NHSScotland chief executive's annual report 2016/17

Chapter 2 - Improving Quality of Care

'...people in the driving seat, with support from professionals to achieve the outcomes that are important to them'

Philip who receives specialist Motor Neurone Disease ( MND) nursing care to help him live comfortably at home. Hear about Philip's story at www.nhsscotannualreport.com

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

Our Quality Ambitions

Through our Healthcare Quality Strategy for Scotland ^[33] 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.

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

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

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

Person-centred Care

Person-centred care has people in the driving seat, with support from professionals to achieve the outcomes that are important to them. It is an approach that extends across health and social care, enabling people to live well, with appropriate care and support, in communities across Scotland. For care and support to be reliably person-centred, there needs to be collaboration and equal partnerships between the people accessing services, their families and carers, and the people delivering those services. It also requires a person-centred system that supports the people who work within it to deliver care that is based on compassion, continuity, clear communication and shared decision-making.

Promoting the What Matters To You? Approach

The 'What Matters To You?' ^[34] approach is at the heart of delivering high-quality care and support that is person-centred, safe and effective. By talking to people about what is important to them, listening deeply to the answers and taking action on what they hear, our staff can provide the care and support that people really need and want.

Scotland is at the forefront of a growing international movement working to improve health and social care by gaining a better understanding of what really matters. Healthcare Improvement Scotland and the Scottish Government formed a partnership with people working in health and social care to hold Scotland's first 'What Matters To You?' day on 6 June 2016. Staff working across health and social care were invited to 'ask what matters, listen to what matters, do what matters.' Over 500 teams took part, with teams joining from other sectors and from countries around the world. The impact of the day has been captured in the 'What Matters To You?' Day Report 2016 ^[35] and the lessons learned were used to deliver an even more successful 'What Matters to You?" Day in June 2017, with more than 2,000 teams taking part in 30 countries around the world. 'What Matters To You?' Day has proved to be a great way to encourage a collective focus on hearing from the people across Scotland who use health and social care services. The aim is for this to become an on-going conversation, taking place every day in health and social care settings across Scotland.

Driving Change through Third Sector Partnerships

Third sector partners continued to work with us to drive change and improvement at national and local level in 2016/17.

The House of Care ^[36] approach supports and enables people with long term conditions to articulate their needs and decide on their own priorities through a process of joint decision-making, goal setting and action planning. In 2016/17, the Health and Social Care Alliance Scotland (the ALLIANCE) continued to work with Year of Care Partnerships, the British Heart Foundation, NHS Boards, the Scottish Government and other partners to support the development of this approach in Scotland, publishing Scotland's House of Care Learning Report ^[37] in December 2016.

The ALLIANCE is funded by the Scottish Government to deliver A Local Information System for Scotland ( ALISS) ^[38] . This continues to map community assets and to connect people with local sources of support that will enable them to manage their own health conditions more effectively. In 2016/17, the team at ALISS developed a new version of the site, which makes it easier to keep information content up to date. The team worked with disabled people, people living with long term conditions, unpaid carers, health and social care professionals and technology professionals to co-produce this digital service.

The Transforming Self Management in Scotland Fund ^[39] provides grants, both large and small, to community and voluntary organisations and partnerships to encourage the development of new approaches to supporting people to live well, on their own terms, with whatever health condition they have. The Scottish Government has committed £2 million annually from April 2016 to March 2019 to the Fund, which is administered by the ALLIANCE.

The ALLIANCE announced 15 new projects to be funded through the Transforming Self Management in Scotland Fund at the Self Management Awards ^[40] in October 2016. The awards highlighted a range of initiatives which are already leading the way in self-management.

Improving Health Literacy

The growing demands and expectations that modern medicine places on people can overwhelm them, undermining the safety and effectiveness of healthcare. Health literacy, which is recognised internationally as a public health concern, is about people having enough knowledge, understanding, skills and confidence to use health information, to be active partners in their care, and to navigate health and social care systems successfully.

Making It Easy: A Health Literacy Action Plan for Scotland ^[41] was published in 2014, setting out an ambition and the means for all of us to live well with any condition we may have by making sure that health and social care services cater for each of us, regardless of our abilities. The Health Literacy Demonstrator Programme, taken forward in NHS Tayside as part of this plan, started reporting in autumn 2016 with learning shared at a national event in Dundee ^[42] in April 2017. A report on progress, Making it Easy: Progress Against Actions ^[43] , was published in July 2017.

Welcoming Feedback and Using it for Improvement

The Scottish Government and NHSScotland are jointly committed to developing a culture of openness and transparency that values people's feedback and uses it to drive and inform continuous improvement.

In 2016/17, Healthcare Improvement Scotland continued to test 'real-time' and 'right-time' approaches to gathering and learning from feedback about people's experience of care as part of its Person-Centred Health and Care Programme ^[44] . Experience Based Co-design Methodology ^[45] , which involves people who access support or care working with the staff who provide it to co-design improvements to services, is being tested as part of the same programme in a diverse range of settings.

The Our Voice Citizens' Panel ^[46] was convened in 2016 and the first panel survey, which included questions on social care, better use of medicines and improved oral health, was issued in October. Our Voice was developed in partnership with the NHS, the Convention of Scottish Local Authorities ( COSLA) and third sector partners (including the ALLIANCE) to support meaningful engagement with people who use health and social care services, families, carers and the public on continuously improving services.

The Scottish Government continues to support NHSScotland to engage with Care Opinion ^[47] , which provides an independent, online route for people to share their experiences of care – whether good or bad – directly with those providing NHS services, and to engage in constructive dialogue with them about how services can be improved. All of Scotland's Territorial NHS Boards are now reading and responding to stories posted on Care Opinion. There were 2,637 stories shared on Care Opinion about NHSScotland in 2016/17, of which 62 per cent were positive, and these stories were viewed over 880,000 times. The increasing number of experiences shared has been mirrored by the numbers of NHS staff accessing the site, with over 780 staff now reading stories, a 48 per cent increase on the previous year. Sixty-eight changes and improvements to services were made or planned as a direct result of stories shared in this way. Scotland is the first country in the world to have such a system in place at national level, and is attracting international interest as a result of this bold and innovative approach. This type of system has the potential to strengthen the voice of people and communities in improving and shaping their health and social care services.

Measuring and Improving Satisfaction - National Surveys

Satisfaction with NHSScotland remains high. The 2015/16 Health and Care Experience Survey ^[48] reported that 87 per cent of people rated the overall care provided by their GP practice positively and the 2016 Inpatient Experience Survey ^[49] reported that 90 per cent of hospital inpatients rated their hospital care and treatment positively. The second Maternity Care Experience Survey ^[50] was conducted in 2015. It showed a positive picture of women's experiences of maternity care, with 92 per cent of women rating the overall care they received during pregnancy and birth as good or excellent.

In autumn 2015, the first national Cancer Patient Experience Survey ^[51] was launched to provide high-quality national and local data on patients' experiences of cancer care. The results, which were published in June 2016, found that 94 per cent of patients rated their cancer care positively. They also show that some areas of care received results which are less positive and require service improvement, particularly around helping patients access support for their wider emotional, financial and practical needs. These results will inform a range of actions being taken forward under the Scottish Government's cancer strategy, Beating Cancer: Ambition and Action ^[52] , which is supported by investment of £100 million. The next iterations of each of the Care Experience Surveys are being planned and will be run over the coming year.

The Patient Rights (Scotland) Act 2011 ^[53] introduced the right for people to give feedback, make comments, and raise concerns and complaints about the services they receive from NHSScotland, and it places a duty on the NHS to actively encourage, monitor, take action and share learning from the views it receives. In accordance with the Regulations associated with the Act, NHS Boards once again published annual reports, showing where lessons have been learned and describing actions taken to improve services as a direct result of feedback, comments, concerns and complaints.

Revising the NHS Complaints Handling Procedure

The NHS Complaints Handling Procedure was revised during 2016/17 to support NHSScotland to handle and respond to complaints in a consistently person-centred way. The new procedure, which was implemented from 1 April 2017, brings the NHS into line with other public service sectors by introducing a distinct, five working day stage for the early, local resolution of straightforward complaints ahead of the 20 working day stage for complaint investigations.

The revised NHS complaints handling procedure was developed by a steering group chaired by the Complaints Standards Authority, part of the Scottish Public Services Ombudsman ( SPSO) service, and involving representatives from across NHSScotland, the National Prisoner Healthcare Network, the NHS Complaints Personnel Association Scotland ( NCPAS), the independent Patient Advice and Support Service ( PASS) and Healthcare Improvement Scotland public partners.

