NHSScotland Chief Executive's annual report 2015-16

Chapter 1 - Transforming Care and Delivering Improved Outcomes

'We are delivering a future where early interventions and better models of holistic care built around communities and localities support people to live longer, healthier lives ...'

High Quality Health and Care for Scotland
The Challenges

The demands for health and social care and the circumstances in which they are being delivered are radically different than a decade ago. NHSScotland and its partners across the public and voluntary sectors are having to collectively recognise and respond to the most immediate and significant challenges faced. These include Scotland's public health record and level of inequalities, our ageing population, the increasing expectations arising from new drugs, treatments and technologies, and the specific impact of inflation on the health service.

Across Scotland, many people are living longer, healthier lives, thanks to better standards of living and advances in our health and social care services - achievements that can be rightly celebrated. NHSScotland and its partners across the public and voluntary sectors recognise, though, that there are challenges still to address. Progress on public health is not experienced equally across society. An ageing population means that we must adapt the way we work so that people living with multiple complex conditions are supported in their own homes and communities for as long as possible. At the same time, of course, we must continue to keep pace with new drugs, treatments and technologies, and maintain our focus on quality and improvement - people rightly expect access to the best possible standards of care, and services that are continually learning from evidence for improvement.

Our 2020 Vision

Our 2020 Vision for Health and Social Care is that by the year 2020, everyone is able to live longer, healthier lives at home, or in a homely setting.

We continue to focus on the priorities for action that will have the greatest impact on achieving our vision in three areas often referred to as the 'Triple Aim':

• Improving the quality of the care we provide;
• Improving the health of the population; and
• Securing the value and financial sustainability of the health and care services we provide.

While we continue to build on existing work in each of these domains, it is important that we accelerate progress. We are seeing some of the biggest and most important changes to the way we care for and improve the health of the people of Scotland, in their communities, since the creation of the NHS. This work has been underway for a number of years. Now every part of Scotland has seen health service professionals and social care practitioners come together in partnership with those who design and commission services across the country to ensure that our changing needs are reflected by changing services, developing technologies and shared successes - all leading to better outcomes for people. We have made brave choices in order to bring about the change we are committed to delivering. Scotland is leading the UK in this and is admired for its vision and commitment.

Our Pursuit of Quality

Through our approach to quality healthcare improvement as described in the Healthcare Quality Strategy for Scotland ^[1] we continue to drive forward improvements in the care people receive. Our Quality Ambitions for person-centred, safe and effective care have continued to guide our work in improving quality, transforming care and delivering improved performance.

Transforming Care

The Wider Contribution of Health and Social Care

The role for health and social care in supporting people to live well, from pre-conception through childhood, adolescence, adulthood, old age and death, is fundamental to the Scottish Government's Purpose of creating a more successful country through increasing sustainable economic growth and to its priorities for a fairer society, improved participation and localisation.

As we look beyond the year 2020, the need for a step change in how services are planned and delivered to take account of the challenges faced has never been greater. Shona Robison MSP, Cabinet Secretary for Health and Sport has confirmed her commitment to pursuing our health and social care agenda in the wider context of delivering better outcomes for the people of Scotland:

"I am committed to taking forward our health and social care agenda in the context of public sector improvement and against the four pillars of public sector reform in our response to the Christie report ^[2] : prevention; integration at a local level; workforce development; and a focus on performance, with outcomes-based targets. The key commitments in our manifesto underpin this Government's future focus for health and social care so that, by 2020, we will have secured our vision of people living longer, healthier lives at home or in homely settings and, over the period to 2030, we will have in place policies, systems and services that support people to begin their lives well, live well, age well and die well."

Shona Robison, Cabinet Secretary for Health and Sport, Scottish Parliament, 7 June 2016

Improving the health and wellbeing of the population, supported by high quality, compassionate, efficient and effective care when and where people need it is also essential to tackling inequalities, raising attainment for all, improving social justice, enhancing democratic renewal and contributing to the wider reform of public services.

Our NHSScotland is therefore central to Scotland's prosperity. It is bigger than the sum of its parts and reaches across welfare, housing, taxation, employability, equalities and the third sector. That is why it remains as important as ever that quality should drive all that we do in developing policy and delivering innovative and integrated services and ways of working.

What Matters to People

We know that these aims continue to matter to people. The Creating a Healthier Scotland national conversation ^[3] that ran from August last year to March 2016 directly reached over 9,000 people at 240 events across the length and breadth of the country, with over 360,000 inputs through digital and social media channels. It showed us that, while the people who use or deliver health and care services want to maintain the core values that drove the creation of the NHS nearly 70 years ago, there is a demand for real change in six broad areas to ensure that we have services fit for the 21st century and which are responsive to its challenges:

• Supporting people to lead healthier lives - with more work on prevention, health education and promotion of individual life-style change;
• Supporting wellbeing and better connected communities - with a focus on early intervention and parity between mental and physical health services;
• Making even greater strides in person-centred care - with people more involved in decision-making and a greater focus on supported self-management;
• Providing responsive and seamless journeys of care - with easier access to services and integration across Primary and Secondary Care as well as across health and social care;
• More focus on social care and caring - better information about entitlement, more support at home, support for unpaid carers and better recognition for those working in social care; and
• Addressing pressures and priorities in the system - getting better at workforce planning and development, looking at targets and outcomes and taking challenging decisions about funding.

