicidal self-harm. The strategy’s first commitment was to undertake separate work on supporting people at risk of non-fatal self-harm, including those in distress.

In 2016, the Scottish Government agreed four pilot areas in which NHS Boards and other agencies will test a proposed Distress Brief Intervention (DBI) model, working with partner agencies including Police Scotland and the Scottish Ambulance Service. The four pilots went live on a controlled and incremental basis in 2017.

An independent evaluation of the DBI pilot will report by March 2021 – however, early observations show a high level of engagement in the DBI programme by those referred, with levels of distress reducing from eight out of ten (extreme distress) at time of referral to four at last contact^[112]. In addition, findings from an outcome questionnaire show that those engaged in the DBI programme: report very high levels of compassion both at Level 1 and Level 2 from those trained; feel they are working towards their own goals; and feel more able to manage their immediate and future distress. Those who had presented in distress previously and prior to DBI also subjectively reported a much-improved experience through DBI^[113].

Managed Clinical Network for Perinatal Mental Health

In January 2017, funding was announced to establish a Managed Clinical Network (MCN) for perinatal mental health. This is the first MCN in Scotland dealing with mental health.

The Scottish Government centrally funds the perinatal MCN at a total cost of £173,000 per year – nearly double the usual total for an MCN. This is to allow the Network to recruit specialists in nursing, maternity and infant mental health, as well as an overall clinical lead. The leadership of the MCN was finalised in April 2017. The long-term aim, over the next three to five years, is that all women, their infants and families have equity of access to perinatal mental health provision, at the level appropriate to need, in all NHS Board areas/regions in Scotland.

During 2017/18, the Network has been carrying out a ‘mapping and gapping’ exercise in support of its shorter-term aim, which is to produce a comprehensive overview of current service provision, pathways into care, and education/training for NHS staff in the area of perinatal mental health. The MCN recommendations informed by this exercise will be published in late 2018.

Success for Digital Approach to Supporting Mental Health

In 2017/18, full national roll-out via the Technology Enabled Care Programme of computerised Cognitive Behavioural Therapy (cCBT) service across all 14 territorial NHS Boards was achieved with the facilitation of NHS 24. cCBT offers a national solution to the increasing demand of common mental health problems such as low mood, depression and anxiety. The service received 12,968 referrals in 2017/18. While more than 85 per cent of referrals made come directly from GPs, others are made up from 23 clinical sources, including clinical psychology, occupational health, social work and acute services. There is growing evidence of the key role cCBT is playing in addressing health inequalities through ever-increasing digital access to the cCBT treatment across Scotland. Projected levels of use by 2019 will exceed 15,000 referrals per annum^[114]. Adopting a Once for Scotland approach, the cCBT model has been developed to act as a ‘central hub’ from which a range of cCBT services can be provided.

Enhancing the Role of Primary Care

Primary Care Reform – Overall Shape of Change

Scotland’s First Minister set a target to increase overall annual funding for primary care by £500 million by 2021/22, with £250 million of that investment being in direct support of General Practice. This will raise the primary care share of the NHS frontline budget from 7.7 per cent to 11 per cent by 2021/22.

Over the past two years, there has been a steady increase in levels of investment within the Primary Care Transformation programme. This has supported all NHS Boards and Health and Social Care Partnerships to develop new and improved primary care services, in collaboration with GPs and other healthcare professionals. The funding totalled £72 million in 2017/18. At national level, emerging learning was brought together from these local Primary Care Transformation Fund projects. In addition, working with GPs, Health and Social Care Partnerships and NHS Boards, a core series of improvements to primary care services across the whole of Scotland were planned and implemented, linked directly to the new GP Contract and supported by significant new investment.

In 2018/19, the level of investment in primary care reform will increase again, to over £110 million.

GP Contract

Most of our healthcare needs, most of the time, throughout all of our lives, are met in primary care through relationships with our family doctors and community-based teams. As a population, those healthcare needs are changing. Publication of the 2018 General Medical Services Contract^[115] offer in November 2017, and its subsequent adoption by the GP profession in Scotland, represented a significant moment in the history of healthcare in Scotland. It was the first ever distinctive Scottish GP contract.

Developed collaboratively between the British Medical Association (BMA) and the Scottish Government, and coming into force on 1 April 2018, the new GP Contract focuses the role of GPs to better meet the population’s changing needs.

Under the new contract, GPs will be able to focus more on acting as the Expert Medical Generalist that they have trained to be. They will have more time for people with complex care needs, for helping those who are unwell and might have a more serious or long term condition, and for acting as the clinical leaders of multi-disciplinary teams in our communities. GPs will face less financial and property risk, will have a reduced workload, and will have stability in their income. General Practice will become a more attractive profession for young doctors to join.