The changes to the procedure reflect the broader ambition for the NHS in Scotland to be an open, learning organisation that listens and acts when people provide feedback or complain. They complement the Apologies (Scotland) Act 2016 ^[54] , the Duty of Candour provisions in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 ^[55] , and the ongoing implementation of a national approach to reviewing and learning from adverse events.

There were 23,507 complaints made about NHS services in Scotland in 2016/17 ^[56] – a 10 per cent increase compared to the previous year. An increase in complaints is not necessarily an indication of a diminished quality of healthcare or services. The number of complaints we are seeing reflects a better awareness of how people can make a complaint and confidence that their complaint will be listened to and acted on.

Supporting People to have Greater Choice and Control in Social Care

Through the Social Care (Self-directed Support) (Scotland) Act 2013 ^[57] , Local Authorities have a legal duty to offer people who are eligible for social care a range of informed choices on what their social care support looks like and how it is delivered. The principles in the Act should apply for all interactions even when the person is not eligible for support. This approach is known as Self-directed Support ^[58] and is based on the understanding that having greater control of your life and decision-making leads to improved health and wellbeing.

Throughout 2016/17, the Scottish Government engaged widely with key stakeholders to understand progress and issues in implementing Self-directed Support as Scotland's mainstream approach to social care and to develop a third phase of implementation activity.

Close collaboration between the Scottish Government, COSLA, Self Directed Support Scotland (a network of disabled people's organisations), Social Work Scotland, the Scottish Social Services Council, the Coalition of Care and Support Providers in Scotland and Scottish Care led to the Self-directed Support Strategy 2010-2020, Implementation Plan 2016-2018 ^[59] . This joint plan focuses the activities of local and national partners around the key challenges raised during engagement activity. The four outcomes of the plan are:

• Supported people have more choice and control;
• Workers are confident and valued;
• Commissioning is more flexible and responsive; and
• Systems are more widely understood, flexible and less complex.

The Scottish Government invested £60.4 million to transition to this new approach between 2011 and 2017. During 2016/17, this included £3.52 million to Local Authorities to support system and culture change.

In 2016/17, £2.9 million was invested in 34 third sector organisations through the Support in the Right Direction Fund, supporting people to: access existing community resources; receive training and development support; set up and manage their care packages; and employ and manage personal assistants.

Just over £1 million was invested in 21 third and independent sector providers of care through the Innovation Fund. Projects built the capacity of social care providers and the social care workforce to deliver more flexible and creative support. Key outcomes achieved between April 2016 and March 2017 include: enabling people to use their social care budgets more creatively; developing training and materials for practitioners and providers on Self-directed Support; and supporting people to co-produce services or explore alternative models of support.

The Social Care Survey 2016 ^[60] shows that 53,000 people made a choice about their support during 2015/16. This is nearly half of all social care clients once those solely receiving a community alarm service or with no support package are discounted from the overall total.

Supporting People in their Caring Role

There are an estimated 788,000 unpaid carers in Scotland, including 44,000 under 18 years of age ^[61] . Carers Scotland estimates that carers save the Scottish economy £10.3 billion per year.

There continued to be a strong emphasis during the year on carers and supporting them in the role they play in our communities. The Scottish Government has worked with people and organisations across Scotland to prepare for implementation of the Carers (Scotland) Act 2016 ^[62] , the main provisions of which take effect from 1 April 2018. The Act extends and enhances the rights of carers in Scotland to help improve their health and wellbeing, so that they can continue to care, if they so wish, and have a life alongside caring. During 2016/17, work started with a range of stakeholders to co-produce the statutory guidance that will accompany the legislation and support authorities to implement the provisions of the Act.

The Scottish Government has provided over £38 million from 2008/09 to 2016/17 to NHS Board Carer Information Strategies, including £4.75 million in 2016/17. This contributes to local carer centres, young carer projects, and other information and support services. Other priorities for this funding have included supporting minority ethnic carers, workforce development and training for carers. The Act will increase the financial commitment to supporting carers.

Initiatives such as the 5th Young Carers Festival in August 2016 allowed carers to have their voices heard and feed into the development of legislation and policies, based on what is important to carers. In September 2016, a development day with stakeholders helped refine the approach to the regulation-making powers of the Act. A Carers Collaborative forum was established in 2016/17 to ensure carer representatives on Health and Social Care Partnerships are appropriately supported in their role as representatives. The implementation of the Carers Act will remain a high priority over the coming year.

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

While dementia is a debilitating and progressive condition for which there is currently no cure, people can nevertheless live satisfying and constructive lives with the right help and support. Our shared vision, as described in Scotland's third three-year National Dementia Strategy ^[63] , is of a Scotland where people with dementia and those who care for them have access to timely, skilled and well-coordinated support from diagnosis to end of life which helps achieve the outcomes that matter to them.

The strategy, published in June 2017, is designed to support the progress which has already been made in transforming services such as Scotland's post-diagnostic support offer, and on outcomes for people with dementia and their carers, including better integrated home care. At the heart of this approach is close engagement with people with dementia, their family and carers and a human rights-based approach to treatment, care and support. The implementation of a national approach to providing palliative and end of life care for people with dementia is ongoing.

Workforce education, training and development, and implementation of the Standards of Care for Dementia in Scotland across the care pathway and in hospitals is at the centre of this work. The Scottish Government has a continuing national commitment to fund this activity through the implementation of Promoting Excellence: A Framework for all Health and Social Services Staff Working with People with Dementia, their Families and Carers ^[64] , backed by around £500,000 a year.

As part of this activity, there are 710 Enhanced-trained Dementia Champions, with over 10 per cent in social services. In social services, over 1,000 Dementia Ambassadors have been inducted, with around 734 currently active ^[65] . All Promoting Excellence initiatives are complemented by an on-going and expanded national approach to service improvement through the national dementia improvement programme, Focus on Dementia ^[66] .

In December 2016, the Scottish Government published its first estimate of annual dementia diagnosis rates in Scotland ^[67] . The first round of national performance data for the dementia post-diagnostic LDP Standard was published in January 2017, relating to performance during the period 2014/15. It showed that 6,660 people with dementia were offered the post-diagnostic service in 2014/15, the equivalent of 40 per cent of people estimated to be diagnosed with dementia in that period. Of that 40 per cent offered the post-diagnostic service, 73 per cent completed the service ^[68] .

This year also saw publication of the independent evaluation of the effectiveness of Alzheimer Scotland's '8 Pillars' model of integrated home-based care and support for people with dementia, having completed the testing of this model in five areas of Scotland ^[69] . The Scottish Government is considering the learning from the report in the context of the new dementia strategy.

Improving Palliative and End of Life Care

The Strategic Framework for Action on Palliative and End of Life Care ^[70] , published by the Scottish Government in December 2015, sets out the ambition of ensuring that by 2021 everyone in Scotland who needs palliative care will have access to it. This commitment was reaffirmed in the Health and Social Care Delivery Plan.

Both the Health and Social Care Delivery Plan and the Strategic Framework for Action on Palliative and End of Life Care highlight not only the importance of identifying those who need palliative or end of life care, but also to ensure the professionals they encounter are appropriately skilled. The publication in early 2017 of the Palliative and End of Life Care Education Framework ^[71] supports professionals in having timely, appropriate conversations to enable the planning of a person's care and support when time becomes short in line with their and their families' wishes.

The commissioning of palliative care and end of life care became the responsibility of Health and Social Care Partnerships in April 2016. One of the 10 commitments in the Framework for Action is to provide new commissioning guidance. This guidance will be available to Health and Social Care Partnerships by December 2017. Other commitments progressed with partners in health, independent hospice, academic, care and the third sector to contribute to achieving our ambition included supporting improvements in palliative care in six Health and Social Care Partnerships, the appointment of three training leads working across health and social care and the creation of a research forum.

Supporting People with Autism and Learning Disabilities to Live Healthier Lives

Scotland is now more than halfway through its 10-year Scottish Strategy for Autism ^[72] , which was launched in November 2011. The strategy's focus remains on outcomes intended to ensure people with autism live healthier lives, have choice and control over the services they use, and are supported to be independent and active citizens. During 2016/17, the Scottish Government has continued to invest in local autism projects throughout Scotland, which have reached more than 6,000 people. Investment has also been made in an Improvement Programme to reduce assessment waiting times by improving diagnostic services and increasing diagnostic capacity across child and adult services. Support was provided for the development and launch, in January, of the Principles to Good Transitions 3 and Autism Supplement ^[73] , which provides a framework to encourage the continual improvement of support for young people with additional needs, including autism, who are making the transition to young adult life. Work is under way to develop the next outcomes framework and to identify strategic priorities for the next phase of the strategy.

