NHSScotland Chief Executive's Annual Report 2013/14

Chapter 3 Improving Quality of Care

IMPROVING QUALITY OF CARE

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

THE QUALITY AMBITIONS

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.

Improving Quality of Care
Person-centred Care

Listening to families.

"My other, older son Callum often comes to visit his brother on the ward and the staff are fantastic with him. They know him by name and take time to talk to him, so he actually enjoys going in to see David, which is a great help for me."
Evelyn

Evelyn and David's Story

David has cerebral palsy and his condition means that he has had to spend a lot of time in hospital. And that means his mum, Evelyn, and the rest of the family are regular visitors too.

"I think what's so important with any child, disabled or not, is to remember he or she is a wee person, who's probably a bit scared and obviously not feeling very well. Our local hospital is great, because we've had time to build up a relationship with the staff there and it's kind of a home from home", says Evelyn.

When David was about a year old and started to go into hospital on a regular basis, Evelyn felt she was being asked the same questions again and again, every time she visited. She understood that they were important questions, and as she and her son would tend to be seen by different members of staff on each occasion, it wasn't surprising that they were asked repeatedly. She did find it distressing, however, particularly as some of the information was quite personal and sensitive.

A simple solution was found by keeping a note of David's basic information on a single sheet of paper in his file, so any new healthcare worker meeting the family for the first time would have instant access to the key facts. This saves time for the professionals, as well as making David and his family feel more comfortable. If the family travels to another part of the country, their community children's nurse will contact a local hospital to let them know of David's current condition, writing a letter in advance and providing the family with a copy. This means that if David suddenly needs attention, the local healthcare staff will have all essential background information to hand, even though they may not have met him or his family before.

Evelyn sees it as a partnership between the family and the healthcare workers. Through good communication and co-operation, they're working together for everyone's benefit.

"I think when healthcare professionals care for the whole family, they're actually doing a better job for the patient. A few extra words of support and understanding make all the difference."
Evelyn

Delivering person-centred care is a strategic priority for NHSScotland and the Scottish Government, and essential to the delivery of our 2020 Vision for Health and Social Care. In 2013/14, activity across NHSScotland focused on strengthening the voices of people using services, their families and carers, and supporting health and care services to listen, learn and make improvements as a result.

Healthcare Improvement Scotland continued to work across NHSScotland and with third sector partners, to test and spread best practice in person-centred care as part of the Person-Centred Health and Care Collaborative.

More patients and families benefited from person-centred visiting in 2013/14. Analysis in March 2014 revealed that people are benefiting from a range of more flexible visiting arrangements in 500 wards across the country. Staff are being supported to develop and test new ways to ensure that patients can spend more time with the people who matter to them.

NHS Tayside's approach, for instance, has seen patients name the visitors they would like to have 24-hour access. All NHS Boards are now being supported, through the Collaborative, to enable friends and family to visit loved ones in hospital at more convenient times.

In NHS Greater Glasgow and Clyde, the What Matters to Me programme at the Royal Hospital for Sick Children gave every child old enough to take part the opportunity to draw or write a list of what matters to them on a poster displayed by their bed. This has helped children to feel more in control of their stay, and contributed to shaping a service that is informed by an understanding of how each child would like to be cared for. The approach has been rolled out to other wards and departments, and paediatric lead nurses from across Scotland have been invited to participate in the Collaborative, so that this approach can be spread across the country, and more children can be involved in their care in this way.

Data collected through the Scottish Care Experience Survey Programme in 2013/14 suggests that most people are positive about their care. In particular:

• 89 per cent of Scottish inpatients say overall care and treatment was good or excellent;^[31]
• 87 per cent of patients rated the overall care provided by their GP Practice as good or excellent;^[32] and
• 93 per cent of women rated the overall care received during labour and birth as good or excellent.^[33]

In particular, the results from the Inpatient and Health and Care Experience Surveys show that health services are generally good at listening to patients, providing appropriate explanations and treating individuals well.

PATIENT OPINION

At the beginning of the year the Cabinet Secretary for Health and Wellbeing announced funding for the independent website Patient Opinion^[34] to be rolled out across Scotland. Funding for a second year was confirmed in December 2013. Patient Opinion enables people to post their experiences of NHSScotland services - whether good or bad - anonymously online, wherever and whenever suits them. It complements existing processes in NHS Boards for dealing with feedback and complaints, but operates independently of government and the NHS, adding an independent dimension to the mix of ways in which NHS Boards can hear the voices of patients, families and carers.

Over 650 stories were posted across Scotland on Patient Opinion in 2013/14, and at the time of publication they have been viewed almost 300,000 times. These stories opened a constructive dialogue between people and healthcare providers that has, in a number of cases, led directly to change.

In 2013/14, for example, new arrangements were introduced for communicating results to patients travelling between Shetland and Grampian for breast screening, as a direct result of feedback posted on Patient Opinion.

THIRD SECTOR PARTNERSHIPS

NHSScotland's strategic partnerships with third sector organisations continued in 2013/14. The People Powered Health and Wellbeing Programme^[35], led by the ALLIANCE, brought together a number of third sector partners with expertise in delivering person-centred care, to enable people with lived experience to contribute to the design and delivery of services and to support local NHSScotland teams to make their services more person-centred.

The ALLIANCE and Royal College of General Practitioners received funding to explore ways in which Primary Care teams can support people to live well in their communities, by connecting them with local resources and support.

Funding was also provided to support the ALLIANCE and Thistle Foundation to work with three early adopter sites in NHS Tayside, NHS Greater Glasgow and Clyde and NHS Lothian to take forward the House of Care^[36] approach to care planning. This approach, which has an internationally-recognised evidence base, puts people and their families in the driving seat of their care. It supports people to develop their own plan of care in active partnership with health and care professionals, and to make full use of the wide range of community assets which can help them stay well.

Work continued to support people to have the knowledge, understanding, skills and confidence they need to use health information, to be active partners in their care, and to navigate health and social care systems. Making it Easy: A Health Literacy Action Plan for Scotland^[37], was launched at the NHSScotland Event in June 2014. It was published alongside an online resource, the Health Literacy Place^[38], which provides resources to help staff collaborate with patients in decisions about their care and support them to live well, on their own terms, with any health conditions they have.

CARERS

Carers have a vital role to play in our society, with more unpaid carers in Scotland than the total health and social care workforce. It is estimated that replacing the care provided by unpaid carers would cost Scotland £10.3 billion a year^[39].

It is important that carers, the person they care for, and those working in health and social care work together as partners to achieve better outcomes for all involved. When carers are recognised and involved as equal partners, this can improve the health, care and treatment of patients. Caring Together and Getting it Right for Young Carers: The Carers Strategy for Scotland 2010-2015^[40] set out 10 key actions to improve support to carers to sustain their caring role, which in turn supports the cared for person and alleviates the pressure that unplanned emergency hospital admissions place on NHSScotland.

The recent Health and Care Experience Survey^[41] indicated that around 15 per cent of respondents look after or provide regular help or support to others. Of these, almost one in three provided a significant time commitment of more than 50 hours care a week. Carers' responses to specific questions regarding their experiences were mixed. Carers were most positive about spending time with other people and having a good balance between caring and other activities. Carers were less positive about the impact of caring on their health with 32 per cent indicating that caring had a negative impact.

