NHSScotland Local Delivery Plan Guidance 2013/14

1 Outcomes

Quality Strategy

The Quality Strategy sets out NHSScotland's vision to be a world leader in healthcare quality, described through 3 quality ambitions: effective, person centred and safe. These ambitions are articulated through the 6 Quality Outcomes that NHSScotland is striving towards:

• Everyone gets the best start in life, and is able to live a longer, healthier life
• People are able to live at home or in the community
• Healthcare is safe for every person, every time
• Everyone has a positive experience of healthcare
• Staff feel supported and engaged
• The best use is made of available resources

Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

Challenges

The demands for healthcare and the circumstances in which it will be delivered will be radically different in future years.

Over the next 10 years the number of over 75s in Scotland's population - who are the highest users of NHS services - will increase by over 25%. There will be a continuing shift in the pattern of disease towards long-term conditions, particularly with growing numbers of older people with multiple conditions and complex needs such as dementia.

The health budget has received the full Barnett consequentials arising from the Department of Health's 2010 UK Comprehensive Spending Review over the current Spending Review period. This has lifted the resource budget to more than £11.3 billion in 2013-14. Funding for Territorial Boards will increase by £256.0m (3.3%) in 2013-14 and £247.4m (3.1%) in 2014-15. This reflects our commitment to direct resources to protect point of care healthcare services. The NHS will still face considerable budget pressures. These pressures mean that the NHS will need to deliver maximum value from our investment through a focus on improving the quality of care by prioritising changes which also deliver greater efficiencies. Even after recognising the resource Barnett consequentials, there will require to be an ongoing focus on delivering efficiency savings and increasing productivity based on past success.

While there are no specific efficiency targets for the years 2012-13 to 2014-15, there is a clear expectation that NHSScotland will take steps to deliver annual operational efficiency savings of at least 3 per cent. These savings will continue to be retained by NHS Territorial Boards for reinvestment in frontline services.

Over the next few years NHSScotland must ensure that - in the face of these demands and changing circumstances - it can continue to provide the high quality health service the people of Scotland expect and deserve into the future.

Responding to the challenges

The Scottish Government, NHSScotland and its partners must collectively recognise and respond to the most immediate and significant challenges - which include Scotland's public health record, our changing demography and the economic environment. The Scottish Government and NHSScotland must be bold enough to visualise the NHS that will best meet the needs of the future in a way that is sustainable, and then make the changes necessary to turn that vision into reality.

The Scottish Government remains committed to the values of NHSScotland: the values of collaboration and cooperation partnership working across NHSScotland and wider public sector, with patients and with the voluntary sector; of continued investment in the public sector rather than the private sector; of increased flexibility, provision of local services and of openness and accountability to the public. The Scottish Government opposes the route being considered in NHS England as their response to the global challenges.

The Scottish Government recognises that in order to meet the challenges which face us all, public services in Scotland must go further, reforming their ways of working in order to improve outcomes for the people of Scotland. There is an expectation that all public service organisations pursue reform in line with four pillars of decisive shift towards prevention; greater integration and collaboration between public services at a local level; greater investment in workforce development and leadership; and a sharp focus on improving performance. This vision of reform is consistent with the Quality Strategy in placing people at the centre of public service design and delivery.

Community Planning is a key means through which reform will be delivered. NHS Boards are key partners within Community Planning Partnerships and have a crucial role to play in delivering improvements on a local and national basis. There is widespread agreement that Community Planning Partnerships focus on a small number of key priorities: economic recovery and growth; employment; early years and early intervention; safer and stronger communities, and offending; health inequalities and physical activity; and older people. Like all public bodies, there is an expectation that NHS Boards as CPP partners have evidence based understanding of local needs and opportunities which is translated in to prioritised plans and delivery of improved outcomes.

The Scottish Government is clear that NHSScotland needs to sharpen its focus on how it will sustain performance, deliver further improvement and transformational change in health and social care. Work is now underway to prioritise a small number of strategic improvement programmes that will provide the basis for NHSScotland to organise its response in the most effective way. These will build on existing and emerging programmes, and will form our plans for pursuing quality and delivering our 2020 vision.