The 10-year Keys to Life ^[74] learning disability strategy was published in 2013. In 2015, a refreshed delivery approach was developed which identified four strategic outcomes: a healthy life; choice and control; independence; and active citizenship. This approach continues to guide workstreams and aims to address the wider socio-economic factors that contribute to the significant inequalities people with a learning disability face, and is aligned to the United Nations Convention on the Rights of Persons with Disabilities. The Scottish Government has invested in a number of projects throughout Scotland to tackle these inequalities, under the themes of parenting, hate crime, complex care, social connectedness, employment and physical activity. Support has continued for the Changing Places toilets campaign ^[75] to ensure people with profound and multiple learning disabilities can participate in community life and day-to-day activities that most of us take for granted. There are now more than 150 Changing Places toilets throughout Scotland, with new ones opening over the course of 2016/17. Work has begun to develop a new outcomes framework for the next phase of the strategy.

Supporting Survivors

Scotland is one of the few countries in the world that has dedicated funding for support services for survivors of childhood abuse. The strategic framework Survivor Scotland Strategic Outcomes and Priorities 2015-2017 ^[76] , published in October 2015, continues to guide this support. The vision is that survivors should be supported to have equal access to integrated care, support and treatment resources and services which can reduce the impact of the inequalities and disadvantage experienced as a result of abuse. This approach is grounded in what survivors say is important to them and has three identified outcomes:

• A healthy life: survivors are enabled and supported to enjoy an attainable standard of living, health and family life;
• Choice and control: survivors are treated with dignity and respect and are empowered and enabled to access the right support; and
• Safety and security: survivors have access to resources and services which are trauma-informed and have the capacity and capability to recognise and respond to the signs of childhood abuse.

Since 2007, the Scottish Government has invested up to £9 million to support delivery of these strategic outcomes and priorities. In addition, the Scottish Government has increased investment with up to £3 million per year for the next five years, from 2016, available to support adult survivors of in care abuse. Future Pathways, Scotland's in care survivor support fund, offers help and support to people who were abused or neglected as children while they were living in care in Scotland. This approach places people at the centre of their own support and is not restricted to health and social care needs, but rather encompasses a much wider range of support.

Safe Care

We have set ourselves clear aims to ensure that there will be no avoidable injury or harm to people from the healthcare they receive, and that an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

The internationally-acclaimed Scottish Patient Safety Programme ( SPSP) continues to drive improvements across a number of key areas of healthcare. Healthcare Improvement Scotland has worked with a range of partners to create a new improvement resource called the Improvement Hub (ihub) ^[77] . Since its establishment on 1 April 2016, it is continuing to support Health and Social Care Partnerships and NHS Boards to improve the quality of health and social care.

Improving Safety

The work of the SPSP has spread from acute adult to maternity, mental health, primary care, pharmacy and dentistry. NHS Boards are responsible for the quality and safety of the care they provide. Every hospital and every NHS Board is expected to scrutinise their data to drive improvement locally, drawing on all the support and expertise available.

Both acute adult and primary care programmes concluded their previous phase of work at the end of March 2016. Development work was undertaken following this to shape the next phases for these programmes from April 2016 onwards ^[78] . This identified three core themes under which future work will be planned: prevention, recognition and response to deterioration; medicines; and system enablers for safety. It will be the responsibility of NHS Boards and Health and Social Care Partnerships to set their own local priorities within those themes to meet local needs. The SPSP will tailor any improvement support required to meet these local priorities.

Acute Adult

Mortality Ratios

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

HSMR at Scotland-level decreased by 8.4 per cent between January and March 2014 (first quarter after new baseline) and January and March 2017 (most recent quarter), with 11 out of the 29 hospitals having a greater than 10 per cent reduction ^[79] .

Sepsis

The SPSP worked to support a Breakthrough Series Collaborative with the aim of reducing mortality through the Sepsis Six. A Breakthrough Series Collaborative is an intensive (six to 15-month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area. The Sepsis Six consists of three diagnostic and three therapeutic steps, all to be delivered within one hour of the initial diagnosis of sepsis. The Collaborative, which ran from January 2012 to December 2014, resulted in acute hospitals adopting an improved approach to identifying and treating patients with sepsis quickly and effectively, which is essential. Delivery of this intervention has improved to around 75 per cent of sampled patients and has helped to reduce mortality from sepsis by 21 per cent in NHSScotland since 2012 ^[80] .

The sepsis work is now part of the Deteriorating Patient Pathway and continues within local NHS Boards by local teams. The aim of the Deteriorating Patient Pathway is to reduce mortality and harm for people in acute hospitals through reliable recognition and response to acutely unwell patients. Progress is monitored through the outcome measures of hospital standardised mortality, mortality from sepsis and cardiac arrest rate.

In July 2016, an 18-month sepsis pilot project began in primary care. The aim is to ensure that patients with sepsis receive optimal care by improving early recognition and timely delivery of evidence-based tools and interventions. It uses the National Early Warning Score ( NEWS) which is a guide to quickly determine the degree of illness of a patient. It is based on six vital signs (respiratory rate, SaO2 or amount of oxygen in the blood, temperature, blood pressure, heart rate, and AVPU ^[81] response) and one other observation, and further aims to improve communication and collaboration across NHS teams when managing patients with sepsis.

Maternity and Neonatal

One of the key areas of focus for the SPSP is women and children's services. This work is overseen by the Maternity and Children's Quality Improvement Collaborative ( MCQIC) which aims to improve outcomes and reduce unnecessary variation for all women, babies and families in Scotland. MCQIC updated its aims in 2016, looking to reduce avoidable harm to mothers, babies and children by 30 per cent by 2019. This aim is a continuation of the programme's previous work which began in 2013. To help meet this aim, the programme launched the national Paediatric Early Warning Score ( PEWS), which is a tool to aid recognition of sick and deteriorating children. During 2016/17, the paediatric SPSP MCQIC programme has seen an impressive 78 per cent reduction in ventilator acquired pneumonia ( VAP) rates in one of the paediatric intensive care units in Scotland ^[82] .

A review of maternity and neonatal services provided an excellent opportunity to identify best practice and also outline where further improvements could be made to our services in Scotland. The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland ^[83] was published in January 2017. The Report includes 76 recommendations based on the views of women and families, professionals and key stakeholders, as well as best available evidence and current good practice. A key recommendation is that every woman will have continuity of care from a primary midwife, who will provide the majority of their antenatal, delivery and postnatal care, as part of a new model of care for maternity services in Scotland.

Mental Health

The Scottish Patient Safety Programme Mental Health ( SPSP- MH) is now part of the ihub, supporting improvement across health and social care. SPSP- MH aims to support National Health and Wellbeing Outcome 7: People using health and social care services are safe from harm, with the overall programme aim being that people should be and feel safe ^[84] . Cultivating learning amongst those delivering and in receipt of care, and using that knowledge to improve safety, are core values of the SPSP- MH.

Through collaboration and innovation from staff, service users and carers, and the use of quality improvement and improvement science over the last four years, we are now starting to see significant reductions in self-harm, seclusion, violence and aggression, and restraint across a number of areas in Scotland.

There are examples of reduction in the rates of restraint of up to 60 per cent, a 28 per cent reduction in the percentage of patients who self-harm (overall reduction across 20/39 acute admission wards) and reduction in the rates of violence of up to 80 per cent. As of July 2017, ten wards show a reduction in the percentage of patients who self-harm; 17 wards show a reduction in the rates of physical violence; and 12 wards show a reduction in the rates of restraint. The programme has developed and integrated patient and staff climate safety tools into inpatient care, with over 700 facilitated patient safety climate tools completed and over 3,000 staff safety climate questionnaires completed ^[85] .

Human rights are an overarching theme of the programme, which is working with the Scottish Human Rights Commission to actively consider ways to further embed rights-based approaches across its work.

Primary Care

Dentistry

Healthcare Improvement Scotland completed a collaborative across dentistry in primary care settings to test improvement interventions and tools. The collaborative was initially due to run until December 2016, but was extended to 31 March 2017. During that time, 15 dental practice teams and their patients: learned about improvement methodology; piloted the use of tools and interventions to deliver safer, more reliable care; explored their safety climate by undertaking a safety climate survey; and shared learning within their teams in their NHS Board and with other NHS Boards.

As part of that work, the dental practice teams identified that a key focus should be on ensuring accurate medical histories are recorded, with risk escalation processes put in place for those on high-risk medicines (due to the number of people who take blood thinners such as warfarin and then need tooth extraction with their blood unable to clot). It is now proposed that the collaborative will be extended for a further two years until March 2019 to support additional dental practices to become involved and to develop a national plan to spread good practice.