Transforming Our Approaches

People want to live happy, independent, healthy lives and, in managing our health and social care system, it is important that we ensure people have access to the best possible care when they do need it, and that we manage our resources efficiently and sustainably in pursuit of that aim.

This will require a transformational change in our approaches which: shift from a fundamentally 'fix and treat' model of care to a model of prevention, anticipation and population health improvement; shift from 'doing things to' people to working with them and putting them at the centre of decisions about their care; and focus on shifting the balance of where care is provided from hospital to community care settings and people's homes where that is best.

We are already making progress on this as we move towards securing our 2020 Vision, and we will make more progress, to 2020 and beyond, through the reform of Primary Care services while the continued deepening and embedding of health and social care integration is providing us with new teams formed from diverse fields of expertise and very different lived and worked experiences. This is allowing us to innovate at an enhanced level, improving the quality of care we provide locally and nationally by building on the shared vision of practitioners who are now free to facilitate change and create anew as never before.

We are delivering a future where early interventions and better models of holistic care built around communities and localities support people to live longer, healthier lives - and where our clinicians and health practitioners are able to work with others across health and social care to target interventions, and grow and develop new models of health improvement for the people who will see the greatest benefit and the most improved outcomes.

As we enhance our understanding and develop long-term strategies for meeting the needs of our people going forward, we realise that for older people and for people with complex needs home is almost always best: best for them and for their families and best for their health and wellbeing. In order to provide the best outcomes for people, we are committed to shifting the balance of care into communities and out of institutions in line with the best medical evidence.

Our National Clinical Strategy for Scotland ^[4] sets out the direction of travel and transformational change necessary to deliver a safe, sustainable and person-centred NHSScotland for the people of Scotland over the next 10 to 15 years and provides the framework for the future of health and social care. It looks at the projected demographic challenges alongside potential innovations and their impact on the planning and delivery of healthcare services for our population as well as the already significant transformation arising from the integration of health and social care. A strand of this work will focus on the concept of Realistic Medicine, first proposed in the Chief Medical Officer's Annual Report 2014-15: Realistic Medicine ^[5] , where the emphasis will be on improving the basis of clinical decision-making to ensure that there is a clearer focus on the provision of healthcare of greatest value to the individual in a way that has the least potential to harm, and is most in line with the patient's wishes.

Digital technology is now a part of our everyday lives and evidence continues to build that health and wellbeing can be better supported through greater use of familiar everyday technology. We are working to transform services to provide fully person-centred care that fits seamlessly within an increasingly digital lifestyle to empower individuals to more actively manage their own care at home and in the community. Our challenge as a health service is how we can make the most of the technology that a significant majority of our population already own and use. At the same time, we should continue to improve our clinical IT infrastructure and make it increasingly easier for clinicians to make more informed decisions, together with colleagues and patients, by providing the right information at the right time through user-friendly digital tools.

In our Technology Enabled Care Programme ^[6] , we have enabled in excess of 20,000 Scottish citizens to benefit from technology enabled care, such as home and mobile health monitoring and telecare, thanks to funding made available during 2015/16.

You can read more about these and other transformational approaches later in this report.

We will continue to engage widely with the public, health and social care professionals, and other stakeholders as we take forward the themes from last year's national conversation and the changes required, using the Our Voice framework (see chapter 2) to help shape policy and delivery options for the future.

The Scottish Government is committed to supporting people at all stages of their lives through a range of measures including:

• Supporting people to start their lives well through the development of a 10-year child and adolescent health and wellbeing strategy, our new health visiting pathways, and the continued roll-out and extension of family nurse partnerships to provide support for young first-time mothers.
• Supporting people to live well through the cancer strategy, supported by £100 million of investment, and through a range of commitments to expand Primary Care services by, for example, giving GP practices access to enhanced pharmacists and recruiting 250 community link workers. GP practices should become more of a community health service that involves teams of health professionals and others working together under the guidance of a GP, with people seeing the right professional at the right time, underpinned by the new GP contract in 2017; and through a 10-year plan to transform mental health care.
• Supporting people to age well through the protection of free nursing and personal care for the elderly; a new three-year dementia strategy; and investing £200 million in five new elective centres and expanding the Golden Jubilee National Hospital so that we can meet the increased demands of an ageing population, are better prepared for winter pressures, and can reduce cancellations, delayed discharge and the use of the private sector.
• Supporting people to die well by ensuring that everyone who needs it has access to palliative care that is designed with people and their families in mind, and with parity between public funding for children's and adult hospices.