NHS Education for Scotland received funding to work with the Scottish Social Services Council to produce Equal Partners in Care (EPiC): Core Principles for Working with Carers and Young Carers^[42]. These principles and framework were developed in collaboration with a range of carers, carers' organisations, workers, educators, and professional and regulatory bodies, and were launched by the Scottish Government in 2013.

Funding of £28.9 million has been provided to NHS Boards and the Scottish Ambulance Service for direct support to carers between 2008-15, with £5 million in 2013/14 to take forward a wide range of initiatives to support carers and young carers. In 2013/14, NHS Boards were asked to continue to support previous priorities including funding of carers centres across Scotland which provide a range of services such as advocacy and advice, carer training, workforce training and short breaks.

NHS Lanarkshire and PAMIS -
Lanarkshire Postural Management Project

PAMIS provides support to families caring for someone with profound and multiple learning disabilities. Through engagement with carers, it was recognised that poor postural management can significantly impact on the body shape, image and pain levels of the cared for, detrimentally impacting on the quality of life for the cared for person and the carer. In response, NHS Lanarkshire provided funding to PAMIS Family Support Service for the development of a project to promote the benefits of postural management. As a result of this, carers have engaged with NHS Lanarkshire physiotherapists in the development of a postural management pathway. Carers have developed materials which have helped families understand the importance of postural management and help prevent the development of significant body distortion.

SELF-DIRECTED SUPPORT

The Scottish Government and CoSLA are committed to driving a cultural shift around the delivery of care and support in Scotland with Self-directed Support (SDS) becoming the mainstream approach. The National Strategy^[43] for SDS is a 10-year strategy which was launched jointly with CoSLA in November 2010. The strategy aims to give individuals more choice and control over their health and social care support, empowering them to identify and communicate the outcomes which they feel will lead to them living a more independent and fulfilling life. It is based on five key principles: respect; fairness; independence; freedom; and safety.

During 2013/14, work was undertaken to progress the Self-directed Support (Direct Payments) (Scotland) Regulations through Parliament in readiness for the Act commencing in 2014. Statutory guidance on SDS was also developed in collaboration with stakeholders to provide a ministerial steer to local authorities. The Social Care (Self-Directed Support) (Scotland) Act 2013 came into force on 1 April 2014. The Act places a duty on local authorities to offer people choice as to how they receive their support. Local authorities will also be required to provide information and support to ensure that individuals can make informed choice as well as ensuring that the resources they allocate to a person are sufficient to meet their needs, and any provision or assistance should be based on a detailed and outcomes-focused social care assessment of which the individual should be an integral part.

FEEDBACK AND COMPLAINTS

In the majority of cases, the care people receive is exceptionally good. However, we know that this sometimes falls below the standards people expect and deserve.

Across NHSScotland, complaints increased to 20,364 in 2013/14, an increase of 23 per cent compared to 2012/13. The total number of complaints received by hospital and community health services increased by 29 per cent. This reflected a significant increase in prisoner complaints (from 151 in 2012/13 to 2,967 in 2013/14), and showed that actions taken by NHS Boards in 2013/14 to ensure that prisoners have easier access to the NHS complaints procedure are now having an effect.

Whilst it is encouraging that more people are aware of how to use NHS complaints system, every complaint is regrettable and should be used to identify changes or improvements that could be made to further improve quality of care and treatment.

This was the first year NHS Boards were required to publish annual reports showing where lessons have been learned, and action taken to improve services, as a result of feedback and complaints. NHS Boards have since reported on their handling of feedback, comments, concerns and complaints in 2013/14, and these reports outline some of the work underway across Scotland to listen to people's voices and use the feedback to make services more person-centred.

NHS Forth Valley's report, for instance, describes how the Board set out to hear and understand the voices of young carers, and use this learning to support staff to improve outcomes. NHS Orkney reports that it has introduced yellow 'Nurse in Charge' badges, so that people know who to approach with any concerns about their care, and NHS Fife describes how the Board takes a person-centred approach to complaints handling by engaging with the person making a complaint from the outset. This approach enables the Board to determine what matters most to the individual, and to tailor the way in which the complaint is handled.

Improving Quality of Care
Safe Care

Raising awareness of a global killler.

"Even as a small charity, living in the information age means we can reach thousands, perhaps millions of people really quickly. Working with Healthcare Improvement Scotland, for instance, we've produced a short animated film that's raised awareness amongst health professionals and the general public."
Craig Stobo,
Founding Chair, FEAT

Craig's Story

In less than 62 hours, Craig's life changed dramatically and irrevocably as a result of sepsis.

Falling ill at his workplace, Craig's initial flu-like symptoms were diagnosed as sepsis during an emergency appointment with his GP. Prompt treatment with antibiotics and intravenous fluids saved his life. The following day his wife Fiona, who was 35 weeks pregnant, was herself rushed to hospital with sepsis. Despite immediate treatment her condition quickly became very grave, the baby girl she was carrying died in utero, and she herself passed away the following morning.

Sepsis is a life-threatening whole-body inflammation which occurs when the body's response to infection damages its own tissues and organs. It's one of the world's biggest killers, with at least 18 million people dying of the condition every year. In the UK alone, sepsis kills around 37,000 each year - more than breast, bowel and colon cancer put together. And the incidence of sepsis is rising by somewhere between 8 and 13 per cent each year.

The onset of sepsis is extraordinarily fast, which is what makes the condition so dangerous. If the patient is treated with antimicrobials and intravenous fluids within the first hour, survival rates can be higher than 80 per cent - but that means prompt diagnosis is literally a matter of life and death.

In the aftermath of his terrible experience of the condition, Craig helped to found a charity, the Fiona Elizabeth Agnew Trust or FEAT, named after his late wife. FEAT campaigns for sepsis research and education, and has raised over £50,000 since its inception in 2013. Much of that money is being made available to fund research through a series of FEATURES awards, and the first grants will be awarded early in 2015. The charity works closely with both the Scottish Patient Safety Programme and Healthcare Improvement Scotland, collaborating on initiatives including World Sepsis Day, and in distributing information throughout the NHS in Scotland.

Sepsis is an extremely serious condition, but FEAT is run on the principle that raising funds and building awareness can and should be fun. The charity's Sock it to Sepsis campaign saw hundreds of stripy red-and-white socks appearing throughout Scotland - and helping to kick this horrific condition into touch.

Sepsis is just one of the harms being tackled by the Scottish Patient Safety Programme, with NHSScotland continuing to receive international acclaim for its approach to implementing improvements in patient safety. During 2013/14, the Programme continued to show evidence of improvements in the safety of care with demonstrable improvements in reliability for the Sepsis 6 treatment package, including antibiotics within one hour of sepsis diagnosis and venous thromboembolism (VTE) risk assessments have been achieved across many NHS Boards.

The Scottish Patient Safety Programme (SPSP) was launched in January 2008 to reduce avoidable harm in NHSScotland and transform the safety of acute care for patients. The Programme's ambition to improve safety has increased as it has spread into complementary areas.

The SPSP is the world's first national safety improvement programme. It aims to support frontline staff to improve care using applied improvement methodology to reliably implement key processes and successful improvements. The SPSP has promoted the application of a set of tested, evidence-based interventions using an improvement model and plan- do-study-act (PDSA) cycles.