Pharmacy

Since September 2016, Community Pharmacies in Scotland have used continuous improvement methodology to support delivery of the highest quality healthcare services to the people of Scotland by ensuring patient safety practices are formalised and embedded in the delivery of services that Community Pharmacies provide. The results from this were monitored by the Scottish Patient Safety Survey ( SPSS) until the end of September 2017. The SPSS is a tool to give comparisons between clinical and non-clinical staff, and management and non-management within the practice. Each time the survey is completed, it can be determined whether there has been a change in the perception of safety culture within the practice. The report is then discussed at a local team meeting, providing a focus for considering patient safety and developing the safety climate in practice and improving care for patients. Pharmacy teams also participate in local learning sessions in each NHS Board area and this provides proactive coaching and encourages sharing of the learning amongst all pharmacy teams.

During the pilot work for SPSP Pharmacy in Primary Care, NHS Fife developed an electronic reporting tool designed to improve the communication of non-urgent, patient-specific clinical queries between the Community Pharmacy and General Practice. This tool has been incorporated into the 'Pharmacy Care Record' ( PCR) system used in all Community Pharmacies in Scotland.

Reducing Healthcare Associated Infections and Tackling Antimicrobial Resistance

Tackling Healthcare Associated Infections ( HAIs) and reducing Antimicrobial Resistance ( AMR) are key priorities and it is vital that people continue to have confidence in the quality and cleanliness of our healthcare environments. The Scottish Antimicrobial Resistance and Healthcare Associated Infection ( SARHAI) Strategy Group oversees and co-ordinates the development and implementation of national strategies and policies for reducing HAI and controlling AMR.

The Scottish Government published its 5-Year Strategic Framework (2016-2021) ^[86] in October 2016. This framework maps out the Government's AMR/ HAI workstreams over the next five years to realise its 2021 vision and commitment for the safety of patients, the public and all healthcare staff, to make our hospitals and communities safer places.

The Healthcare Environment Inspectorate ( HEI) operates a robust inspection regime and scrutinises standards of cleanliness in healthcare settings across NHSScotland. The HEI publicly reports its findings together with any improvement action plans it has asked NHS Boards to develop and implement. It operates independently of NHS Boards and is an integral part of our drive to tackle hospital cleanliness and prevent infection ^[87] .

There have been substantial reductions in HAI. Figures published in July 2017 show that cases of Methicillin-resistant Staphylococcus aureus ( MRSA) have reduced by 90 per cent and cases of Clostridium difficile in patients aged 65 and over have reduced by 87 per cent since 2007 ^[88] .

Improving Care, Experience and Outcomes Following a Fall

A multi-agency improvement collaborative started in November 2016 to improve the care, experience and outcomes for the people the Scottish Ambulance Service ( SAS) responds to following a fall. All Health and Social Care Partnerships and their SAS partners are working collaboratively to transform the way the SAS cares for older people who have fallen – around 45,000 calls each year ^[89] . New care pathways enable SAS to refer a person directly to community-based services, including crisis care and rehabilitation. For an older person this can avoid an unnecessary, and often stressful, attendance at an Emergency Department. The collaborative aims to improve care following a fall by: preventing unnecessary conveyance to an Emergency Department; supporting recovery and return to independent living, in the home setting; and preventing recurrent falls and accumulated disability.

This integrated approach enables people to remain at home, with timely access to the right support, often at an earlier point in their care journey, and alleviates pressures in the hospital system. The collaborative will run to March 2018.

Developing Excellence in Care for Nursing and Midwifery in Scotland

Following the publication of the Vale of Leven Hospital Inquiry report ^[90] in November 2014, the Cabinet Secretary for Health and Sport tasked Scotland's Chief Nursing Officer and Scottish Executive Nurse Directors to develop a national assurance and improvement programme for nursing and midwifery. The programme is called Excellence in Care ( EiC) and development is well underway.

EiC has four key deliverables: a small set of measures; a framework that sets out key principles and guidance for NHS Boards; development of a dashboard that enables reporting from ward to board (Care Assurance and Improvement Resource); and a set of record-keeping standards and principles. To ensure staff are involved in the work from the beginning, the Scottish Government is funding EiC leads within each NHS Board and is working with leads to co-develop the programme nationally with the opportunity to undertake quality improvement leadership training.

Regulating Independent Clinics

In April 2016, Healthcare Improvement Scotland commenced regulating independent clinics in Scotland. Independent clinics are defined in the National Health Service (Scotland) Act 1978 as clinics that are not part of a hospital and from which a medical practitioner, dental practitioner, registered nurse, registered midwife or dental care professional provides a service which is not part of the NHS. The term 'service' includes consultations, investigations and treatments. Service providers were given until April 2017 to register with Healthcare Improvement Scotland and meet the standards expected of them, prior to the inspection process beginning. Failure to meet the regulatory requirements could lead to the service provider being referred to the Procurator Fiscal's Office.

Effective Care

Many of the areas for improvement that have been prioritised during 2016/17 make a direct contribution to our Quality Ambition for more effective healthcare services and feature prominently in the Health and Social Care Delivery Plan. 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.

Investing in Elective Centres

We are investing £200 million over five years to expand the Golden Jubilee Hospital and create a new network of five elective and diagnostic centres in Aberdeen, Dundee, Edinburgh, Inverness and Livingston. Progress on plans for the new centres continued throughout 2016/17 and remain on track, supported by national work by Health Facilities Scotland and National Services Scotland. These centres will be completed by 2021 and will be fully integrated into local, regional and national health and social care systems to help ensure that people will receive the highest quality care before returning to their home or homely setting.

Providing Urgent Access to Emergency Care

In 2016/17, 94.1 per cent of patients were seen, treated and discharged or admitted within four hours in Scotland's A&Es. This is the best performance since 2011/12 ^[91] . Scotland continues to see the best A&E performance across the UK administrations – and has done for over two years ^[92] .

The Scottish Government invested more than £9 million in 2016/17 to progress the national clinically-led unscheduled care Six Essential Actions improvement programme. The work supports local health and social care systems with a strong focus on ensuring that people get back to or remain in their home or community environment, avoiding unnecessary hospital stays. The programme will seek further improvements in 2017/18, including the promotion of regular local meetings of acute hospital, community, SAS and NHS 24 leaders.

Saving Lives. Giving Life Back – Scottish Trauma Network

In May 2016, Scottish Ministers set out a clear commitment to implement a Scottish Trauma Network. By December 2016, a National Implementation Group chaired by the Chief Medical Officer had developed a unique model of care that will save more lives, deliver improved outcomes for severely injured patients and fully support them to quickly return to normal life. The Network's vision is 'Saving lives. Giving life back' and aims to improve trauma patient care throughout the care pathway from prevention through to rehabilitation. The Network will involve hospitals across Scotland working together to realise this vision ^[93] .

Given the scale and complexity of the changes required, we expect it will take up to five years to fully implement the network. For this reason, an extra £5 million was allocated in 2017/18 and significant further investment will be provided over the next few years in order to fully establish the Network.

Launching the Modern Outpatient Programme

In December 2016, the Scottish Government launched a new Modern Outpatient Programme, which aims to: deliver care closer to the patient's home; provide more person-centred care; utilise new and emerging technologies; and maximise the role of clinicians across primary, secondary and community-based services. We have seen successful improvements in the way some outpatient services are delivered in some NHS Boards which are recognised in the Modern Outpatient Programme.

The Modern Outpatient Programme will transform the way outpatient services are delivered across the whole of Scotland, building on Realistic Medicine and the National Clinical Strategy, and is based on the following principles:

• Strengthening knowledge exchange and self-management in the community with people at the centre;
• Accessing decision support, care planning and care services in the community wherever safe and appropriate;
• Emphasising competency-based roles in secondary care (to focus consultant resource on more complex patients), recognising the role of the GP as the 'expert clinical generalist', and raising the profile and enhancing the role of the wider multi-disciplinary team of community-based practitioners;
• Optimising eHealth and digital opportunities at the primary/secondary care interface as the norm; and
• Reducing widespread variation in secondary care return appointments and review processes, wherever clinically appropriate.

Developing New Outpatient Pathways

A coeliac disease clinical pathway was developed during 2016/17 ^[94] based on recent published coeliac disease guidelines ^[95] and during 2017/18 supporting tools will be developed, such as:

• Clinical decision support to aid GPs to identify and manage diagnosis;
• A Gastrointestinal mobile app to provide support to clinicians through the coeliac disease pathway; and
• Simple telehealth to support patients to manage dietary treatment.