NHS Boards will make contributions to improve outcomes through these strategic programmes, but are also expected to make contributions building on existing local partnership work.

We know from previous Local Delivery Plans, the importance of developing a shared understanding of the goal that is to be achieved, using data to understand what is happening at national and local level; and identifying early gains to create momentum. NHS Boards have increased their capability and capacity to deliver change through the full range of improvement methodologies including performance management, collaboration, benchmarking, and empowerment. The strategic improvement programmes will employ a combination of these methodologies. Where appropriate, the strategic improvement programmes will be underpinned by new HEAT targets - which have supported significant improvements. It is recognised that the targets approach will not be the optimal for every programme. Likewise, not every HEAT target will be appropriate for inclusion in Single Outcome Agreements. The three year Local Delivery Plan, updated annually, and its HEAT targets and standards continue to have a crucial role in sustaining performance, improving performance and transformational change. The following sections, which are by no means comprehensive, help describe the role of HEAT and LDPs going forward.

Sustaining Performance

The NHSScotland Chief Executive's Annual Report and Scotland Performs set out the significant achievements delivered by NHSScotland staff over a number of years. Sustaining achieved performance levels in order to secure better outcomes for the people of Scotland is important - with performance management underpinning this. For example, patients continue to hold prompt access to treatment, delivered as locally as possible, as one of their top priorities, and there is increasing evidence that long waits have a detrimental impact on health and well-being outcomes over the immediate and longer term. Waiting times are at their lowest levels, with over 90% of patients now waiting less than 18 weeks from Referral to Treatment, NHS Boards are achieving cancer waiting times and patients now benefit from the treatment time guarantee that is enshrined in law. Sustaining waiting times performance is crucial and the Unscheduled Care Expert group is redoubling efforts through work with NHS Boards and partners to address access to A&E waiting times performance through a national action plan which will include a focus on efficient and effective utilization of capacity in both hospitals and the community.

At the same time we must continue to actively identify and pursue opportunities to prevent health problems arising in the first place. Prevention or early intervention provides clear benefits to individuals and families but also reduces the likelihood of more intensive and costly treatment at a later stage. Alcohol Brief Interventions are a highly effective early intervention to help individuals to reduce hazardous or harmful alcohol use which contributes significantly to Scotland's morbidity, mortality and social harm. The ABIs support people to reduce their chances of developing more serious alcohol-related problems. The HEAT target enabled ABIs to be scaled and delivered across Scotland. 97,830 interventions were carried out in 2011/12. On the back of delivery of ABIs in healthcare settings, interventions are now being delivered in youth work, occupational health, and criminal justice settings. The focus of ABIs needs to be sustained going forward.

The HEAT target on drug and alcohol misuse treatment helps ensure more people recover from drug and alcohol problems so that they can live longer, healthier lives, realising their potential and making a positive contribution to society and the economy. The first stage in helping people to recover from drug and alcohol problems is to support action across the country to provide a wide-range of services for individuals and their families that are recovery focused, good quality and that can be accessed when and where they are needed. In the quarter ending June 2012, almost 11,000 clients started their first treatment for drug or alcohol use, with 90.0 per cent of clients experiencing waits of 3 weeks or less. This HEAT target will become a HEAT standard in 2013/14.

Further Improvement

The Scottish Government remains committed to quality improvement underpinned by performance management where appropriate. We have seen significant reductions in HAI, with a 41 per cent reduction in rates of Staphylococcus aureus bacteraemia between 2005/06 and year ending June 2012, and a 78 per cent reduction in Clostridium difficile since 2007/08. The reductions have been underpinned by strong leadership and a comprehensive delivery plan including improved reporting at all levels; and implementation of best practice (hand hygiene, antimicrobial prescribing). Reducing preventable HAI directly supports healthcare that is free from avoidable harm, a new HEAT target has been introduced to further reduce the levels of staphylococcus aureus bacteraemia (including MRSA) and Clostridium difficile.

The establishment of the Scottish Patient Safety Programme which was the first such programme in the world to be implemented across a whole health system is delivering significant improvements which include a renewed focus, improvement methodology and significant reductions in HSMR (11.4% since 2007). The programme has been extended until 2015, with a focus on harm free care in the NHS - focussing on infections, falls, blood clots and pressure sores. There are no specific HEAT targets associated with this programme.