A key element of the programme is that the changes have been led by the staff who are directly involved in caring for patients. Staff can monitor improvements through the collection of real time data at the individual unit level. The work is dependent on the full participation of NHS Boards and staff, and is supported and led nationally by Healthcare Improvement Scotland (HIS).

The second phase was launched in January 2013 to build on the established practices and progress made in the first phase and to bring focus to a number of priority areas for improvement. It was launched with the aims to achieve a 20 per cent reduction in Hospital Standardised Mortality Ratios (HSMR) and 95 per cent harm-free care, by December 2015. The work in acute care has been extended to include sepsis and VTE. Complementary programmes to improve safety in Primary Care and mental health are underway. In March 2013, the Maternity Care Quality Improvement Collaborative (MCQIC) was launched. This name was subsequently changed to Maternity and Children Quality Improvement Collaborative to reflect wider work on paediatric and neonatal care.

In September 2013, the Scottish Government wrote to NHS Boards (Chief Executives Letter CEL 19^[44]) to set out expectations for the universal implementation of 10 Patient Safety Essentials to be delivered to all patients who might benefit. NHS Boards have been asked to ensure that staff are supported to deliver these measures reliably and consistently. The Scottish Government requested that the emphasis should now shift from testing and spread towards sustainable universal implementation. This will require different approaches to ensuring that these interventions are adopted as standard in all clinical areas.

Source: Aggregated SPSP self-reported data - shown from participating sites/ wards only

Outcomes for a number of the Patient Safety Essentials are reflected in the Annual Scottish Intensive Care HAI Prevalence Report^[45] published by Health Protection Scotland and the Scottish Intensive Care Society Audit Group. Data from January to December 2013 showed the lowest rates since reporting commenced in 2010 for Ventilator Associated Pneumonia (VAP), Blood Stream Infections (BSI) and Catheter Related Blood Stream Infections (CR-BSI). The rates for VAP and BSI are at the lower end of the range of those seen across the rest of Europe.

There is widespread implementation of the surgical brief and pause (also known as the World Health Organization surgical safety checklist), with an 18.7 per cent reduction in surgical mortality between 2008 and 2014.

Work is underway to better integrate improvement and inspection processes. Healthcare Environment Inspectorate (HEI) inspections report emerging evidence that Peripheral Vascular Catheter (PVC) bundle reliability is being delivered reliably and consistently to patients in NHSScotland.

Executive Director walkabouts where Executive Board Members meet with staff locally to look at ways of doing things better and safer have proved to be very popular and have led to many simple but effective improvements within wards and clinical areas.

Hospital Standardised Mortality Rates (HSMR) are a way of measuring mortality rates in acute hospitals, attempting to adjust for age, gender and reason for admission. Scotland's HSMR has decreased by 14.4 per cent between October to December 2007 and January to March 2014. Twenty-nine hospitals participating in the SPSP have shown a reduction in HSMR since October to December 2007. Thirteen of these hospitals had a reduction in excess of 15 per cent, with five showing a reduction in excess of 20 per cent - Crosshouse Hospital, NHS Ayrshire and Arran (33.3 per cent); Southern General Hospital, NHS Greater Glasgow and Clyde (21.3 per cent); Ninewells Hospital, NHS Tayside (20.9 per cent); Wishaw General Hospital, NHS Lanarkshire (21.2 per cent); and Western Isles Hospital, NHS Western Isles (22.6 per cent). Rolling annual HSMRs show that there was a sustained reduction in hospital mortality between 2009 and 2011; the level remained relatively constant until mid-2013, with subsequent data showing a further reduction in hospital mortality^[46].

Source: ISD Scotland

Following concerns about the quality of care in NHS Lanarkshire, Healthcare Improvement Scotland published its Rapid Review of the Safety and Quality of Care for Acute Adult Patients in NHS Lanarkshire^[47] in December 2013. Following this, NHS Lanarkshire has made significant changes in the structures and processes it has in place to support the actions that Healthcare Improvement Scotland identified as necessary. It has increased improvement support resources, invested in additional nurse and medical staffing, implemented new hospital management structures and has changed the way in which it measures, monitors and reports on the quality and safety of care. NHS Lanarkshire has also significantly improved the way in which it responds to feedback and complaints. The NHS Board is now working to ensure that there is a sustained focus in all of the areas identified for improvement - ensuring that there is staff engagement and involvement with this work at all levels - and that the changes it has made in quality monitoring and improvement support are consistently and effectively implemented.

The SPSP has developed a range of tools and resources to support those working within Primary Care to improve safety and reduce harm. During 2013/14, the number of GP Practices across NHSScotland participating in the safety climate survey has increased to 90 per cent.

Oakley Health Centre in Fife used its positive survey results in a recruitment advert and the practice found itself being able to quickly fill vacancies for two new doctors.

"It has been a real bonus to reap such a positive spin-off benefit from the survey. This had undoubtedly had an impact on the candidates we were able to attract, but during the interview process the survey was also discussed in great depth, allowing us to highlight our commitment to continually improve the safety and care of our patients."
Dr Iain Mathie, Oakley Health Centre

GP Practices are also being supported to improve processes for the prescribing and monitoring of high-risk medications. To date, 819 GP Practices across Scotland have introduced care bundles with 83 per cent monitoring at least one bundle in areas such as warfarin and disease modifying anti-rheumatic drugs.

Work in the mental health programme is focused on reducing levels of harm in adult psychiatric inpatient units and includes the development and implementation of the Patient Safety Climate Tool, a Scottish innovation that is leading the way in person-centred, safe delivery of care. With the facilitation of a number of third sector organisations, over 200 patients across Scotland have had the opportunity to participate in this survey to date. The results are then used to inform improvement work locally.

"The Patient Safety Climate Tool will give patients the chance to express their feelings and concerns about their safety while on a ward. This information will then allow services to make any improvements needed, resulting in a better patient experience of hospital care."
Gordon Johnstone, Director of Voices Of eXperience

The Mental Health Safety Programme has co-opted, tested and developed a safety climate tool with patients and service users. This enables people to share how they feel about their experience of care. It has been used in 11 NHS Boards with 270 service users.

Funding has also been secured from the Health Foundation to explore the contribution that pharmacists can make to delivering safer care in community pharmacy and general practice settings.

Measurement of safety climate in Scottish maternity units is underway as part of the Maternity and Children Quality Improvement Collaborative (MCQIC). Since its launch, there has been a 125 per cent increase in the number of pregnant women offered carbon monoxide monitoring. This is a test which can help pregnant women to understand the dangers smoking can cause them and their unborn baby, and is a useful aid in reducing smoking during pregnancy.

Source: ISD Scotland: Hospital Standardised Mortality Ratio

It is important that improvement efforts and inter-relationships between person-centredness, safety and flow are integrated. The hospital safety huddle (for safety prediction and flow) has been successfully implemented in all three Scottish paediatric hospitals and is being implemented in a growing number of acute adult hospitals, with NHS Lothian and NHS Ayrshire and Arran recently introducing this fundamentally-important team activity. One objective of the SPSP is to support the spread of this to all acute hospital sites in Scotland.

Work has been undertaken to provide better and integrated reliable anticipation, recognition and person-centred response to deteriorating patients across the continuity of care from primary and community settings to hospital. Data from NHS Boards indicates progress towards a reduction in cardiac arrests amongst participating NHS Boards.