However, the GP Contract is about considerably more than just the terms and conditions for Scotland’s GPs. Multi-disciplinary teams are at the heart of our new approach to primary care services and the new GP Contract. In November 2017, a Memorandum of Understanding was signed by the Scottish Government along with representatives of NHS Board Chief Executives, Health and Social Care Partnership Chief Officers and the BMA to signal a joint determination, across the whole healthcare system, that the wider aspects of the GP Contract would be delivered.

Workforce

In 2017/18, Parts 1 and 2 of the National Workforce Plan^[116] were published, with Part 3 specifically covering primary care published in April 2018^[117]. All primary care stakeholders agreed on the importance of improving capacity in primary care, with enhanced, integrated pathways to wider health and social care services including third sector service provision.

Under the Memorandum of Understanding, it was agreed that developments in the primary care workforce would be led and planned locally by Health and Social Care Partnerships, working hand in hand with NHS Boards, GPs, people using healthcare, their carers, the third sector and other key stakeholders. Building on investment in 2017/18, increased investment will be made in key multi-disciplinary teams in the community – physiotherapists, mental health workers, nurses, pharmacists, link workers and others – so that people who need healthcare have quicker access to the right provider at the right time.

The Scottish Government has continued to support people living in areas of higher levels of socio-economic deprivation by investing in non-clinical link workers based within General Practices. In May 2017, a £2.5 million investment was announced to train receptionists and practice managers to signpost patients to the most appropriate sources of help or advice; and for additional training for General Practice nurses, in recognition of the importance of the General Practice nurse role in the future delivery of care to patients in a primary care setting.

It is clear, though, that increased demand for primary care services will mean more GPs are needed. In 2017/18, £5 million was invested in GP recruitment and retention measures. In December 2017, the Cabinet Secretary for Health and Sport set a new and ambitious target to expand the number of GPs working in Scotland by at least 800 over the next decade to address increasing demand.

This will require a comprehensive package of retention measures (including coaching and mentoring schemes) to support GPs, helping combat workload pressures and retaining them in the workforce, and a further £7.5 million will be invested in 2018/19 to support that work. It will also require medical undergraduates to receive more of their medical education in a General Practice setting and more doctors to train as GPs. Between 2015/16 and 2020/21, the Scottish Government will have increased the number of medical places in Scottish universities by 22 per cent. In 2017/18, Scotland’s first Graduate Entry Medical programme was also developed, which will be accepting graduates from September 2018, and which will have a particular focus on General Practice and rural working.

Sustainability and Premises

There are real pressures on General Practice now, and the Practice Sustainability Group has been working on a number of fronts throughout 2017/18 to address these – both by ensuring that as many as possible of the recommendations of the group were supported by the 2018 GP Contract, and by sharing and developing best practice at local and national levels. The new GP Contract also included a commitment to reducing risk arising from ownership or private leasing of GP premises. In November 2017, a Code of Practice^[118] was published which set out how the Scottish Government and NHS Boards will do that. A total of £30 million over three years will be invested to support GPs.

Primary Care Out of Hours Services

Out of Hours services are a critical part of urgent care. Out of hours pick up the reins when GP practices are closed from 6.00 pm in the evening, overnight to 8.00 am, over weekends and on national and local public holidays. Each year around 850,000 patients access out of hours services leading to nearly 1 million consultations. Of these around 20 per cent are provided in the home of the patient, with 56 per cent of patients seen at out of hours centres^[119].

Over the last few years, out of hours services have faced a number of challenges – mainly due to a reduction in the pool of GPs willing to work in the service. This has often led to short-term closures of out of hours centres. The decision to close centres is always taken on the grounds of patient safety. However, closures put further pressure on out of hours staff and the home visiting service, and often means that patients are asked to travel further to visit an out of hours centre. The review of out of hours by Sir Lewis Ritchie, Pulling Together: Transforming Urgent Care for the People of Scotland^[120], set out a framework for out of hours services across Scotland. Progress towards achieving the recommendations in the report has been steady, but the service needs to be nurtured and supported if it is to continue to meet the needs of patients seeking urgent medical attention when GP practices are closed.

