Respiratory care - action plan: 2021 to 2026

Chapter Two

Priority 1 - Prevention

Environmental and lifestyle factors play a significant role in the burden of respiratory conditions and we know that the pandemic has heightened risks for some vulnerable groups of people in Scotland. In order to reduce exposure to the known risk factors such as tobacco, cold homes, air pollution, obesity and respiratory infections, we must collaborate across multiple sectors.

The Scottish Government has set out ambitious aims through its Strategies and Plans to ensure preventative approaches are a priority. All of these strategies have a clear focus in tackling the health inequalities faced by many groups across Scotland.

For respiratory disease, we will consider:

• 1.1 Tobacco & Smoking
• 1.2 Clean air
• 1.3 Warm Homes
• 1.4 Vaccinations
• 1.5 Diet & Healthy Weight

1.1 Tobacco

The World Health Organisation describe tobacco as 'one of the biggest public health threats the world has ever faced,' with more than 7 million deaths worldwide as a direct result of tobacco use and a further 1.2 million attributed to second-hand smoke exposure. As the cause of around one in five deaths and the primary preventable cause of premature death, smoking represents the chief threat to Scotland's public health . Smoking rates continue to be highest in Scotland's most deprived areas, underlining smoking as a key ongoing health inequality challenge.

The Scottish Government published its five year strategy 'Raising Scotland's Tobacco Free Generation' in June 2018, The action plan sets out interventions and policies to help reduce the use of and associated harms from using tobacco in Scotland. This Plan focuses on the inequalities within groups of people that smoke, prevention and reduction of uptake of smoking among young people and providing the best possible support for those people who want to give up.

The Scottish Government have introduced a 2034 tobacco free target. Our aim is to reduce smoking rates to 5% or below by 2034, creating a generation of young people who do not want to smoke and are protected from the harms of smoking. The Tobacco-Control Action Plan 2018; Raising Scotland's Tobacco-free Generation, continues our work on protecting children from taking up the habit of smoking and creating a tobacco-free generation by 2034.

The NHS free stop-smoking service was rebranded in 2018 with the emphasis on helping people find their own way to stub out the habit. The free Quit Your Way helpline provides a uniform service across Scotland with smokers offered specialist support and advice.

The health impact of smoking in relation to respiratory conditions, cannot be underestimated. Therefore it is critical that this Plan and subsequent implementation programme collaborates with the tobacco policy team and wider public health services. Whilst this draft Plan contains specific commitments in relation to respiratory conditions, we must not lose sight of broader aims.

The emergence of Nicotine Vapour Products (NVPs) over the past decade has added another dimension to the landscape. A consensus statement; created by NHS Scotland in collaboration with over 20 expert groups in the field including the Royal College of Physicians and Surgeons of Glasgow, the University of Stirling and the campaigning public health charity, Action on Smoking & Health (ASH) agree that, "based on the current evidence, vaping e-cigarettes is definitely less harmful than smoking tobacco." They are useful only as a potential route towards stopping smoking and should not be used by children or non-smokers.

There remains a lot that we do not know about NVPs and the potential long-term negative impact on respiratory health. While less harmful than tobacco, they are not risk free and, along with being the first country to devise a specific quit vaping programme, we plan to introduce stricter controls on the advertising and promotion of NVPs in Scotland. A full public consultation on NVPs is hoped to be launched in 2021.

The COVID-19 pandemic has raised a number of concerns around the ability of smokers to fight a COVID-19 infection. While evidence on this subject is mixed, the World Health Organisation has stated that smokers are at higher risk from contracting the illness and becoming more severely unwell as a result.

As well as well as helping current smokers to quit and reducing exposure to second-hand smoke, policy advocates health and wellbeing education including messaging about the harms of smoking. One such initiative was the Border and Regions Airways Training Hub (BREATH) which worked with a number of organisations researching chronic obstructive pulmonary disease (COPD) to raise public awareness of the condition and alleviate its impact. Academics and PhD students from the University of the West of Scotland took the programme to schools in Dumfries and Galloway – an area where COPD related hospital admission is amongst the highest in the UK.

1.2 Clean Air

The Scottish Government is also taking decisive action to improve air quality. We recognise the impact that poor air quality can have on human health, especially on the young, elderly and those with pre-existing health conditions. Compared to the rest of the UK and other parts of Europe, Scotland has a high level of air quality.

We have set more stringent air quality targets than the rest of the UK. Our commitment to introducing Low Emission Zones in our four largest cities is a key initiative in further improving urban air quality, the first of which has already been introduced in Glasgow.