The Scottish Patient Safety Fellowship was introduced to develop and strengthen clinical leadership and improvement capability to support the implementation of the SPSP. A total of 105 fellows have now been trained and the 7th cohort has recently commenced its fellowship programme. NHS Education for Scotland (NES) currently leads the delivery of the fellowship programme in collaboration with Healthcare Improvement Scotland (HIS). The programme attracts international participants from The Republic of Ireland, Northern Ireland, England, Denmark and Norway.

The Quality Improvement Hub was established to support NHS Boards and clinicians to build and embed improvement capability.

Don Berwick, former adviser to President Obama, and the founder of the Institute for Healthcare Improvement, who was tasked with improving patient safety in NHS England has said that "the Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world". His report, published in August 2013, drew on the expertise of Jason Leitch, Scottish Government lead for the SPSP. Ten of the 11 recommendations that Berwick made were already in place in Scotland.

HEALTHCARE ASSOCIATED INFECTION

Reducing Healthcare Associated Infection (HAI) is a priority for Scottish Government Ministers and NHSScotland. It is vital that people have confidence in the quality of healthcare they receive in hospitals and other healthcare settings and that zero tolerance to infections is adopted. A wide range of measures has been put in place to reduce HAI and improve healthcare outcomes.

From 2008 to 2011, the Scottish Government provided over £65 million to tackle HAI and continues to provide substantial financial support for the HAI Delivery Plan^[48]. This includes nearly £2 million annually to NHS Boards to employ key infection control personnel consisting of Infection Control Managers, Antimicrobial Pharmacists, and HAI Quality Improvement Facilitators. A revised National Cleaning Services Specification^[49] has been implemented and over £5 million of additional resources made available to NHS Boards annually since 2009 to pay for hundreds of additional cleaning staff.

Evidence of work to reduce HAIs is demonstrated by the latest NHSScotland statistics (published October 2014) which show that, since 2007, cases of Clostridium difficile in patients over 65 have reduced by almost 82 per cent and that MRSA has fallen by just over 89 per cent in the same timescale (the lowest number of MRSA cases since mandatory surveillance began)^[50].

Point Prevalence Survey (PPS) results, last published in 2012, indicated that cases of HAI in Scotland were around a third lower than when the previous PPS was published in 2007. PPS results are published for acute settings and care homes. A further PPS will be undertaken in 2016.

Compliance with hand hygiene remained at 95 per cent to 96 per cent during 2012. Health Protection Scotland published bi-monthly reports into hand hygiene compliance until the final report on 25 September 2013 which confirmed 96 per cent national compliance with hand washing opportunities. Monitoring is now reported locally by NHS Boards.

Source: Aggregated SPSP self-reported data; shown from participating sites/ wards only

The latest figures published by Health Facilities Scotland on 7 August 2014 show that NHS Boards continue to achieve high cleaning standards with national domestic services (cleaning) compliance for the period April to June 2014 remaining high at 95.6 per cent for Scotland and that all acute hospitals, health boards had achieved a Green compliance rating. For the same period, estates services reported an overall Green rating compliance of 95.7 per cent.

Over £6 million has been invested in HAI-related research since 2007 via the Scottish Infection Research Network (SIRN). SIRN is about to establish a Scottish National Research Consortium to develop research that deals with emergent threats to the Scottish population from HAI and emergent organisms. The Consortium will strengthen the HAI research infrastructure within Scotland by integrating both local and national expertise, and will include collaborations from across Scotland and, where necessary, the UK.

A review of HAI priorities for the next five years is underway.

ANTIMICROBIAL PRESCRIBING

Prudent prescribing and active stewardship of antibiotics is vital in the prevention and control of infections such as Clostridium difficile, MRSA, MSSA and E. coli bacteraemia.

Figures from the latest Scottish Antimicrobial Prescribing Group (SAPG) report^[51] published in October 2014 show that there has been a decrease of 6.5 per cent in the total number of prescriptions for antibacterials in Scotland. This is equivalent to a decrease of 276,383 prescriptions in 2013/14. The use of broad spectrum antibacterials associated with higher risk of Clostridium difficile infection reduced by 11.6 per cent (44,173 fewer prescriptions) in 2013/14 than in 2012/13. This is the fifth successive year in which a reduction has been observed.

INSPECTION

The Scottish Government operates a robust scrutiny and inspection regime, which continues to drive improvements in HAI. It is the remit of the Healthcare Environment Inspectorate (HEI) to undertake a programme of inspections in acute, non-acute and community-based hospitals. It carries out a cycle of at least 30 risk-based inspections each year, most of which are unannounced.

The HEI Chief Inspector's fourth and latest annual report was published in February 2014^[52]. Headline figures show that the Inspectorate made 104 requirements and 90 recommendations. Requirements and recommendations have reduced significantly since the Chief Inspector's first annual report, demonstrating the improvements and progress that have continued to be made by staff across hospitals in NHSScotland.

In the HEI Chief Inspector's fourth and latest annual report, published in February 2014, HEI Chief Inspector, Susan Brimelow, stated: "Overall, the public should be assured by our findings which show that NHSScotland continues to make good progress in raising standards of hospital cleanliness, hygiene and infection control."

Older People in Acute Hospitals Inspections began in 2012, following an announcement by the then Cabinet Secretary for Health and Wellbeing in June 2011. The inspections were to provide assurance that the care of older people in acute hospitals is of a high standard. As of 31 March 2014, there had been 25 inspections of which five were unannounced and four additional unannounced follow-up inspections. The inspection programme continues with a revised methodology, following the recommendations set out in the Report for the Review and Methodology and Process for the Inspection of the Care of Older People in Acute Hospitals (the Whittle Report) which was published in November 2013^[53]. Healthcare Improvement Scotland continues to test out new elements with its methodology for the inspection process.

Improving Quality of Care
Effective Care

Breaking with the old ways - a world-leading virtual fracture clinic at Glasgow Royal Infirmary.

"Before the new system was in place, patients would automatically come to the clinic with minor injuries which didn't need operative treatment. We'd often see a patient wait three hours to spend five minutes with a consultant, only to be sent away and told to rest. That just doesn't happen anymore - they're here only when they need to be, and they see the right specialist first time."
Margaret Nugent, Fracture Clinic (FC) Redesign Audit Nurse, Glasgow Royal Infirmary

Margaret's Story

Under the old system at Glasgow Royal Infirmary, a patient with a minor fracture injury would typically attend the Emergency Department for initial treatment. They'd be told to come back within a day or so to attend the Fracture Clinic, where they might wait hours to see a consultant even if the injury did not require attention. The experience was often distressing and inconvenient for the patient, and an inefficient use of valuable resources.

A new, more efficient pathway costs practically nothing to implement but delivers a significantly improved patient experience while saving time and resources. It may sound almost too good to be true, but by making a complex system simple, a redesigned fracture service has achieved this win-win scenario. Now it's being emulated throughout the UK and beyond.

The new pathway has been developed by Glasgow Royal Infirmary's Orthopaedic and Emergency Departments and Stobhill Minor Injuries Unit. Now patients who can be safely discharged are given information to help them monitor their own condition, together with contact details for the Virtual Fractures Clinic. They can phone or walk in to the Clinic any time it's open - and as of 2014, it's been a seven day service.