Supporting Better Treatment and Services

The Scottish Primary Care Information Resource (SPIRE)^[121] was launched in December 2017 following extensive consultation with health and care professionals, Royal Colleges and patient groups. The service gathers de-personalised data from GP surgeries to inform the development of health and care services, identify population health trends, and ultimately improve outcomes. SPIRE is intended to support GPs by providing practices with a simple way to view their own information and to get intelligence that will be of use to them in the care of their patients, particularly those with conditions such as diabetes and heart disease, as well as for older people who may have multiple conditions and take several drugs. Being able to use this information will mean NHS Scotland can improve the quality of care for all patients, better plan services for people with health needs, and support research into new treatments for particular illnesses.

Transforming Urgent Care – In-Hours GP Triage

NHS 24 is leading on a collaborative test-of-change, providing in-hours triage support for three GP practices in Scotland, in Lothian, Lanarkshire and Forth Valley. The key aims of the test-of-change collaboration are to: demonstrate a new way of working, both for NHS 24 and the local primary care system; reduce the numbers of patients requiring ‘same day’ face-to-face consultation; support primary care demand management through NHS 24’s infrastructure, skills and capabilities during the day; and raise awareness of care alternatives.

Early evaluation of the initiative has shown that this model has the potential to be transformational across the health and social care system, with a significant reduction in patients requiring ‘same day’ access to their GP (by 40–50 per cent across the test-of-change). Together with increased benefit and outcomes demonstrated through the NHS Lothian ‘integrated hub’ approach to multi-disciplinary delivery of care, there is also evidence that GPs are able to increase appointment times to 15 minutes in supporting the management of more-complex patient care.

Successful Implementation of NHS 24’s New Technology

In 2017, NHS 24 successfully completed the implementation of its new technology platform across the organisation as part of its strategic Organisational Improvement Programme (OIP). The transition took place in a three-staged approach: introduction of the new technology across select services in September 2016; transitioning the 111 service onto the new platform for a single NHS Board area (NHS Ayrshire and Arran) in May 2017; and full national roll-out in October 2017 of the 111 and the Scottish Emergency Dental Service for the remaining 13 NHS Boards.

Improving Eye Health

Ten years on from the introduction of free NHS-funded eye examinations in Scotland in 2006, the Scottish Government commissioned a review of community eyecare services provision in Scotland. The Community Eyecare Services Review report^[122] was published in April 2017 and highlighted the successes of the service and identified areas where the service could be further improved.

The Review made a number of recommendations, including schemes to reduce geographical differences in services, more-tailored arrangements for patients with specific complex needs to support care closer to home, and suggesting that some eye services traditionally offered in hospitals (such as post-cataract surgery appointments and managing stable glaucoma patients) should be made available locally.

The Scottish Government is in the process of implementing the recommendations of the Review and is engaging with a range of stakeholders, including health professionals and patients.

Improving Oral Health

The publication of the Oral Health Implementation Plan (OHIP)^[123] in January 2018 signalled an ambitious programme of work which will make a significant contribution to improving the oral health of the population and to transforming how our services are delivered. The publication was timely as, whilst the oral health of the population has significantly improved, challenges still exist in improving the oral health of the people living in our most disadvantaged areas, meeting the needs of an ageing population and making appropriate dental care available to a younger cohort of people with good oral health.

The plan signals an intent to introduce an evidence-based preventive care pathway to follow on from an Oral Health Risk Assessment (OHRA), with all adult patients receiving a personalised care plan based on an assessment of the level of risk to their oral health. The OHIP announced that the successful Childsmile Programme will be complemented with ambitious community-led early-years initiatives supported by an Oral Health Challenge Fund, allowing our partners in the third sector to support families and their communities to improve their oral health.

The pressures faced by secondary care are recognised, and plans will be introduced to transfer some treatments away from secondary care towards primary care where the skills of local practitioners can meet the need. Training initiatives are being introduced where practitioners can develop these enhanced clinical skills to deliver a wider range of complex care on behalf of NHS Boards.

The initial priority is establishing new domiciliary care arrangements allowing enhanced skills general dental practitioners to be assigned to a number of care homes to provide routine dental care to care home residents. These practitioners will work in partnership with care home staff to ensure the maintenance of good daily oral health and hygiene.

Achieving Excellence in Pharmaceutical Care

Building Clinical Capacity

Last year’s annual report described the good progress made to deliver the Programme for Government commitment that every GP practice in Scotland will have access to a pharmacist with advanced clinical skills by 2021. Up to March 2018, some £20 million had been invested to support this commitment. This investment from the GP Pharmacy Fund has meant that the initial target to recruit 140 whole-time equivalent (wte) pharmacists has been exceeded, together with a number of wte pharmacy technicians.