The pathway and tools developed ensure that this patient-centred, self-managed, community-based and dietetic-led approach will result in short- and long-term benefits for patients and the NHS. This will lead to faster diagnosis and treatment, reduced unnecessary investigations, improved information ^[96] and self-management support, reduced secondary care visits, follow-up close to home ^[97] , reduced long-term complications, and improved quality of life and experience. The implementation of the clinical pathway will be used to demonstrate new transformational approaches to coeliac disease care in 2017/8 as the pathways are tested in four NHS Boards.

Primary and secondary care clinicians from across Scotland came together to update existing dermatology clinical pathways. The pathways are now available in a mobile app and website – Dermatology Patient Pathways ^[98] . This aims to provide GPs and primary care professionals across Scotland with quick and convenient access to high-quality specialist dermatology advice. The majority of users are from Scotland, but there has been interest from other countries and the British Association of Dermatologists is currently discussing the potential of the material across the UK.

Making Local Improvements in Inpatients and Day Case Services

Through the FLOW programme, Glasgow Royal Infirmary has been implementing the Institute of Healthcare Optimization's ( IHO) Variability Methodology since April 2015. There has been a focus on improving theatre scheduling and, as a result, they have achieved improvements to the safety and quality of patient care. A standardised approach to classify the urgency of each patient has been implemented across all specialties accessing emergency theatres, with patients consistently getting to theatre without delay.

A trauma and orthopaedic improvement programme has worked with clinicians to improve care for orthopaedic patients by developing dashboards based on best-practice/clinical evidenced interventions that make a difference to the experience and outcome for patients and enable teams to focus local improvement initiatives. For hip fracture, between 2015 and April 2017, six measures saw improvement, including use of nerve-blocks to ease pain straightaway, cognition assessments, and comprehensive geriatric assessment of frail patients who often have multiple co-morbidities. The important post-operative mobilisation of patients and Occupational Therapy input to support their readiness for discharge home also increased. The renewed focus of the work is on preparing patients to be discharged directly home into the care of support services in the community. There is increasing evidence that mobility, recovery and general wellbeing are enhanced in the home environment. For patients undergoing hip and knee replacement surgery, there has been an increase in the proportion of patients admitted on the day of surgery and an increase in the proportion of patients discharged by the end of day three post-operatively ^[99] . Patients are receiving more and earlier information about their care through informative booklets and DVDs.

Improving Mental Health Services

Mental Health Strategy 2017-2027

The Mental Health Strategy 2017-2027 ^[100] launched in March 2017, a significant component of the Health and Social Care Delivery Plan, describes a 10-year vision for Scotland. Following the Creating a Healthier Scotland national conversation ^[101] , it was shaped by feedback from over 600 people and organisations.

The vision is of 'a Scotland where people can get the right help at the right time, expect recovery, and fully enjoy their rights, free from discrimination and stigma'. Its themes include the need to prevent and treat mental health problems with the same commitment, passion and drive as we do physical health problems. It recognises the importance of early intervention and access, especially in relation to children and young people, and commits to action to improve physical health in those with mental health problems, a focus on rights, and work to improve how outcomes are better measured to allow quality improvement.

The Strategy recognises that we all have mental health. Improvement will require work across policy areas and services. People are at the centre of the Strategy and for that reason a biannual forum of stakeholders has started to meet to monitor and advise on progress, influencing the direction of travel and future actions.

Distress Brief Intervention

A better response by services across the NHS, emergency services, social services and the third sector to people in distress is seen as a key component in supporting people at risk of non-fatal self-harm, and of future suicide prevention.

In July 2016, the Scottish Government announced the host organisation and four partner organisations to develop pilot work to test the Distress Brief Intervention ( DBI) – a time-limited, supportive and problem-solving contact with an individual in distress. North and South Lanarkshire Health and Social Care Partnerships are hosting the DBI central team and participating as one of four partnership test sites running local pilots, along with Penumbra in Aberdeen, Support in Mind in Inverness, and NHS Borders Joint Mental Health Service. Development work on the pilots has been taking place since late summer 2016 and DBI training has been in the process of development by the University of Glasgow. The pilot will run until March 2021 and will be evaluated independently.

Suicide

The Scottish suicide rate reduced by 18 per cent between the periods 2001-2005 and 2011-2015, using five-year rolling averages (European Age Standard Rates) – from 16.7 per 100,000 population to 13.7 per 100,000 population. The statistics, published in August 2016 by ISD Scotland and National Records of Scotland ^[102] , show that 672 people died by suicide in 2015, compared with 696 in 2014. Based on the old coding system, which is used for longer-term comparisons, the number of suicides in 2015 was the lowest in a single year since 1974 ^[103] .

Suicide is extremely complex so it is impossible to ascribe any single reason for the long-term downward trend in the suicide rate. However, over the past several years a range of Scottish Government-funded actions have been underway to help improve mental health and wellbeing, including some action specifically focused on suicide prevention. This includes work led by the NHS Health Scotland Suicide Prevention Programme ^[104] , the Breathing Space ^[105] telephone and web advice service for people experiencing low mood or depression, and a programme of action to improve recognition and treatment of depression and anxiety, including development of better access to psychological therapies. In addition, the See Me programme ^[106] has led much work to tackle the stigma and discrimination which can be associated with mental ill-health. The programme, co-funded by Comic Relief, is thought to have helped more people feel comfortable about coming forward to ask for help when they need it.

Managed Clinical Network for Perinatal Mental Health

In January 2017, funding was announced to establish a Managed Clinical Network ( MCN) for perinatal mental health. This is the first Managed Clinical Network in Scotland dealing with mental health. The network will bring together health professionals who work in the area of perinatal and infant mental health. This joint expert leadership will identify gaps in current perinatal care and pathways for care. It will develop and implement guidelines and best practice, helping to improve standards and make sure everyone gets the same high level of care regardless of where they live. The long-term aim is that all women, their infants and families, have equity of access to perinatal mental health provision, at the level appropriate to need, in all NHS Board areas in Scotland. A lead clinician, together with dedicated maternity, nursing and infant mental health experts and management support, are in place. They have started delivering their work plan with initial mapping and identification of gaps of geographical service provision.

Enhancing the Role of Primary Care

Primary Care Transformation

Shifting the balance of care to ensure that more healthcare services are provided in the community is a critical part of our National Clinical Strategy and the Health and Social Care Delivery Plan. We have provided funding of £23 million in 2016/17 to support and deliver the redesign of primary care across Scotland, including the treatment of mental health in primary care, daytime and out of hours.

Health and Social Care Partnerships and NHS Boards have identified their priorities for improvement within their own areas. These include tests looking at redirecting patients to see the most appropriate healthcare professional, ensuring GPs see patients with more complex needs, supporting patients with mental health, expanding the multi-disciplinary team within GP practices and exploring the provision of safe and effective primary care services in rural settings.

Following the publication in November 2015 of the National Review of Out of Hours Services, Pulling Together, Transforming Urgent Care for the People of Scotland ^[107] , led by Professor Sir Lewis Ritchie, a Peer Review Group was established drawn from a group of experts across the Review's main task group themes: workforce and training; information and technology; quality and safety; and models of care. The group also drew in other professionals and stakeholders as appropriate. The objective of this peer-review-based approach was to enable a co-production-based design with mutual understanding of the aims and outcomes for local urgent care services.

Following an initial investment of £1 million to carry out tests of change in eight pilot areas in 2015/16, a further £10 million was made available in 2016/17 to roll out the transformation of urgent care across Scotland. The Scottish Government asked all key delivery partners, through lead Health and Social Care Partnerships, to propose funding bids which would deliver the report's recommendations locally. All funding bids were assessed by the Programme's Peer Review Group. Tests of change include the development of Urgent Care Hubs and better use of multi-disciplinary teams to support out of hours services.

A New GP Contract

Although primary care goes beyond General Practice, General Practice services remain one of the most critical parts of healthcare delivered in the community. The Scottish Government and the Scottish General Practitioners Committee of the British Medical Association ( BMA) are currently negotiating a new General Medical Services ( GMS) contract for 2018, as a foundation for developing multi-disciplinary community care teams and a clearer leadership role for GPs.

Their vision is: for General Practice to be at the heart of the healthcare system; for those who need care to be more informed and empowered than ever, with access to the right person at the right time, while remaining at or near home wherever possible; and for multi-disciplinary teams in every locality, both in and out of hours, involved in the strategic planning and delivery of services.