NHSScotland supports a range of clinical audit work which helps drive improvement in care. These audits include stroke, trauma, arthroplasty, intensive care, surgical mortality, musculoskeletal services, electroconvulsive therapy, gastro-intestinal endoscopy, renal and MS registries. The audits have helped drive improvements in treatment outcomes. HEAT targets have supported improvements in access to stroke units and time to hip fracture time to theatre. This has improved the quality of care and treatment outcomes which is a critical measure of success.

Timely access to healthcare is a key measure of quality in mental health and other services. Early action is more likely to result in full recovery and in the case of children and young people will also minimise the impact on other aspects of their life, so improving their wider social development outcomes. Most children's mental health problems can be prevented from getting out of hand. More serious problems, disorders and illnesses too can be helped and improved. Community Child and Adolescent Mental Health Services (CAMHS) treat and help children and young people and their families. There has been a 37% increase in the size of the specialist CAMHS workforce between the end of 2008 and September 2012. NHS Boards have developed, for the first time, systems to measure CAMHS waiting times from referral to treatment. During the quarter ending September 2012, around 2,400 children and young people started treatment at CAMH services in Scotland. The initial estimates from data at an early stage of development indicate that around 89% of people were seen within the 26 weeks HEAT target. The HEAT targets will support further improvement and delivery of 18 weeks waiting times for CAMHS and Psychological Therapies.

Smoking has long been recognised as the biggest single cause of preventable ill-health and premature death. It is a key factor in health inequalities and is estimated to be linked to some 13,500 deaths and many more hospital admissions each year. From April 2008 to March 2011, NHSScotland smoking cessation services reported 89,075 successful quit attempts (at one month post quit). The new HEAT target focuses on targeting smoking cessation in deprived communities, with over 24,000 successful quit attempts in 2011/12.

Transformational Change

Person centred care is not just about doing what we currently do in a more person-centred way. While there are some problems we can fix and some improvements we can make in the short term, a new focus on applying improvement science in person centred care offers an opportunity to work across health and social care settings to agree a shared understanding and approach to achieving the sort of changes that are needed. In order for these transformational changes to be sustainable, they will require action at all levels of our health and care system and in the communities in which people live. Work is underway to assess whether HEAT targets can support delivery.

One of the most important functions of the NHS is prevention of ill health and there is increasing need to take the prevention agenda to a new and more effective level. The increasing incidence of illness, in an ageing population, underlines the importance of finding new ways of detecting illness earlier and treating it at a stage at which significant benefit is possible. Projects such as Generation Scotland will offer new insights into the biological mechanisms of disease and particularly the genetic and epigenetic factors at work in the Scottish population. Such projects are already offering opportunities to translate the knowledge gained in the laboratory into patient benefit and we must be ready to apply that knowledge effectively. In addition, insights into population health inequalities point to significant psychosocial issues as the basis of much of the ill health which has emerged in Scotland over the past few decades. Supporting families and individuals living difficult and chaotic lives in ways which allow them to avoid damaging lifestyles requires better understanding, at an individual level. There is increasing evidence new approaches to data collection and analysis can identify problems much earlier than previously thought. Sophisticated analytical algorithms which allow large datasets to be examined for trends which indicate impending problems well before conventional diagnostic methods confirm the existence of a problem are now available and have the potential to allow intervention before serious, and perhaps tragic outcomes befall individuals. The NHS together with other public sector bodies should begin to explore the use of such analytical methods with a view to developing novel approaches to prevention and early detection of problems.