By March 2018, NHS Boards reported the recruitment of 201.1 wte pharmacists and 47.7 wte pharmacy technicians.^[124] This means that around half of the GP practices across Scotland are receiving some form of pharmacist support depending on local need. The combined skill mix of these pharmacists and technicians is supporting patients and GPs on a range of medicines related issues, freeing up GP time to spend with people with more-complex care needs.

As part of the new GP Contract arrangements in Scotland, this work is helping to establish a sustainable pharmacotherapy service to embed pharmacists and technicians as members of core GP practice clinical teams across our communities. The implementation of this service will be a key component of Primary Care Improvement Plans being developed by every Health and Social Care Partnership. An evaluation of models of pharmacists working in GP practices being conducted by the two Scottish Schools of Pharmacy will report later in 2018. This will help to inform the implementation of the pharmacotherapy service over the next three years.

Access to New Medicines

Reforms continue to be made to the ways that patients can access new medicines. A new process has been announced that applies to medicines for very rare conditions with fewer than 100 patients in Scotland. This new process allows defined licensed medicines to be available for at least three years on the NHS, while information about the outcomes they achieve is gathered. There has also been change to the system that permits individual access to medicines not generally available on the NHS. This new system means that the acquisition cost of the medicine is not to be a factor in deciding whether it is made available to an individual patient.

The Scottish Medicines Consortium (SMC), part of Healthcare Improvement Scotland, supported improved access to newly licensed medicines throughout 2017/18. In 2017/18, the SMC has assessed and issued advice on 75 medicines, with 71 per cent of full submissions being accepted for use by NHS Scotland. Conditions which medicines were approved for included breast cancer, hepatitis C, multiple myeloma and HIV.

Enhancing the Role of the Ambulance Service

New Clinical Response Model

The Scottish Ambulance Service continues to evaluate its New Clinical Response Model (NCRM), introduced in November 2016 to improve the way the Service responds to 999 calls. However, early evidence already shows that by prioritising immediately life-threatening cases, an additional 62 people suffering a cardiac arrest returned home safely to their families in 2016/17 compared to the previous year. Under the new approach, patients with immediately life-threatening conditions are now being identified earlier in the 999 call-handling process. There has been a 40 per cent increase in the number of cardiac arrest patients being attended to by three Ambulance Service responders, which is known to increase the chance of survival and to improve patient outcomes.^[125]

In addition, working with Save a Life Scotland, the Scottish Ambulance Service has helped to equip more than 200,000 people in Scotland with life-saving skills, enabling more bystanders to initiate cardiopulmonary resuscitation (CPR) before emergency care arrives. This strategy is proving invaluable in helping to save the lives of patients who have suffered an out-of-hospital cardiac arrest and, since 2013, survival rates have almost doubled for cardiac arrest patients^[126].

New Ways of Working – See and Treat

Whilst patients with serious conditions will need treatment at the scene before being taken to hospital, some patients the Scottish Ambulance Service responds to do not need to be taken to hospital; many can be safely treated by a responding paramedic in their own homes or at the scene of an incident. Working with NHS Boards across Scotland, over 100 trained specialist paramedics are now working in communities, some attached to GP practices, to treat patients in their own homes, relieving pressure on both busy A&E departments and GP practices.

To ensure resources are being used effectively and patients are spared unnecessary journeys into hospital, the Scottish Ambulance Service is developing its staffing and working with partners to identify community care pathways. Last year over 100,000 people were helped in this way. This includes the recruitment of additional clinical advisors to establish a clinical services hub and joint working with NHS 24 to improve the experience, safety and efficiency for people who can be safely treated or referred by telephone triage^[127].

Improving Cancer Outcomes

Increase in Cancers Diagnosed at the Earliest Stage

The most deprived communities in Scotland have seen the largest increase in people diagnosed at the earliest stage of breast, lung and colorectal cancers – an 11.8 per cent increase. For lung cancer specifically there has been a 31.0 per cent increase in stage 1 diagnoses in the most deprived areas since the Detect Cancer Early (DCE) Programme began in 2012^[128]. A new DCE social marketing campaign will launch later in 2018 to continue momentum, targeting those in the most deprived communities, to reduce fear of cancer and remind people of the importance of acting early.

Meanwhile, to support GPs in finding cancer early, and in light of emerging new evidence, the DCE Programme has funded a clinically-led refresh of the Scottish Referral Guidelines for Suspected Cancer. Updated guidelines are expected to be published later in 2018.

Melanoma was the latest tumour group to be added to the DCE Programme in 2016/17. Local tests of change have been piloted in five NHS Boards across Scotland, with several exploring best practice for referrals of Suspicious Pigmented Lesions (SPL). Pilots for phase two are being developed for roll out later in 2018, focusing on scaling up best practice and learning.