In November 2016, the Scottish Government and the BMA published a joint letter and Principles of the Scottish Approach to GP Contract. These were followed by a second publication in May 2017 outlining progress in negotiations, culminating in the announcements made at the Scottish Local Medical Committee Conference held on 10 March 2017 by the Cabinet Secretary for Health and Sport. These announcements included the pledge to increase overall annual funding for primary care by £500 million by 2021/22. It was announced that £250 million of that investment will, in negotiation with the BMA, be in direct support of General Practice.

GP Recruitment and Retention

General Practice is under significant pressure due to the increasing healthcare demands of the population. Difficulties in recruiting and retaining GPs presents a significant risk. The GP Recruitment and Retention Fund invested a further £1 million in 2016/17. This increased investment will enable the scheme to expand and continue to explore with key stakeholders the issues surrounding GP recruitment and retention across Scotland. Pilots tested in 2016/17 include:

• A range of GP fellows, including a project in Deep End practices;
• Royal College of General Practitioners ( RCGP) GP Recruitment Programme;
• Island-wide practice Mull and Iona – to develop a sustainable GMS service model which is attractive to recruit and retain staff, address professional isolation, reduce the burden of on-call, establish and strengthen primary care team services to better meet needs, and enhance access to specialities;
• GP Returner Scheme run by NHS Education for Scotland ( NES);
• NHS Shetland – a short term project March-May 2016 to work in collaboration with Promote Shetland to take forward a GP recruitment campaign; and
• The 'Being Here' remote and rural primary care sustainability project hosted by NHS Highland also successfully bid for funding to provide a stand at the RCGP Conference in Harrogate in October 2016. The aim of the stand was to promote the recruitment of GPs in remote and rural areas of Scotland through hi-profile networking at the largest UK GP conference, with approximately 4,000 attendees. This was an opportunity for rural boards, including Shetland, Orkney and Western Isles, to work together to raise awareness of alternatives to urban GP practice as a rewarding and interesting career choice.

Improving Eye Health

Scotland is rightly proud of its world-leading approach to eye health. We have just celebrated the 10th anniversary of General Ophthalmic Services ( GOS), which has supported not just universal free eye tests, but also a more systematic focus on improving eyecare. The time was right to review GOS, and so the Cabinet Secretary for Health and Sport commissioned the Community Eyecare Services Review in August 2016.

The Review considered eyecare services currently provided across Scotland to identify areas of good practice that could be rolled out nationally. The Review was published on 19 April 2017 ^[108] and made a number of recommendations including: schemes to reduce geographical differences in services; more tailored arrangements for patients with specific complex needs to support care closer to home; and suggesting that some eye services traditionally offered in hospitals (such as post-cataract surgery appointments and managing stable glaucoma patients) should be made available locally. The Scottish Government is in the process of implementing the recommendations of the Review and will be engaging with a range of stakeholders, including health professionals and patients, as it does so.

Improving Oral Health

In response to a commitment within the 2016 Programme for Government ^[109] , the Scottish Government launched a consultation exercise on Scotland's oral health on 15 September 2016 ^[110] . The consultation exercise recognised some of the key challenges around oral health inequalities, an ageing population and how we begin to shift the emphasis from restorative dentistry to a more preventive-focused approach. The analysis of responses was published in June 2017 ^[111] with the final Oral Health Improvement Plan due for publication before the end of 2017.

Despite the success of the Childsmile programme, health inequalities in oral health persist in Scotland. People of all ages who live in the most deprived areas are more likely to experience poor oral health than the rest of the population. We know that poor oral health can have a negative impact on an individual's general health so it is vital we do as much as we can to reduce oral health inequalities. Tackling oral health inequalities is seen as a priority for practitioners and the public.

Action 23 of the Fairer Scotland Action Plan ^[112] commits the Scottish Government to extend the delivery of Childsmile interventions, such as nursery and school fluoride varnish application, to reach even more comparatively deprived communities. This will particularly benefit children in Greater Glasgow and Clyde, and Ayrshire and Arran.

Achieving Excellence in Pharmaceutical Care

Following a two-year long process led by the Scotland's Chief Pharmaceutical Officer, Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland ^[113] set out the priorities, commitments and actions for improving and integrating NHS pharmaceutical care in Scotland over the next five years. The strategy refreshes the 10-year vision and action plan Prescription for Excellence ^[114] launched in September 2013. It aligns pharmaceutical care with the strategic and policy direction described in the Health and Social Care Delivery Plan, National Clinical Strategy, Realising Realistic Medicine, and transformational change in urgent and primary care.

Over the next five years, Achieving Excellence in Pharmaceutical Care will be driven by two main priorities: improving NHS pharmaceutical care and enabling NHS pharmaceutical care transformation. This is supported by nine commitments and a series of 29 actions which focus on integrating and enhancing the role of pharmacy across all areas of pharmacy practice in both hospital and in the community, increasing capacity, and offering the best possible person-centred care. It also describes a range of ways that pharmacy and pharmacy services are already adapting: pilot projects to test new ways of working; and plans to evaluate developments in order to gather evidence to help these new approaches to pharmaceutical care to become sustainable across the NHS in Scotland.

Pharmacy – Building Clinical Capacity

Building capacity through multi-disciplinary team working is a core plank of the programme to transform primary care. Good progress is being made to deliver the Programme for Government commitment to ensure that every GP practice in Scotland has access to a pharmacist with advanced clinical skills by 2021. By the end of 2017/18 we expect to have invested up to £20.4m to support this commitment. Through this investment, we are on track to recruit the 140 WTE pharmacists announced in June 2015 and, in addition to this, 28.8 WTE technicians, benefiting patients in around a third of GP practices across Scotland. Further progress during 2017/18 will put in place the strong foundations to deliver the Programme for Government commitment ^[115] .

These pharmacists and technicians are supporting GP practices with a range of medication management and clinical activities including medicines reconciliation, high-risk medicine reviews, polypharmacy reviews and specialist clinics such as pain management and other long term conditions. Evidence from robust research is an essential part of future decision-making. As this Programme for Government commitment is taken forward, the two Scottish Schools of Pharmacy will evaluate the new ways of working emerging for pharmacy teams in General Practice to inform sustainable models of care going forward and the considerations for the wider pharmacy workforce.

Access to New Medicines

Access to new medicines has been improved significantly in recent years as a result of investment and reforms. Between 2011 and 2013, the combined acceptance rate for orphan/cancer medicines by the Scottish Medicine Consortium ( SMC) was 48 per cent and between 2014 and 2016, the SMC approved 75 per cent of ultra-orphan, orphan and end of life medicines under the new approach. Nevertheless, we recognise that there is more to do and fresh reforms are now underway to change the way new medicines are approved to ensure better access for patients in Scotland. The Scottish Government is working in collaboration with partners and stakeholders across Scotland, including NHSScotland, the third sector and the pharmaceutical industry, to take forward the recommendations of Dr Brian Montgomery's Review of Access to New Medicines ^[116] which sets out how the process for appraising medicines could be made even more open, transparent and robust. These additional reforms will help patients get access to medicines that can give them longer, better quality lives.

Tackling Polypharmacy

The Scottish Government has provided national leadership for three significant medicines-use improvement strategies in 2016/17. The National Polypharmacy, Respiratory and Diabetes prescribing strategies aim to provide a consistent approach to improving the safe and effective use of medicines through the use of a holistic person-centred medication review. There is widespread implementation of the strategies via the Scottish Prescribing Advisers Association and prescribing data demonstrates the impact on reducing variation across Scotland.

The Polypharmacy Guidance 2015 ^[117] focuses the review of frail patients and those with multiple morbidities on multiple medicines, which include those considered as high risk. Consistent evidence shows that up to 11 per cent of hospital admissions are attributable to adverse medicine events, and the majority of those that are preventable are for patients over the age of 65 years on multiple medicines ^[118] . The Respiratory Prescribing Strategy 2014-16 ^[119] focuses on person-centred review with the emphasis on effective inhaler use and the reduction in steroid burden for suitable patients. Excessive use of steroids is associated with increased risk of developing osteoporosis, growth retardation in children and adrenal suppression. For patients with chronic obstructive airways disease there is also an increased risk of developing community-acquired pneumonia with high-dose steroid use. The Diabetes Prescribing Strategy 2014-16 ^[120] focuses on promoting medicines that provide the greatest evidence-based benefits for patients, and the withdrawal of therapies that are no longer working.

Since the introduction of the Polypharmacy Guidance 2012, there has been a reduction in the annual volume increase from 3 per cent to 1.5 per cent ^[121] . This reduction correlates to the 120,000 polypharmacy reviews performed each year. Since the introduction of the Respiratory Prescribing Strategy 2014-16, there has been a reduction in the proportion of high-dose inhaled corticosteroids from 25.1 per cent to 18.8 per cent ^[122] . Since the introduction of the Diabetes Prescribing Strategy 2014-16, there has been an increase in the use of the first-line medicine, metformin, to it being used by over 90 per cent of patients with type 2 diabetes ^[123] .