"The Virtual Clinic is an open-door system, so patients can come back any time they like. The great thing is that they usually don't need to, so everyone benefits" says Margaret.

In most cases the patient can be dealt with on the spot, but if they do need to see a consultant, they're given an appointment with the appropriate specialist at a defined time.

By promoting self-care and shared decision making, the pathway avoids unnecessary visits, freeing up time and resources to improve standards of patient care in more complex situations.

The new system is resulting in markedly increased patient satisfaction, together with cost savings calculated at up to £156,000 per year.

Unsurprisingly this local solution has attracted global interest, with more than sixty hospitals talking to GRI about implementing a similar system.

"With built-in failsafe features including x-ray reviews, the new system is more secure and it saves patients - many of them elderly - the distress of travelling to attend hospital when they're in pain or feeling vulnerable. There's also a welcome side-effect in that patients spend less time in the Emergency Department. We give them practical, simple self-care information and discharge them quickly, knowing they have access to the Clinic as and when they need it."
Alastair Ireland, Clinical Director, Emergency Medicine, NHS Greater Glasgow and Clyde

Many of the areas for improvement that have been prioritised during 2013/14 make a direct contribution to our Quality Ambition for more effective healthcare services. A focus of this activity has been to identify those 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.

INTEGRATING CARE

What people expect are services that work in a co-ordinated way with them, to understand what matters most in their lives, and to build support around achieving the outcomes that are important to them. Many of those outcomes will involve keeping them safe, physically and mentally well - out of hospital, in their homes and local communities, in the best possible health; but as important will be that the co-ordinated support people receive also enables them to live their lives the way they would like to live them, including in relation to their housing, mobility and social needs.

At the beginning of April 2014, the Scottish Parliament unanimously passed the Public Bodies (Joint Working) (Scotland) Act 2014 which will come into effect from April 2015. It puts in place a framework to make sure that health and social care services are planned, resourced and delivered together by NHS Boards and Local Authorities to improve outcomes for people using services, their carers and families. The new arrangements, which apply primarily to adult health and social care services (NHS Boards and Local Authorities can also choose to include other functions in their integrated arrangements locally), includes a strong role for the third and independent sectors, clinicians, social workers, other professionals, and local service users and communities.

NHS Boards and Local Authorities will establish integrated partnership arrangements, called Integration Authorities, which will replace Community Health Partnerships, and will deliver national outcomes for health and wellbeing. Integration Authorities will set up locality arrangements with local professional leadership of service planning. There will be a heavy emphasis on the importance of effective strategic commissioning of services underpinned by a good, shared understanding of the population's needs, and informed by professional and local community input.

"The integration of health and social care presents the opportunity for the radical redesign of health and care services through the creation of seamless, person-centred care pathways from the home, through the community to our acute services. The empowerment of our local communities to shape these new services through the participation of elected council members, health professionals, service users, carer and voluntary groups in making the vital strategic decisions, in areas traditionally controlled by councils and by the NHS, is also, I believe, essential to ensuring the delivery of efficient and effective high quality services tailored to best meet the needs of our communities."
Councillor Peter Johnston, COSLA Spokesperson for Health & Wellbeing

NHS Boards and Local Authorities are now setting up shadow integrated arrangements and developing their integration scheme which must be submitted to Ministers for approval. Integration Authorities must be fully functioning by 1 April 2016.

NHSScotland and its partners in local government, and the third and independent sectors are committed to putting in place a system of health and social care that is robust, effective and efficient, and which reliably and sustainably ensures the high quality of support and care for people who use health and social care services.

"The Public Bodies (Joint Working) (Scotland) Act 2014 is an important step towards transforming health and social care across Scotland. People who use support and services, carers and the third sector have long argued for integrated, high quality support that enables people to access their right to good health, dignity and independent living.

"As we move beyond the legislation the real work begins. The new Health and Social Care Partnerships have a crucial role in building on the Reshaping Care for Older People Programme and Change Fund, and driving the shift towards person-centred, sustainable models of support."
Ian Welsh, Health and Social Care Alliance

Health and Social Care Integration in Tayside

In Tayside, three new Integration Authorities are being set up in Perth and Kinross, Angus and Dundee. A Chief Officer has been appointed to each Integration Authority to lead the transition arrangements in their local area. The new Integration Authorities will be accountable to NHS Tayside and to their Local Authority.

"In Perth and Kinross we are keen to build on the existing strengths of our collaborative working with our local partners. This will allow us to concentrate straight away on improving outcomes for service users.

"I'm excited by the possibilities of health and social care integration becoming truly patient and service user-focused in Perth and Kinross. We need to move away from doing things 'to' people and towards having a conversation with them, finding out what care and support they want, and making sure they understand their options. There's also a real chance to pool local knowledge so that we can target early intervention where it is most needed.

"With more choice and control for patients, service users and their families and carers, we are working towards providing an integrated service that produces real, positive outcomes for individuals."
John Walker, Chief Officer Integrating Health and Social Care in Perth and Kinross

PRIMARY CARE

For many people, Primary Care is the part of NHSScotland service provision that they will come into contact with most, covering day-to-day interactions with GPs, Pharmacists, Dentists and Optometrists. It also spans many of the community nursing and allied health professional services received in the community or at home. In General Practice alone, there are around 25 million appointments in Scotland every year. These professionals deal daily with a wide range of people in many different settings. They have a significant role in understanding the needs of their community and in ensuring services are tailored to meet those needs.

As in other parts of the service, pressure on Primary Care continues to increase as the population grows and people are living longer with one or more long term conditions. Achieving our 2020 Vision will require a major shift in thinking and resources from acute hospitals towards primary and community care. Supporting Primary Care professionals to help people manage their long term conditions within the community and ensuring that as much time as possible is freed up to deal directly with patients and in planning for their needs are key priorities.

In pharmacy, Prescription for Excellence^[54] charts the development of the pharmacy profession over the next 10 years to ensure all patients, regardless of their age and setting of care, will receive the highest quality of pharmaceutical care using the clinical skills of the pharmacist to their full potential.

In order to meet the needs of people in areas of high deprivation, NHS Boards are delivering new models of services such as Link Workers in some Deep End GP Practices.

Given the challenges presented by an aging population, health inequality, rurality and many other factors there is still a long way to go. But meeting these challenges is crucial to ensuring safe and effective patient care throughout health and social care.

Key to achieving this has been a new approach to the GP Contract. Until 2012, the GP Contract had been negotiated annually on a UK-basis with some Scottish variation. In late 2013, however, a Scottish contract was negotiated which reduced GP bureaucracy, emphasised quality of service, and asked that every GP Practice in Scotland conduct an annual review of access to support patient appointments. This was welcomed by GPs and, with later confirmation that this contract would apply until 2017, has brought much needed stability to General Practice. The aim for 2017 is to have a much simpler GP Contract in place that supports the role of GPs in primary and community care, ensures they have the time to deliver safe and effective care for those who need it, and supports the integration of health and social care.

Developments in Community Optometry have resulted in the first NHS Prescribing Pads being issued to 68 Optometrists across Scotland. These independent prescribers are now managing more patients than ever before within the community without the need to refer on to the hospital eye service. Over £1 million has also been provided to develop the skills of Community Optometrists through education delivered by NHS Education for Scotland. Advanced clinical skills are being taught to support improved patient care within Optometry practices.