Cancer Strategy

In 2017/18, £16 million was invested in delivering the commitments set out in the Scottish Government’s Beating Cancer: Ambition and Action^[129] strategy.

In this second year of the five-year strategy, the Scottish Government investment has already resulted in service improvements across Scotland, and across all areas of the cancer journey. Investment in prevention activities included £1 million to deliver Human Papillomavirus (HPV) screening and a further £0.5 million to address screening inequalities, particularly in the most deprived communities. To enable a more rapid cancer diagnosis, an investment of £2 million was made into the Cancer Diagnostic Fund to deliver an increase in scopes capacity, and a further £1 million to address diagnostic waiting times.

Across all treatment areas, significant investment was made, providing £7.9 million into maintaining and modernising radiotherapy equipment and £1.5 million to the cancer regions to transform radiotherapy services, and improve chemotherapy (SACT) and surgical services. This has enabled staff recruitment and more-effective use of resources. Investment of £0.4 million into the Managed Services Network Cancer Plan has helped to ensure better cancer services for children and young people in Scotland, while £1.3 million is helping to improve the quality of cancer services and to capture robust cancer data from across Scotland. This will help address service gaps and drive improvements in cancer services, benefiting all who need to use these services.

Screening

The new bowel screening test Faecal Immunochemical Test (FIT) was introduced into the Scottish Bowel Screening Programme in November 2017 and replaced the guaiac faecal occult blood test (gFOBt). FIT is a more sophisticated and reliable test than gFOBt. The more specific nature of FIT means fewer negative colonoscopies can be expected. Scotland is the first of the four UK nations to implement FIT nationally. The new FIT single-sample test is easier and more hygienic for participants to complete, helping to reduce barriers to bowel screening and increase the number of people taking part when invited. This will enable the detection of more conditions at an early stage, helping more people to beat cancer than ever before.

NHS National Services Scotland (NSS) National Services Division (NSD) co-ordinates the Scottish Cervical Screening Programme and nationally commissions the Scottish Cytology Training School, the Cervical Cytology External Quality Assurance Scheme and the IT system to support the programme. In September 2017, it began a project to replace cervical cytology as the primary screening test with high-risk Human Papillomavirus (Hr-HPV) testing and the use of cytology-based tests as the triage for women who test positive for Hr-HPV. Implementation of this change is scheduled for 2020, and will help ensure the early signs of cervical cancer are identified and treated earlier. NSS Information Technology (NSS IT) oversees the operational management of the Scottish Cervical Call Recall System (SCCRS), a Scotland-wide database which manages cervical screening and is accessible by over 18,000 users. In July 2017, NSS IT began implementing developments to SCCRS, including updates to interfaces to other clinical systems to support call/recall advice and notification to GPs.

Improving Care and Outcomes for People Living with Diabetes

Clinical evidence shows that some people may benefit from the use of technologies such as Insulin Pump Therapy and Continuous Glucose Monitors to achieve good glucose control. The Scottish Government has continued to monitor the provision of insulin pump therapy across Scotland, following the excellent progress that has been made by NHS Boards in exceeding the 2012 Ministerial commitment for young people.

In December 2016, to build on this success, the Scottish Government announced additional funding of £10 million over the course of this Parliament to support NHS Boards to increase Insulin Pump Therapy for adults and Continuous Glucose Monitor devices for people in all age groups. The first instalment of £2 million was allocated to NHS Boards in financial year 2017/18. In 2017, the number of people maintaining good glucose control increased from 24.5 per cent in 2016 to 25.3 per cent, and the percentage with poor glucose control decreased from 33.9 per cent to 32.6 per cent^[130].

Roll-out of Pre-Exposure Prophylaxis (PrEP) for HIV Prevention Across Scotland

Pre-Exposure Prophylaxis (PrEP) is a medication taken by people who are HIV-negative to lower their risk of acquiring HIV infection. The SMC approved the use of PrEP in NHS Scotland in Scotland in April 2017 and PrEP became available in Scottish sexual health clinics from July 2017. Scotland was the first country in the UK to provide HIV PrEP to all eligible, at-risk individuals on the NHS.

In the first eight months of PrEP being available, NHS Boards adapted their sexual health services so that it could be prescribed to nearly 1,300 people who were at high risk of sexual transmission of HIV^[131]. PrEP is highly effective at preventing HIV transmission when taken as directed^[132]. It is expected that the addition of PrEP to other HIV prevention strategies will play a key role in reducing the transmission of HIV in Scotland, although safer sex practices such as using condoms will continue to be important.