Enhancing the Role of the Ambulance Service

New Clinical Response Model

In November 2016, the Scottish Ambulance Service ( SAS) began piloting a new response system which aims to save more lives and improve the quality of care for patients. Patients with immediately life-threatening conditions, such as cardiac arrest, are prioritised and receive the fastest response. In less urgent cases, call handlers may spend more time with patients to better understand their health needs and ensure they are sent the most appropriate resource for their condition. The new model has been developed following the most extensive clinically-evidenced review of its kind ever undertaken in the UK, with nearly half a million calls examined. It is the first major change to the time-based targets system since 1974. Initial results are encouraging, with the latest statistics showing that, on average, 66 per cent of patients suffering a witnessed cardiac arrest by ambulance crews were successfully resuscitated and alive on arrival at hospital over the last six months ^[124] . Another improvement in 2016/17 saw conveying resources sent first time to 95 per cent of patients likely to need to be taken to definitive care, further improving outcomes for patients ^[125] .

New Ways of Working

The SAS strategy, Towards 2020: Taking Care to the Patient ^[126] , aims to provide more patients with the care they need, where and when they need it. In 2016/17, the SAS managed more than 30 per cent of eligible unscheduled cases either by telephone or face-to-face assessment, avoiding unnecessary hospital admissions ^[127] . This work is being supported by the introduction of specialist paramedics, whose enhanced skills enable more patients to be treated within community settings.

Skills Enhancement

The SAS is continuing to invest in its workforce. In 2016/17, it trained 193 new paramedics and recruited 82 specialist paramedics. A further 254 technicians were recruited and commenced training ^[128] . Paramedics are increasingly working within primary care teams, enabling more patients to be treated within community settings. Additional investment in the development of clinical advisors in ambulance control centres also supported the aim of the SAS to provide more patients with the care they need, where and when they need it, and avoid unnecessary hospital admissions. The establishment of a trauma desk will enable more effective trauma recognition, triage and tasking, with the SAS having a key role in the Scottish Trauma Network.

Improving Cancer Outcomes

Increase in Cancers Diagnosed at the Earliest Stage

Overall cancer death rates have dropped by 10.6 per cent over the past ten years and early detection is vitally important to continuing this trend ^[129] . During 2016/17, our Detect Cancer Early Programme has successfully carried out social marketing campaigns on bowel cancer screening, lung cancer and breast screening. The campaigns aim to highlight the benefits of earlier presentation of symptoms to a GP and of screening participation through a combination of targeted media campaigns, digital engagement and extensive work with primary care, NHS Boards and the third sector. This has helped contribute to an increase in the proportion of breast, lung and colorectal cancers diagnosed at the earliest stage. In 2015 and 2016 (Year 5), 25.5 per cent of people were diagnosed at stage 1 for breast, colorectal and lung cancer (combined) – this is a 9.2 per cent increase from the baseline of 23.3 per cent (in 2010 and 2011). The largest increases were observed in early stage lung cancer diagnoses (an increase of 39.2 per cent) and for those living in the most deprived areas of Scotland (an increase of 17.4 per cent) since baseline ^[130] .

Cancer Strategy

In 2016/17, more than £13 million has been invested in delivering the commitments in the Beating Cancer: Ambition and Action ^[131] strategy, including £2 million on the provision of robots to deliver prostate cancer surgery and £4.3 million on radiotherapy equipment.

Supporting People to Start Their Lives Well

Health, Wellbeing and Learning Outcomes for Children, Young People, Families and Communities

Through the Children, Young People and Families Early Intervention and Adult Learning and Empowering Communities Fund, the Scottish Government provided £14 million in 2016/17 to 118 third sector organisations to use early intervention and prevention to improve health, wellbeing and learning outcomes for children, young people, families and communities. This fund is tackling inequality and building opportunity, making a difference to the lives of thousands of children and families, in many cases preventing the need for costly acute service input. One of the themes supported by the Fund is ensuring that children reach their full potential through strengthening early child development. A number of organisations were supported under this theme, including Children's Health Scotland, which promotes children's healthcare rights and needs, and Place2Be, which delivers counselling in schools, often meaning that the requirement for input from Child and Adolescent Health Services can be avoided. Another organisation that benefited from this fund is Bobath Scotland which, working in partnership with NHSScotland, helps children with cerebral palsy make the most of their abilities and reach their full potential.

In Vitro Fertilisation

Scotland leads the way on In Vitro Fertilisation ( IVF) access in the UK. Targets for improved IVF waiting times continue to be met by NHSScotland as a result of £6 million investment in NHS IVF treatment to drive down waiting times. In June 2016, the National Infertility Group published a report ^[132] recommending changes to IVF criteria, which were accepted by Scottish Ministers. Implementation of the first of these – allowing access to IVF treatment for couples with an existing child in the home – commenced in September 2016 and work commenced to implement introduction of a third funded cycle of NHS IVF treatment for all eligible couples from 1 April 2017. This means that more people are accessing IVF treatment more quickly, which is good news for couples in what can be a very stressful time.

Improving Care and Outcomes for People Living with Diabetes

Access to Insulin Pump Therapy

Achieving good glucose control is key to living well with diabetes and reducing risk of associated complications such as diabetic retinopathy and kidney disease. In 2012, the Scottish Government introduced a programme of work to support a substantial increase in access to insulin pump therapy for people with type 1 diabetes, supported by £7.5 million of funding. By the end of 2015, the initial target had been exceeded, with over 30 per cent of young people under 18 years and over 7 per cent of adults using the therapy ^[133] . In 2016, the number of people maintaining good glucose control increased from 22.1 per cent in 2015 to 24.5 per cent, and the percentage with poor glucose control decreased from 36.6 per cent to 33.9 per cent ^[134] . In supporting continued improvement in glucose control, in December 2016 the Scottish Government announced funding of £10 million over the course of the Parliament to support further increase in access to insulin pump therapy for adults and to deliver increased access to Continuous Glucose Monitors.

Improving Inpatient Care

Approximately one in five hospital inpatients at any given time will have diabetes ^[135] . Nearly half of these will be insulin dependent, with most admitted to hospital cared for in non-diabetes specialist inpatient areas. Insulin is considered to be in the top three high-risk medications for error and harm, with the effect of poor insulin dosing including hypoglycaemia, hyperglycaemic emergencies (diabetic ketoacidosis and diabetic coma) and foot ulceration, all of which are largely avoidable and are associated with longer stays in hospital.

Following the completion of the Think, Check, Act project in March 2016, Healthcare Improvement Scotland introduced a range of tools and resources to improve the care and experience of people with diabetes admitted to hospital ^[136] . This package of online learning modules provides essential skills training in treatment with insulin, hypoglycaemia management, foot CPR (Check Protect Refer), and glucose monitoring. The project also recommends that 'hypo boxes' are available in hospital wards to ensure access to prompt and effective treatment for all patients in the event of hypoglycaemia. Evidence from the project has demonstrated improved hypoglycaemia management, reduced bed days and improved patient experience ^[137] . It is estimated that adoption of Think, Check, Act across the whole of NHS Greater Glasgow and Clyde alone could save in excess of 2,900 bed days per annum. Implementing CPR for feet across Scotland could prevent 75 per cent of new foot ulcers developed in hospital, save £15 million per annum and reduce unscheduled bed days ^[138] . Work continues with funding from the Scottish Government to purchase hypo boxes, while National Co-ordinators are working with NHS Boards to spread the learning of the project and embed this work.

Improving Motor Neurone Disease Care

In January 2015, the First Minister announced an additional £2.5 million per annum to enhance the provision of specialist nursing and care. NHS Boards have enhanced support in ways that reflect local needs, including the creation of 31.4 WTE additional specialist nurse roles (at May 2017) which are supporting patients and families affected by a wide range of conditions, across the life spectrum and in hospital and community settings. The number of Motor Neurone Disease ( MND) nurse specialists had more than doubled, increasing by 7.64 WTE ^[139] , including the appointment of a National Co-ordinator, funded by the Scottish Government in collaboration with MND Scotland and the University of Edinburgh to develop a strategic approach to delivering MND services and promote the delivery of first-class, evidence-based care. Patient contact with the MND Clinical Team has risen significantly ^[140] . Care is now proactive, with patient and clinical specialists both reporting an improvement in service provision, including quality and frequency of time spent with patients and families.