NHSScotland Performance in 2015/16

NHSScotland sees and treats hundreds of thousands of patients every year and it is vital that services are planned effectively. Performance measures are an important part of the planning process. There is no doubt that the way services are configured has changed markedly over recent years, including new acute hospitals in Glasgow and Forth Valley and major refurbishments in other hospitals including those in Ayrshire, Fife and Grampian. These new modern acute facilities, along with developments in eHealth systems, and new community hospitals and health centres around the country are important for the people who provide services and for those who use them. This report sets out a range of improvements that have been implemented across Scotland, recognising that the way services are delivered will change at an even faster rate over the next few years.

We have learned that improving and sustaining performance is dependent on investment in national clinically-led improvement programmes which support local teams to learn from international best practice, and from each other, with additional support where required. It is important that people understand why key performance measures are important and the positive impact that they have on outcomes. Clinical decision-making in the interest of patients is paramount and improvements in performance should be pursued in the right spirit and in a sustainable way. For example, we know that eliminating crowding in emergency departments has positive impacts on patient outcomes and for the staff working there and in the wider system; and being able to support suspected cancer patients along their whole diagnostic, treatment and care pathways is vital.

The official statistics show that Scotland's A&E performance in 2015/16 was the best since 2011/12. Some 94.1 per cent of patients were seen and subsequently admitted, transferred or discharged within four hours ^[7] , reducing the risk of crowding and improving the quality of care. Scotland saw the best performance throughout the UK ^[8] , with the UK often seen as the best-performing system in the world. The number of bed days occupied by delayed patients reduced by 9 per cent ^[9] which helped to reduce the risk that people lose their ability to live independently. The focus on planning and performance across the whole system for winter 2015/16 has helped to improve outcomes and performance in the last year - including the Six Essential Action national clinically-led improvement programme.

In 2015/16, 90.8 per cent of patients began cancer treatment within 62 days of their urgent referral with suspicion of cancer, while 95.7 per cent of all cancer patients commenced treatment within 31 days of a decision to treat ^[10] . Improving outcomes for cancer patients is a key priority as we implement the new cancer strategy Beating Cancer: Ambition and Action ^[11] , which includes priority action on pathways and capacity in gastro and urology diagnostics.

Elective waiting times have been transformed over the last 10 years despite growth in demand. However we recognise that sustaining elective waiting times is a challenge. We expect that demand for elective treatment will increase over the coming years and the elective strategy will support the NHS in Scotland to establish the new elective centres which will transform elective services in Scotland. In 2015/16, diagnostic waiting times statistics showed that 94.6 per cent of elective patients had been waiting six weeks or less at the end of March 2016 ^[12] . Almost 300,000 or 94.4 per cent of elective inpatient and day case patients were treated within 12 weeks in 2015/16, while 88.0 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2016 ^[13] .

During the quarter ending March 2016, 84.2 per cent of children and young people started treatment at Child and Adolescent Mental Health Services ( CAMHS) in Scotland within 18 weeks ^[14] . In 2015/16, decisions were taken to fund a significant increase in capacity as well as work to redesign local services to be more efficient, effective and sustainable.

Most patients were positive about the care and treatment they received at GP practices. The overall positive rating of GP care has remained the same as last year at 87 per cent ^[15] . Innovative projects to improve GP recruitment and retention have been funded by the Scottish Government.

The Scottish Inpatient Patient Experience Survey 2016 found that 90 per cent of hospital inpatients who participated in the survey, rated their overall care and treatment as good or excellent, the highest rating since the survey began ^[16] .

Significant improvements have been made in reducing Healthcare Associated Infections in recent years. These improvements were sustained in 2015/16 ^[17] .

The Scottish Government sets out its priorities in Local Delivery Plan ( LDP) guidance. This requires NHS Boards to develop concise plans focused on new actions planned in a small number of strategic improvement priority areas to improve outcomes for patients and the people of Scotland. In order to ensure high quality, continuously improving health and social care in Scotland, it is important that we strike the right balance between improvement, performance management and scrutiny. The LDP also sets out standards that NHS Boards should pursue to improve services for patients. LDPs should address these with a focus on demand and capacity planning.

Information on LDP Standards is updated throughout the year on the Scotland Performs website ^[18] .

Review of Health and Social Care Targets and Indicators

Targets play an important role in our NHSScotland, and can be a useful tool to drive improvements in performance. As our new integrated arrangements for health and social care establish across Scotland, we must ensure that our approach to measuring progress is outcome-based, is focused on people and communities, and helps to ensure that people get the right care for their circumstances, at the right time and in the right place. With the support of our partners in local government, we are taking forward a review of the targets and indicators that underpin our understanding of the care people receive across health and social care in Scotland, focusing particularly on improving population health, promoting early intervention and enhancing community-based approaches to care. We also continue to invest in better data to support improvement in local systems.