UNSCHEDULED CARE

The challenges witnessed during the 2012/13 winter period were unprecedented in recent years and, as a result, unscheduled care performance deteriorated in line with other parts of the UK and, indeed, other similar health systems across the world. The Scottish Government recognised that radical measures had to be put in place to improve performance and launched the three year, £50 million Unscheduled Care Action Plan in February 2013^[55]. The key elements of the Action Plan support improvements, transformation and sustainability of unscheduled care performance whilst supporting patient flow through the hospital.

Substantial funding was invested during 2013/14, both centrally and locally (£30 million), in recognition that NHS Boards would need to commit considerable resources in the first year of the Action Plan. This has led to significant results, particularly for those patients waiting over 12 hours in A&E with a 56 per cent reduction between 2012/2013 and 2013/2014. Fewer than 1 per cent of all patients waited longer than 8 hours^[56].

Other improvements include the recruitment of additional staff, including 18 A&E consultants and the roll out of digital whiteboards to improve the flow of patients throughout hospitals right across Scotland.

The first year of the Action Plan is already delivering better and faster care for the people of Scotland, with years two and three focusing on further sustainable improvements and whole system approaches - creating local Community Partnerships where hospitals and primary/community care services are aligned and focused on patients being seen by the right member of the multi-disciplinary team, at the right time.

While the majority of patients continue to get the excellent care they deserve within shorter waiting times, there is still more to be done. There are ongoing challenges also being experienced by the other UK countries and beyond. NHSScotland is continuing to work with its partners to address these challenges and bring about sustained improvements for the people of Scotland.

CARE FOR MULTIPLE AND CHRONIC ILLNESS

Helping people to live longer, healthier lives at home or in a homely setting will involve people having to manage their health condition. With an aging population, for many that will mean managing multiple and chronic illnesses. An action plan^[57] was developed to improve the care and support for people who live with multiple conditions. This Action Plan describes actions we must take on whole person, whole team, and whole system levels.

For the whole person, this will mean changing the conversations we have and shifting the relationship between the person and the professional in every consultation. From April 2013, more than 120,000^[58] people have had an Anticipatory Care Plan developed and shared so that other health and care providers are aware of their care preferences in the event of a future deterioration, or a sudden change in circumstances for their carer.

Three community wards in Ayrshire and Arran provide an anticipatory care service for people with long term conditions and home-based health care wherever possible. The various skills used include advanced clinical assessment, differential diagnosis, review and administration of medications, and proactive anticipatory care planning and co-ordination.

"I feel less anxious knowing I can get help and advice at the end of the telephone, knowing that community ward staff will explain what is happening and what I should do to remedy the situation."
Patient

"The community ward service has helped to keep me out of hospital for over one year and I am very grateful to them."
Patient

For the whole team, this will involve developing new ways for health and care professionals to work together, and with volunteers and community support services, around the GP Practice. For example, a Lothian GP used headroom funding to participate in a cross-sector leaders programme in order to learn more about the worlds of others and to consider how to work better together. As a result of this, the GP invited Thistle^[59] to establish a presence in her surgery to build a relationship with the Primary Care team. Thistle is receiving a small but consistent number of referrals to their lifestyle management programmes.

At a whole system level, improvements will be required in the way that care and support is planned and coordinated across the whole pathway between home and hospital.

DEMENTIA

Scotland's second three-year National Dementia Strategy was published in June 2013^[60]. It continues to focus on supporting local change and improvement in dementia services and individual outcomes in all care settings and for all stages of the illness.

From April 2013, everyone in Scotland newly diagnosed was given what has been described by Alzheimer Scotland as a world-leading guarantee of a minimum of a year's worth of dedicated post-diagnostic support coordinated by an appropriately-trained and named Link Worker. The service adopts Alzheimer Scotland's '5-Pillar' model of support and is designed to enable people with dementia and their carers to adjust to a diagnosis, connect better to the range of services and support available and plan early for future care options. The guarantee is underpinned by a HEAT target that everyone newly diagnosed will be receiving this service by 2016. The target is also helping to sustain the HEAT diagnosis standard by focusing services on the benefits of timely diagnosis as a gateway to effective post-diagnostic support.

Throughout 2013/14, funding has been provided for the ongoing roll-out of the Promoting Excellence^[61] national dementia health and social care workforce framework, to support the workforce in implementing the Standards of Care for Dementia in Scotland and achieving better quality and more consistent outcomes for people with dementia. This includes updating pre-registration education, increasing access to psychological therapies and improving training and awareness about dementia for adult day care and residential care home staff.

In 2013 a national action plan^[62] was published to improve dementia care and outcomes in general hospital settings, and funding was provided along with Alzheimer Scotland for the Alzheimer Scotland dementia nurse network to help lead strategic change in this area of care at NHS Board level. In addition, around a further 100 Dementia Champions, drawn from the frontline of care, were trained and will graduate in early 2015, taking the overall number to 500 with a further 100 to be trained in 2016.

In August 2014 the Scottish Government's response and action plan was published^[63] following The Mental Welfare Commission's critical report in June into specialist and continuing dementia NHS care settings^[64]. This includes an initial round of NHS Board self-assessments, which will be submitted to, and assessed by, the Scottish Government in late 2014.

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES

The two HEAT access targets in Child and Adolescent Mental Health Services (CAMHS) and Psychological Therapies (access to specialist CAMHS treatment within 18 weeks from December 2014 and access to a psychological therapy within 18 weeks from December 2014) are driving improvement in mental health through service redesign, strong leadership and the hard work of clinicians and other staff.

Latest figures for the CAMHS access target show that in the quarter ending September 2014, just over 3,300 children and young people started treatment at Child and Adolescent Mental Health Services in Scotland, with 78 per cent seen within 18 weeks. Progress has also been seen in growing the workforce. Since 2009, the CAMHS workforce in NHSScotland has risen from 764.6 WTE in September 2009 to 936.4 WTE at the end of September 2014^[65]. Data quality and collection continue to be amongst the challenges to delivery, emphasising the importance of investment in information systems and outcome measurement.

In 2002, the Scottish Government set a target of reducing the suicide rate in Scotland by 20 per cent by 2013. Since then the Scottish Government has worked with a range of partners, across sectors, to improve mental health services and the diagnosis of depression and mental health problems. More support is now available for those affected and much has been done both to improve safety for patients experiencing mental health problems and to tackle the stigma of mental ill-health. Over the period 2002-2013, suicide rates in Scotland have fallen by 19 per cent, demonstrating that suicide is preventable and that having the right support available can make a big difference^[66].

DETECTING CANCER EARLY

The Detect Cancer Early (DCE) programme was launched in February 2012 to address the poor quality of life and poor survival rates resulting from late diagnosis of cancer. The sooner that cancer is diagnosed and treated, the better the survival outcomes and, in the case of advanced or incurable disease, increases the possibility of treatment that prolongs life or manages symptoms. The programme has successfully delivered four social marketing campaigns to help people identify the signs and symptoms of cancer earlier, encourage them to seek advice from their health professional, and equip them with information that allows them to make an informed choice about participating in cancer screening programmes.