Tackling Polypharmacy and Improving Patient Care

Polypharmacy Reviews

Around 120,000 polypharmacy reviews are carried out in Scotland every year. These holistic, patient-centred reviews result in the cessation of one or two repeat medications with the focus on stopping ‘high-risk’ medicines most commonly implicated in causing unscheduled hospital admissions. The total medicine items stopped is between 0.7 and 2.8 million per annum^[133].

The effect of polypharmacy reviews is now reflected in the national prescribing data. Before the introduction of the first polypharmacy guidance document in 2012, there was an annual volume increase of 3 per cent for the preceding 20 years. Between 2012 and 2017, the annual volume increase fell to a rate of 1.5 per cent per annum. Within 2017/18 there was an actual drop in the volume of medicines prescribed, which is the first time since the creation of the NHS that this effect has been seen^[134].

One of the challenges in the clinical appropriateness of polypharmacy reviews has been the lack of published evidence. This is because most medical research has focused on the use of single medicines to treat single conditions, whereas most people have more than one condition and multiple medicines is the norm. The team behind the polypharmacy guidance continue to work with academics and data experts to improve the evidence base for the management of patients with multi-morbidities.

Polypharmacy in the Elderly

A key public health challenge for Europe is to address the issue of inappropriate polypharmacy and non-adherence to medicine regimens in the elderly. Through a collaborative initiative funded by the European Union (EU), SIMPATHY, knowledge and best-practice in the management of polypharmacy has been shared with other EU member states. By addressing the inappropriate use of polypharmacy, 0.3 per cent of the global health budget could be saved by reduction in harm caused by medicines^[135].

The SIMPATHY project was co-ordinated by the Scottish Government with subject matter expertise brought in from across NHS Scotland to contribute to this cross-EU project. The SIMPATHY consortium explored how healthcare management programmes can be implemented to improve medication safety and prevent patient harm by addressing multiple medicines. This included using the Scottish Polypharmacy Guidance as a flagship publication.

Seven EU countries were involved in the two-year project, which provided some important additions to the evidence base for polypharmacy management in different healthcare settings. Significant outputs from the project include the final handbook, Polypharmacy Management by 2030: a patient safety challenge^[136], which was launched by the Cabinet Secretary for Health and Sport in Brussels in 2017. This event also resulted in Scotland’s lead role in the third WHO patient safety challenge, Medication without Harm^[137], which aims to identify polypharmacy as an international issue.

Supporting People to Start Their Lives Well

The Best Start

The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland^[138] describes a new and transformational model of maternity and neonatal services, and makes 76 recommendations to improve care and the experience of care for women, babies and families.

In 2017/18, a programme board was established to drive forward the programme of improvement. The programme board has begun the process of implementing the recommendations and has put in place the structures and building blocks to deliver the change described. This will result in: greater continuity of care, reducing rates of medical intervention, rates of preterm birth and early pregnancy loss and improving the experience for women; a new model of neonatal care that will result in fewer babies being admitted to neonatal care, a reduced length of stay for babies in such care and safer care for the very smallest and sickest babies; and a shift in the focus of care to keep mother and baby together which will significantly improve bonding, attachment and parental confidence, improve breastfeeding rates, and improve clinical and psycho-social outcomes for the baby.

Key achievements include establishment of five early-adopter NHS Boards which are leading the way in implementation of priority recommendations, including: delivery of the midwifery continuity of carer model for all women, including vulnerable women and families; introduction of neonatal transitional care to keep mums and babies together; and establishment of Community Hubs for the delivery of local maternity care and, in time, neonatal outreach.

In addition, a £1.5 million neonatal expenses scheme has been introduced to reimburse families of babies in neonatal care with day-to-day expenses and local Best Start leads have been established in NHS Boards leading local implementation of the recommendations.

In Vitro Fertilisation

Scotland continues to lead the way in providing access to In Vitro Fertilisation/Intracytoplasmic Sperm Injection (IVF/ICSI). The 90 per cent standard for eligible patients to start NHS IVF has been met since it was first measured in March 2015. For the period from April 2017–March 2018, 99.9 per cent of patients were seen within 365 days at one of the four centres that provide NHS IVF in Aberdeen, Dundee, Edinburgh and Glasgow^[139].

Following on from the expansion of access to IVF/ICSI to allow couples with children in the home access to NHS IVF from 1 September 2016, all newly-referred eligible patients from 1 April 2017 can now access up to three full cycles of NHS IVF, giving more patients the opportunity to conceive. Further investment of £7 million was made available to support widening of access criteria and to ensure waiting times continue to remain low. The National Infertility Group is currently considering further improvements to the service in Scotland.