Saving Lives at Risk from Cardiac Arrest

Out-of-Hospital Cardiac Arrest: A Strategy for Scotland ^[141] sets out the commitment to improve survival and outcomes from cardiac arrest. Over 140,000 people have been equipped with cardiopulmonary resuscitation ( CPR) skills by Save Life for Scotland partners since its launch in October 2015 ^[142] . A main aim in the Strategy for Scotland is to equip an additional 500,000 people with CPR skills by 2020 in order to increase rapid bystander intervention in an out-of-hospital cardiac arrest. Save a Life for Scotland is the partnership that has come together to help many more people learn CPR skills. It co-ordinates activities that raise awareness of cardiac arrest and help people learn CPR via the partner organisations.

Improving Organisational Resilience

In 2016, new standards covering organisational resilience were published for NHSScotland ^[143] . These provide a framework for NHS Boards to improve resilience against disruptive events, ranging from severe weather and transport disruption to dealing with potential terrorist incidents. These will help to ensure that health services are robust to cope with disruption and that arrangements ensure the safety of patients and staff. To support the aims of the standards, two major exercises have taken place in Scotland during 2016 to enhance the resilience of NHS Boards.

Developing Healthcare Science

Healthcare scientists are pivotal within the collaborative professional environment to ensure that NHSScotland can appropriately manage waste and unwarranted variation in diagnostic testing. While some NHS Boards are reporting a 15 per cent year-on-year increase in diagnostic testing activity and associated costs, the Carter Review of pathology services in England ^[144] estimates that around 25 per cent of diagnostic tests currently undertaken are inappropriate. This significant waste impacts on patient pathways and experiences, increases service workload and consumes precious resources. Variation in practice at NHS Board level is evident across a range of variables, including costs, quality and patient experience. The healthcare science community has published guidance and recommendations to help achieve a Scottish approach to demand optimisation which will ensure the right test at the right time to the right person.

Healthcare scientists have worked with their medical colleagues to reduce waste and optimise patient pathways. The realistic approach achieved by implementing the use of B-type natriuretic peptide ( BNP), a blood test to triage breathless patients for echocardiography, has demonstrated reductions of approximately 10-11 weeks from General Practice appointment to the patient commencing treatment, with a new model of delivery in 2-3 weeks. In addition, these models have reduced echo and outpatient appointments by approximately 50 per cent, with projected savings (avoided cost) of around £30,000 ^[145] .

Investing in Cutting-edge Medical Research

The Scottish Government has continued to invest in high-quality applied research across a very wide health and social care remit. In addition to £3 million in 2016/17 for precision medicine – the practice of tailoring treatment to individual patients based on knowledge about their genetics and other biology and information from their health records – and £0.5 million for the Scottish Genomics Partnership ^[146] , around £61 million has been invested to enable NHSScotland to host and participate in research across a wide range of disciplines and disease areas.

This funding has supported the necessary research infrastructure across NHSScotland, including: clinical research facilities; research units; biorepositories; data safe havens; 24 Clinical Leads across key areas such as Cancer, Diabetes, Stroke, Dermatology and Rare Diseases; and the SHARE register of patients willing to take part in clinical research and trials which is now approaching 200,000 participants – a real testament to the willingness of the Scottish population to support and be involved in clinical research.

It has also enabled Scotland-based researchers access to UK-wide research funding, supported collaborative working with other research funders such as the Medical Research Council and various medical research charities, and has helped to build future research capacity in NHSScotland and academic institutions through clinical research fellowships.

The Golden Jubilee Research Institute approved a record number of 40 academic and commercially sponsored research projects in 2016/17. The Golden Jubilee was the first in the world to participate in the Ready MRI study, treating a patient with an Implantable Cardioverter Defibrillator using a Magnetic Resonance Imaging ( MRI) scan. This could allow thousands more patients at risk of sudden cardiac arrest to safely undergo MRI tests. The T-TIME study also started in 2016/17, aiming to assess more than 600 heart attack patients with a new drug to restore blood flow to the small heart vessels. The new Golden Jubilee Motion Analysis Lab will allow for improved analysis of impact and movement, with the goal of helping a person achieve optimum mobility, balance and performance. This is a major development in how orthopaedic patients are assessed and has the potential to benefit patients with sports injury, spinal injury, stroke, prosthetics and cerebral palsy.

Empowering People and Improving Care through Digital Health

Digital technology has a key role to play in helping to transform services, and to ensure person-centred care is provided in a way that fits with people's lives, particularly in an increasingly digital age. Empowering people to more actively manage their own health and wellbeing through the use of technology and information contributes to achieving our aim for everyone to live longer, healthier lives at home, or in a homely setting.

The publication of the Health and Social Care Delivery Plan committed to a new Digital Health and Care Strategy. This new integrated Strategy will build on achievements to date but will provide greater alignment between the already-strong foundations in eHealth, technology-enabled care and the use of data, intelligence and research.

NHSScotland is already a technology-driven organisation, with all aspects of care touched by the use of technology. This includes how staff communicate with each other, the use of patient records and the transfer of images and lab results, the use of technology to help people to manage their own conditions, and the use of data generated from this to better plan and deliver services.

Significant developments in 2016/17 include the launch of the Scottish Primary Care Information Resource ( SPIRE) ^[147] , used by local GP practices to manage their own information and provide evidence for quality improvement, audit and performance appraisal as well as using depersonalised and anonymised data for research into population health, including multi-morbidity and cancer. A public information campaign was launched in March 2017 using radio advertising, leaflets and posters in GP surgeries to inform the public about the purposes for which data would be used and offer an opportunity to opt out if preferred. Further public information will be issued in the coming year as SPIRE continues to roll out in each area.

The Golden Jubilee Foundation is the first NHS Board to trial pre-assessment clinics for ophthalmology via telehealth links. This innovative collaboration with NHS Fife sees patients attend their local hospital for a high-tech consultation by secure video link, reducing travel time and allowing faster access to treatment. A further redesign of the Golden Jubilee ophthalmology service has introduced optometrist and nurse-led clinics, allowing them to treat an additional 1,000 patients every year. The Golden Jubilee Patient Portal will revolutionise the way electronic records are managed and will allow more patients to be directly involved in their care. Currently, the system enables patients to access their clinical information from their laptop, smartphone or tablet, allowing them to share this information with other clinicians. In the future, patients will have direct access to upload their own documents and information, enabling new ways of engaging with health and social care.

NHS inform ^[148] , Scotland's Health and Care Information service originally established in 2010, was redesigned and re-launched in November 2016. The refreshed NHS inform hosts an extended range of health and social care information topics, a new Self Help Guide, National Services Directory and personalisation tool 'Info for Me'. In October 2016, NHS inform was attracting around 40,000 visits a month and since then access to the online service has risen to more than 300,000 visits per month in July 2017. At launch, web chat was offered as an alternative public access channel which now receives around 1,000 monthly contacts. NHS 24 continues to engage with the public and partners to ensure the service remains relevant for the people who use its services.

Work continued during 2016/17 on scaling up telehealth. The European-funded United4Health ^[149] programme ended, with almost 7,000 Scottish patients benefiting from being able to remotely monitor their long term condition. Data from around 4,500 patients were evaluated, making this one of Europe's largest ever studies into how to implement telehealth at scale. This work has continued through the home and mobile health monitoring workstream of the Technology Enabled Care Programme, with a National Service Model for Home and Mobile Health Monitoring ^[150] released to support local implementation.

An example of the potential for remote monitoring is provided by NHS Lanarkshire. A 90-day test of change ran from March-May 2016, aiming to assess the benefits and challenges of remotely monitoring patients' blood pressure using SMS text messaging. GPs were asked to recruit patients at the point of diagnosis or initiation of medication. Nine practices and 115 patients contributed to the study. An average of 4.4 face-to-face contacts per patient were saved compared to usual care, with 100 per cent of clinicians involved in the study agreeing that the monitoring had been an aid to decision-making. In 69 per cent of cases it led to faster decision-making, with 99 per cent of patients reporting that it was easy to use, 84 per cent feeling it helped them to monitor their blood pressure and 94 per cent stating they would use it again if they needed to. Interestingly, it revealed no treatment was required in 33 per cent of cases. The study demonstrated that remote monitoring of blood pressure improves efficiency and supports clinical decision-making. Most people find it easy to use and would use it again if required. Fifteen months after the 90-day test started, the pathways remain intact with around 1,000 patients benefiting in total. A further analysis of the 820 patients who had used the service estimated that the number of clinical contacts avoided was over 3,200 ^[151] . Experience in this area will inform the development of a Patient Portal, through which people will be able to access and contribute to their health record.

If all new cases of hypertension in Scotland were diagnosed in this way, it is estimated that some 140,000 primary care appointments would be avoided each year.