As an example of the impact of the campaigns, following the breast awareness phase, there was a 50 per cent increase in the number of women attending their GP with breast symptoms compared to the previous year. The bowel screening campaign is influencing more people from the most deprived areas in Scotland to take up the invitation to screen (from 41.9 per cent to 43.6 per cent). Men in particular have increased from 39.6 per cent to 41.7 per cent. Also, there are indications of an increase in the volume of chest x-rays carried out, linked to the timing of the lung campaign^[67].

One of these key change themes is 'Reducing Child Poverty'. Pioneer sites working to improve the uptake of Healthy Start Vouchers are seeing an improvement, where better communication and enhanced documentation have led to pregnant women and young children receiving support to access healthy food and vitamins at critical times for them in terms of brain development for growing babies and children.

This work has captured the imagination of other members of the Collaborative who have now formed themselves as 'shadow sites' to scale up and spread this important intervention. Thirteen of the CPPs are either working on or planning to work on better uptake of healthy start vouchers and vitamins and are working together to learn from each other to improve faster.

The Teenage Cancer Trust is being supported by the programme to provide cancer awareness in schools that will help maximise the awareness messages amongst families of teenagers and a new Primary Care initiative recognises the importance of the role of GPs in supporting informed uptake of screening. Healthcare Improvement Scotland (HIS) has published refreshed Scottish Referral Guidelines for Suspected Cancer^[68] and education sessions for Primary Care professionals have been conducted in partnership with cancer charities. NHS Boards are being funded to take forward implementation plans to improve diagnostic and treatment capacity.

Already there have been encouraging improvements in data recording and staging.

EARLY YEARS

Through its active involvement in the Early Years Collaborative (EYC), led at local level by Community Planning Partnerships (CPPs), NHSScotland continues to make an important contribution to the Scottish Government's aim of improving outcomes for children and young people, and the strategic objective that Scotland is the best place to grow up for our children.

The Early Years Collaborative is an outcomes-focused, multi-agency, quality improvement programme. A wide variety of agencies are involved including education, police, social work and the third sector as well as health.

Multi-agency CPP teams have worked together on a large variety of projects including: increasing the amount of physical activity undertaken by children in Primary 1; improving speech and language support for children at risk; maximising income for families by helping them take up the benefits to which they are entitled; and helping expectant mothers give up smoking. All of the projects are taken forward using the Model for Improvement^[69] which underpins the EYC. This enables practitioners to reliably implement interventions for every child, every family, every time.

Our 2020 Workforce Vision

We will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations. We will continue to modernise the way we work and embrace technology. We will do this in a way that lives up to our core values.

Together we will create a great place to work and deliver a high quality healthcare service which is among the best in the world.

WORKFORCE

Our workforce is vital to responding to the challenges that NHSScotland is facing. We are committed to all staff being empowered to influence the way they work, leaders who show by example and managers who have the skills to manage well - all held to account for what we do and how we do it. We want to see all staff being fairly treated, supported to do the best job that they can. Evidence shows staff who are motivated and valued deliver better quality care for patients.

To deliver this, in June 2013, we launched Everyone Matters: 2020 Workforce Vision and our shared values which were developed through extensive engagement and consultation with around 10,000 staff and key stakeholders, resulting in one of the largest consultations undertaken in NHSScotland.

We expect everyone to live by our shared values which are:

• Care and compassion;
• Dignity and respect;
• Openness, honesty and responsibility; and
• Quality and teamwork.

Our five priorities to deliver our 2020 Workforce Vision are:

Healthy organisational culture - creating a healthy organisational culture in which our values are embedded in everything we do, enabling a healthy, engaged and empowered workforce.

Sustainable workforce - ensuring that people are available to deliver the right care, in the right place, at the right time.

Capable workforce - ensuring that all staff have the skills needed to deliver safe, effective, person-centred care.

Integrated workforce - developing an integrated health and social care workforce across NHS Boards, local authorities and third party providers.

Effective leadership and management - leaders and managers lead by example.

The work taken forward in 2013/14 delivers on one or more of these priorities, supporting and delivering our vision that by 2020 everyone is able to live longer, healthier lives at home or in a homely setting.

2013 NHSScotland Staff Survey

The NHSScotland Staff Survey response rate was 28 per cent, 2 per cent higher than in 2010. The results have provided important feedback on progress to improve staff experience, but more importantly, where attention needs to be focused to do more. The Cabinet Secretary for Health and Wellbeing has been clear that NHS Boards have a duty to listen to what staff are saying, and to take action to address the issues which are of concern to them. Progress to address key issues is being monitored locally.

iMatter Staff Experience Continuous Improvement Model

In responding to the results of the 2013 Staff Survey, the Cabinet Secretary wrote to NHS Board Chairs setting out a number of commitments. These included the commitment to roll out the iMatter Staff Experience Continuous Improvement Model to all NHS Boards.

The iMatter Model was successfully developed and piloted in four NHS Boards - NHS Tayside, NHS Dumfries and Galloway, NHS Forth Valley and NHS National Waiting Times Centre. The Model will enable Boards to have more accurate information about staff experience throughout their organisation, and see where improvements are being made, year on year, and where further interventions may be required. It will encourage teams to take action and make improvements, which will contribute to better performance and higher standards of patient care. Implementation will take place across all Boards on a phased basis, beginning in 2014/15.

Staff Governance Monitoring

Achieving the Staff Governance Standard is essential to achieve continuous improvements in service quality. In November 2013, a revised Staff Governance Standard Monitoring Framework^[70] was introduced. This is used by all levels within each NHS Board to help each year to review progress in implementing the five strands of Staff Governance and to identify issues requiring attention through the Staff Governance Action Plan.

National Confidential Alert Line for NHSScotland Staff

A new pilot National Confidential Alert Line for NHSScotland was launched to ensure staff are supported in raising concerns and know how to do so. Launched in April 2013, this confidential service provides a safe space for staff to discuss their concerns with legally-trained staff. Where appropriate, these concerns can be passed to the relevant regulatory or scrutiny body. Further information, including the number and type of calls received and the interim evaluation of the service is available on the Scottish Government website71. Following the conclusion of the successful pilot, the Cabinet Secretary announced that the National Confidential Alert Line would continue for a further two years from August 2014.

Youth Employment

As part of the Scottish Government's Making Young People Your Business campaign, all NHS Boards have been asked to provide a range of employment-related opportunities for young people aged 16-24. Over 5,000 opportunities, ranging from Modern Apprentices to work experience, have been offered over the two years to March 31 2014. The Cabinet Secretary has since announced that NHS Boards are being asked to deliver a national target of 500 new Modern Apprenticeships across NHSScotland over the coming three years to August 2017.

NHS Pay and Conditions

The recommendations of the NHS Pay Review Bodies for 2014/15 was implemented in full. This meant that all NHS staff groups in Scotland covered by the remits of these bodies received a 1 per cent pay increase from 1 April 2014, while staff earning under £21,000 also received an additional sum to increase their pay by £300 in total. Work with the British Dental Association and NHS Employers in Scotland delivered a new terms and conditions package for salaried dentists.

NHS Boards already have met the Scottish Government target of reducing senior management posts by 25 per cent by 1 April 2015. The latest figures show that the overall reduction in senior management in the first four years of the target (financial years 2010/11-2013/14) has been 386.2 WTE (down 29.3 per cent), exceeding the target by 4.3 percentage points72. Work is continuing with all stakeholders on the implementation of statutory changes to the pension scheme in 2015 and the related Working Longer Review.