Improving Access to Post-partum Contraception

The Pregnancy and Parenthood in Young People Strategy, Sexual Health and Blood Borne Virus Framework 2015–2020 Update^[140] and Refreshed Framework for Maternity Care in Scotland^[141] highlight the importance of enabling women to have access to contraception immediately after birth, should they wish.

As a result of successful work in NHS Lothian to increase access to and provision of post-partum contraception to women who wish to have it, a short-life working group was set up in April 2017 to explore the sharing of learning across Scotland. The working group invited two NHS Boards to take forward a pilot approach using the experience of NHS Lothian, as well as their own local expertise. Over the next two years, it is intended that these pilots will improve access to and provision of post-partum contraception in local areas as well as providing more evidence on how best to offer post-partum contraception across Scotland in differing contexts. It is intended that in sharing experience of effective practice, more women will be empowered to control their reproductive health and access effective contraception, should they wish to, immediately post-delivery.

Baby Box

By April 2018, 35,000 Baby Boxes were delivered to families across Scotland, providing essential items for the first six months of a child’s life. Through early engagement with ante-natal services as part of the registration process, the expectant parents were also introduced to a wide range of health promotion information such as adopting healthy eating and lifestyle habits, smoking cessation and carbon monoxide monitoring as well as ‘no alcohol’ messaging^[142].

Healthcare Science

Patients Participating in Genomics Research

One thousand people are being recruited across Scotland by NHS genetics clinics, to participate in genomics research^[143] to help provide a diagnosis for people with rare genetic conditions, and look at how genome sequencing and analyses can be used in the NHS to improve diagnosis and management of rare conditions. This is part of a four-year investment by the Scottish Government (£4 million) and Medical Research Council (£2 million) that started in 2016 in the Scottish Genomes Partnership – a collaboration between Scottish Universities and NHS Scotland – to use whole genome sequencing technology for research on rare diseases, cancers and Scottish populations and to work with Genomics England on the diagnosis of patients in Scotland with rare diseases.

By the end of 2017/18, around half of the target number had been recruited for whole genome sequencing in Scotland, and the technical process had been established for submission of the data to Genomics England for analysis and clinical interpretation. The first return of the findings are expected during 2018/19.

The Golden Jubilee Research Institute approved a record number of 45 academic and commercially sponsored research projects in 2017/18. Taking research from bench to bedside, CardioMEMS are new devices that are inserted into the patient’s distal pulmonary artery to look for and monitor heart failure. Used in the Golden Jubilee Cardiac Catheterisation Laboratries, the device potentially reduces hospital admissions and also improves the quality of life for patients living with heart failure. The Golden Jubilee now uses the Organ Care System (OCS) as part of their heart transplant service. The system is designed to keep recently donated hearts functioning outside of the body, ensuring a donor heart remains viable for longer.

In 2017/18, the Golden Jubilee also provided patients with Non ST Elevation Myocardial Infarction (NSTEMI) direct and faster access to specialist heart attack treatment. This is now implemented and working effectively across the West of Scotland. In Orthopaedics, the Golden Jubilee Motion Analysis Lab (MAL) opened in May 2017 and is now being used effectively as an established outcome measure for orthopaedic research projects.

Supporting Victims of Rape and Sexual Assault

In 2017, the Scottish Government commissioned Healthcare Improvement Scotland to develop the first national standards for forensic medical examinations and healthcare for victims of rape and sexual assault in Scotland. These were published in December 2017 and provide NHS Boards with clarity on best practice, so that anyone who has experienced rape, sexual assault or child sexual abuse can receive the same high level of person-centred care across Scotland. Ensuring a consistency in approach to the quality of forensic medical and healthcare services will also help to improve the person’s wellbeing, reduce the likelihood of further trauma for victims, and ensure the timely collection of evidence to support any criminal justice proceedings. Work is underway to undertake a gap analysis and to develop local plans in order to drive immediate improvements.

Digital Health and Care

Chapter 1 highlighted how the wider use of digital actively supports, and helps to realise, the integration of health and care services as we build person-centred services for the people of Scotland. With the recent publication of Scotland’s Digital Health and Care Strategy: Enabling, Connecting and Empowering^[144], collaborative work continues towards a more joined-up, integrated and effective service for people in Scotland. The new Strategy will equip health and care services with the tools that are needed to deliver a transformation into 21st century place-based care. In order to achieve that ambitious transformational agenda, the opportunities of new technology need to be maximised.