An emergency admission to hospital may be the right course of action for an older person who has a potentially serious or life threatening health problem that needs urgent specialist investigation or treatment in hospital. However for some older people an admission to hospital can be followed by complications such as a serious loss of confidence that prolong their stay, compromising their independence. While rehabilitation services can minimise this risk it is important to prevent avoidable emergency admissions. Reshaping Care for Older People has a HEAT target on reducing emergency bed days for 75+ which is framed to encourage the development of proactive community support; planning ahead to manage anticipated crises; earlier access to specialist assessment and treatment at home, in the accident and emergency unit or within hospital; and better co-ordination of health and social care support to enable a timely, safe and supported return home. The NHS and its community care partners, Local Authorities, are fully committed to this preventative approach that is intended to ensure older people receive the best possible care whenever they need it. There was a 7.6 per cent decrease in the rate of occupied bed days for patients aged 75+ who were admitted in 2011/12 compared with 2009/10. Tackling delayed discharges continues to be a priority - with a challenging 14 day delayed discharge target from April 2015 already agreed. This builds on impressive improvements delivered through partnership which have seen a drop in six week delayed discharges from almost 2,000 in 2002 to 95 today. Data is now available on bed days lost to delayed discharge and there is an expectation that NHS Boards and their partners make major reductions.

NHS Boards have an important role to play in the economy, as an employer, a consumer and partner. The Scottish Government has a vision to increase partnership working so that NHSScotland can develop its use of new innovative technology and improve the quality of care which patients receive, including the ability for more people to be cared for at home. This will also help to achieve the aim of doubling the economic contribution of life sciences to the Scottish economy. Scottish scientists and businesses' recent developments include a new class of cancer drugs, stem cell treatment which could potentially reverse corneal blindness and a treatment for diabetics which reduces dependence on insulin. NHS Boards are committed to tackling youth unemployment and are providing additional opportunities for unemployed young people including Modern Apprenticeships, student placements and work experience programmes. All NHS Boards are actively working to develop new or existing plans and programmes in order to meet national expectations.

In order to take forward transformational change in the early years of life, we need to build on a range of evidence based preventative interventions. These, applied over the first five years of a child's life will transform their future. For example, the existing HEAT target on booking antenatal care by the 12th week of gestation is based on evidence that those women at highest risk of poor pregnancy outcomes are less likely to access antenatal care early and/or have a poorer experience of that care. Meeting this target will clearly contribute to improved outcomes but it is only one element. The Early Years Taskforce has set out the vision of what needs to be done to ensure the best possible outcomes for our children, the ways families and communities can help improve these outcomes and how services can best be targeted to support them. The Early Years Change Fund represents the Scottish Government, Local Government and NHS Scotland's intention to shift resource where it makes the most difference, by supporting prevention and early intervention. The new Early Years Collaborative is based on the successful Scottish Patient Safety Programme, it will create a structure in which partners can easily learn from each other and from recognised experts in areas where they want to make improvements. Initially this will be a 2 year learning system that brings together Community Planning Partnerships to seek improvement in the Early Years with NHS Boards fully engaged.

Physical inactivity is considered to be the second biggest risk factor for mortality, behind high blood pressure. Getting Scotland fit would increase life expectancy and offset much of the health problems of obesity - releasing cash and improving health outcomes at scale. At present, the NHS offers brief advice interventions from a health professional to encourage physical activity. This preventative approach is highly cost effective but is, in itself inadequate to deliver a step change in population uptake. Those with the greatest need are often the least likeliest to respond to such advice. There is a challenge here in how we deliver the required transformational change.

The earlier that cancer is diagnosed and treated, the better the survival outcomes. Improving the percentage of early stage diagnoses will mean fewer premature deaths from cancer and this will have a positive effect on overall life expectancy in Scotland. Scottish Government and NHSScotland aim to address this in the Detect Cancer Early programme and improve survival outcomes for people with cancer to amongst the best in Europe. There will be a continued drive to improve on the current high quality cancer service provision and patient and carer experience. Earlier diagnosis will be one route to achieving these aims and will result in fewer recurrences, improvement in cancer mortality rates and longer term wider societal benefits.

The workforce is absolutely central to achieving transformational change, and that is why we are now developing the 2020 Workforce Vision for NHSScotland, a robust plan for the long term which will set out a vision for NHSScotland to unlock its workforce potential. Engaging the workforce in developing the vision and throughout the period of implementation to 2020 is a fundamental part of this work.

In summary, the Local Delivery Plans remain a vital part of the delivery framework and are the 'performance contract' between Scottish Government and NHS Boards, with continued alignment to the strategic improvement priorities for Scotland. This guidance sets out Ministers' key operational targets and performance measures for NHSScotland.