Sustainability and Seven Day Services

In October 2013, the Cabinet Secretary for Health and Wellbeing shared his vision for the NHS in Scotland to provide a genuine sustainable, seven day service where required. While NHSScotland already provides round-the-clock care, more is required to remove variation in the way care is delivered, particularly at the weekend. This is not about routine operations being carried out at midnight or on Sunday afternoons but about giving patients the best possible care and access to the services they need to move through the system, including being discharged from hospital, regardless of the day of the week.

Phase one of the programme is focusing on the services that people need most out of hours and at weekends and which have the greatest benefit for patient outcomes. It is also taking forward specific work to support delivery of sustainable seven day services in remote and rural areas. A taskforce is leading this work and will identify the key steps needed to provide a sustainable seven day service. The initial report is due by the end of 2014.

Workforce Planning

Recommendations aimed at strengthening workforce planning within NHS Boards were set out in the report Pan Scotland Workforce Planning Assessment and Recommendations^[73] produced under the auspices of the National Workforce Planning Forum. Discussions about how to implement these recommendations made good progress and in the coming year will help each NHS Board to use its workforce more intelligently; taking account not only of numbers but of a broader range of influences on staff, and ensuring workforce planning reflects the need to deliver high quality services within an integrated context.

Medical Revalidation

Revalidation is the process by which doctors demonstrate that their skills, knowledge and competencies are up to date and that they remain fit to practise. It is a UK legal requirement that all licensed doctors revalidate every five years and is an important component in the governance of medical staff. The aim is to give the public confidence that doctors are performing well and are aware of the latest developments in their medical specialty and that the doctor is being regularly checked by their employer and the GMC. It also helps doctors reflect on how they can improve their practice and how they interact with patients. The process has been implemented in Scotland and subject to external review by Healthcare Improvement Scotland (HIS). In the last year, 90 per cent of doctors in NHSScotland had an appraisal undertaken.

INNOVATION

New technologies and different service models will be important in realising our 2020 Vision. The Route Map to the 2020 Vision for Health and Social Care built on Health and Wealth In Scotland: A Statement of Intent for Innovation In Health^[74], making a commitment to 'increase our investment in new innovations which both increase the quality of care, and reduce costs and simultaneously provide growth in the Scottish economy'.

The challenge is not only to encourage inventive ideas, but also to make sure that these ideas are adopted and spread. It was on this basis that the Scottish Government made £2 million available to allow all NHS Boards to have electronic whiteboards on wards so that clinical teams can get and update all the information they need about a patient in a readily usable way.

Innovation by its very nature is often about longer-term change, but during 2013/14 there were clear signs of momentum behind the drive to increase investment in innovations.

A new service in West Lothian now offers people over 75 in an emergency a choice of not being admitted to hospital. Following a GP referral, a member of the Rapid Elderly Assessment and Care Team (REACT) will arrange to see the person in their home on the same day to undertake an initial assessment. Thereafter, the team can provide hospital-level support and therapy interventions within a person's own home.

Innovation has also been making a difference not just for individual patients but for whole communities. Living It Up has enlisted local communities to help design and develop ways in which local services can be connected digitally. Living It Up has started in five areas and aims by 2015 to provide services for 55,000 people (most of whom are over 50), supporting them to use familiar technology to be better connected to what matters to them and to keep them healthy and independent at home.

Innovations using digital technology are also being developed for those with specific illnesses. My Diabetes, My Way is the NHSScotland interactive website helping people manage their diabetes and look out for the signs of Hypoglycaemia - providing access to their own test results, clinic letters and treatment plan, and a variety of high quality multimedia resources.

The United4Health programme, operating across 14 regions throughout Europe, commenced in Scotland in 2013 for three years. The programme will trial a range of digital health monitoring solutions using familiar technologies to support home-based health monitoring of patients living with diabetes, respiratory disease and heart failure as an alternative to hospital care.

Touch Bionics, a Scottish company spun out of the NHSScotland, launched the first powered prosthetic hand to have five independently powered fingers that open and close around objects in a natural and anatomically-correct way. During 2013, working with the company through the joint NHSScotland-industry Health Innovation Partnership for Medical Technologies, arrangements were put in place both for patients in Scotland to benefit from this innovative technology and for its benefits to be evaluated.

Across Scotland there are many innovations being taken forward through the third sector drawing upon its agility, different perspectives, direct knowledge of people's needs and links to local communities.

Loneliness is common amongst older men and is associated with significant health problems such as high blood pressure. Drawing on Change Fund^[75] money, five organisations in Aberdeen have launched a befriending service to help people aged 55 plus overcome isolation.

RESEARCH

Research is a substantial contributor to effective care, providing insight into new ways of working and enabling new techniques and technologies to be tested out in a safe and controlled environment and, importantly, have their perceived benefits properly evaluated. The Chief Scientist Office (CSO) of the Scottish Government supports a substantial portfolio of research benefiting NHSScotland and patients.

Two of these CSO-funded research studies were awarded prizes by the Royal College of General Practitioners this year in recognition of the quality of their ground-breaking work. In cancer research, Dr Peter Murchie and colleagues at the University of Aberdeen found that GPs can effectively perform biopsies to test for melanoma without leading to poorer long term outcomes for patients. They demonstrated that patients who have their initial diagnostic excision biopsy in Primary Care experience fewer subsequent hospital admissions and fewer days in hospital. Dr Hillary Pinnock and her team at the University of Edinburgh were also recognised for their work on the effectiveness of telemonitoring - when integrated into existing clinical services - on hospital admission for Chronic Obstructive Pulmonary Disease.

Other recently-published or funded CSO studies on diabetes have developed techniques to allow clinicians to estimate a patient's three-year risk of developing type 2 diabetes according to their blood glucose level and, in a study that if successful would transform the quality of life of type-1 diabetic patients, will assess the efficacy and safety of co-transplanting Mesenchymal Stromal cells with Pancreatic islets with a view to restoring hypoglycaemic awareness and in some cases reduce or eliminate insulin dependence.

CSO also supports the development of non-research innovations through Scottish Health Innovations Ltd (SHIL), a not-for-profit company owned by Scottish Ministers and NHS Boards.

E-HEALTH

Primary and secondary care organisations rely more than ever on secure, resilient and reliable information, communication and technology systems in order to deliver safe, effective and person-centred services. Health and care workers require access to the right information 24 hours a day, seven days a week wherever they need it to inform their decisions and ensure the best possible care is given to each individual.

During 2013/14, work to deliver improved outcomes has included:

• Increasing the level of clinical information available online to healthcare professionals;
• Increasing the capacity of patients to order prescriptions and book appointments online; and
• Agreeing an Information Sharing Strategic Framework^[76] that provides guidance and protocols for sharing information across health and social care.

Over the last year, the Key Information Summary (KIS) has been introduced which supports people with long term conditions and those most likely to require additional care at the weekend or out-of-hours. The KIS is a rich information resource for healthcare professionals and provides almost fully up-to-date information extracted from the general practice record, including details such as current medications, adverse reactions and allergies, anticipatory care plans, carer details, and particular wishes the patient wants recorded. This development was implemented in all GP Practices across Scotland over a three-month period and there are now over 110,000 KIS records - already helping people with complex needs to be cared for at home.