The Scottish Government’s world-leading Technology Enabled Care Programme is playing a key part in achieving the ambitions of the new digital strategy – using proven technology to accelerate the support people have to manage their health and wellbeing at home, and in their community. Over 70,000 people have so far benefited from the programme, including facilities such as the secure video conferencing service Attend Anywhere; Home and Mobile Health Monitoring; and Telecare, including its move from analogue to digital service^[145].

Virtual Reality – Improving Patient Experience

Having an MRI scan can be a daunting and unfamiliar experience. This can often be the case for children, when occasionally a scan has to be stopped if a child is too nervous. In some cases, general anaesthetic has to be used, which can also be a distressing experience.

Children who are anxious about having an MRI scan are being supported in NHS Highland by using a Virtual Reality (VR) app developed between the radiology and medical physics and bioengineering departments at Raigmore Hospital in Inverness^[146]. The project, led by NHS Highland radiographers, play specialists and a clinical scientist, was a collaboration with the Royal Belfast Hospital for Sick Children and King’s College in London. Using VR headsets provided by the ARCHIE Foundation and a standard smartphone, the app allows children to rehearse the MRI procedure through an interactive 360^o experience and to be more prepared for the appointment.

Since its launch, the app has won five national awards including the Viapath UK Award for innovation in healthcare science, and there are enquiries from across the world. The app has potential to reduce general anaesthetic prior to MRI by 50 per cent^[147] as well as achieving its primary aim of improving patient experience and providing more accurate results. Feedback from young patients and parents alike has been consistently positive and the VR offer is being rolled-out across the NHS Highland area.

Home and Mobile Health Monitoring

Home and mobile health monitoring, such as the Florence system^[148], is used to inform people’s self-management decisions and support diagnosis, treatment and care decisions by professionals through simple low-cost SMS text messaging. Florence, for example, allows people to send their readings to clinicians and sends reminders to people to take medication. Just under 15,000 people have benefited from this programme, with particular success in monitoring high blood pressure^[149]. The technology continues to be scaled-up and is now being used across many long term conditions.

Attend Anywhere

People across Scotland are increasingly making use of a secure, virtual consultation facility for GP appointments – providing convenience, reducing travel and disruption, and improving access. Developed in Australia, Attend Anywhere^[150] was launched in Scotland by the Cabinet Secretary for Health and Sport. The web-based service allows patients to consult health professionals using their own devices such as laptops, tablets and smartphones.

The facility provides a secure connection, allowing patients the opportunity to speak in real-time to their doctor, nurse, consultant or allied health professional. Each patient has a unique link with access to a secure virtual waiting room and consultation room. The system is purpose-built to meet the needs of the health and care sectors, with the ability to deliver video consulting services at scale. Attend Anywhere is now operational across Scotland, supporting some 80 clinical services and, since its launch, some 1,900 consultations have taken place. Patient satisfaction rates are high, with 98 per cent of users stating that they would use it again^[151].

NHS Near Me is a service developed by NHS Highland to avoid patients travelling long distances for clinic appointments. Patients are invited to attend their local hospital to use Attend Anywhere for the appointment or attend from home, rather than travelling to Inverness. During the initial phase of the programme, clinics were established between patients in Wick and consultants in Raigmore Hospital in Inverness. This stage focused on developing a process for embedding video consulting into NHS outpatient appointments. A total of 112 patients, over 10 clinical specialties, benefited from using the service in the development phase. NHS Near Me is now being rolled out across NHS Highland, with an aim to deliver 20 per cent of outpatient activity via Near Me by summer 2019.

The NHS Near Me^[152] service model is also being used as a blueprint for the development of video mediated services across NHS Scotland, and Attend Anywhere is supporting innovation and collaborative working between other NHS Boards. Hand surgery clinics in the Western Isles are being held in Stornoway with support from the local physiotherapist that links to the consultant in Glasgow. This provides a remote, first-contact service that allows patients to receive initial assessments by video, in order to prevent unnecessary travel to mainland Scotland. In addition to being more convenient for patients, each clinic saves the NHS around £3,000 in travel expenses^[153].

Workforce

A digital-first approach must be central to the planning and delivery of services in order to truly develop and transform the integration of health and social care in Scotland, consistently and at scale. Key to this is equipping the health and social care workforce with the necessary skills. Existing investment in the Nursing, Midwifery and Allied Health Professions Leadership Programme is creating digital champions to embrace and spread the importance of digital innovation. This is now an established programme and almost 200 nurses, midwives and allied health professionals have completed this initiative. The programme has generated a range of successful digital innovations in health and social care services, and the team behind it was Digital Leadership Team of the Year at the UK Digital Awards 2018^[154].