An independently led review of our air quality strategy 'Cleaner Air for Scotland – The Road to a Healthier Future' to assess progress and identify priorities for further action, has been completed and will be used as the basis for developing a revised and updated strategy. A report setting out the conclusions and recommendations of the review was completed in 2019. The recommendations arising from the review have been used to draft a new air quality strategy. A public consultation on the draft concluded in January 2021 and the finalised strategy will be published later in 2021.

Improvements in air quality was raised as a key concern by many individuals during the consultation. We will continue to work closely with the Cleaner Air for Scotland programme.

1.3 Warm Homes

Cold-related deaths are a significant weather related source of mortality. The reason more people die in the winter compared to other times of year are complex, however one of the main causes is thought to be related to cold homes. Cold homes are often the result of poor quality housing and poverty, which poses a significant risk to the development or exacerbation of respiratory disease.

Fuel poverty is defined as a household where more than 10% of its net income (after housing costs) is required to heat the home and pay for fuel costs, and if after deducting fuel and childcare costs and disregarding the value of specified benefits which are received for care need or disability, the remaining net income is insufficient to maintain an acceptable standard of living for the members of the household, defined as 90% of the UK Minimum Income Standard (MIS).

The Scottish Government is committed to reducing the impact of fuel poverty and whilst COVID-19 has caused us to pause development of the Fuel Poverty Strategy, this work will resume as soon as possible and we aim to publish the final Fuel Poverty Strategy in 2021.

The Scottish Government believes that everyone in Scotland should have a safe, warm place to call home, but we know the COVID-19 pandemic has caused many people to worry about the cost of their fuel bills.

We are also determined to reduce the widening fuel poverty gap and will continue providing enhanced support through our energy efficiency schemes in remote rural communities in recognition of the generally higher costs and already provide enhanced support through our energy efficiency schemes in recognition of the generally higher costs of installation work in these areas.

1.4 Vaccinations

People with chronic lung diseases are significantly more likely to get flu and are more likely to require admission to hospital if infected^[6]. We know that the flu vaccinations for people living with lung disease can reduce hospital admissions by up to 52% and reduce mortality by 70%. In 2020, uptake of the flu vaccine increased^[7] and there were also less admissions to hospital with flu.

In 2018, the contract for General Practice introduced a new model for vaccine delivery across Scotland and the roll out of the COVID-19 vaccine at the end of 2020 has transformed the way people think about vaccination.

The COVID-19 vaccine roll out has required many additional staff to be trained to vaccinate and a significant public health campaign has increased knowledge and awareness of the benefits of vaccinations. We will continue to monitor the development and roll out of vaccination programmes and the role they play in respiratory disease.

1.5 Diet and Healthy Weight

In July 2018 the Scottish Government published 'A Healthier Future: Scotland's Diet & Healthy Weight Delivery Plan', following consultation with stakeholders.

The Plan sets out a vision where everyone in Scotland eats well and has a healthy weight. Among its aims are to reduce diet-related health inequalities significantly. The Plan includes actions to transform the food environment, including restrictions on the promotion of foods high in fat, sugar or salt where they are sold to the public. Population-wide interventions are likely to be more effective in reducing inequalities as they do not rely on individual behaviour change. The Plan also sets out targeted and tailored support to those individuals, children and families who need it most. As well measures to prevent overweight and obesity, the Plan includes actions to improve access to effective weight management services.

As poor diet and excess weight can lead to increased risk of respiratory conditions, implementing the Diet and Healthy Weight Delivery Plan plays an important role in their prevention. Supporting people to eat well and maintain a healthy weight must be integral to our work in reducing the risk of people developing respiratory conditions.

Commitment 1

We will work with all relevant policy areas to ensure preventative measures are embedded in all aspects of respiratory care.

Priority 2 - Diagnosis, Management and Care

2.1 Early and Correct Diagnosis

Early and accurate diagnosis of respiratory conditions can enable treatment and support to begin before the disease has progressed. When people are given information about their condition early, they have more opportunity to explore self-management techniques and may be able to avoid more intensive treatments.

Late diagnosis, under-diagnosis and misdiagnosis can have significant impact on the long term outcomes of respiratory conditions and on a person's quality of life. We know that surveillance and screening are key to early diagnosis and ultimately better health outcomes for the individual.

To diagnose respiratory conditions correctly and provide the best care possible, healthcare professionals need ongoing education. This requires access to equipment and up to date guidance on a regular basis. In order to grow the diagnostic capacity within the NHS, respiratory specific education should be made available to a wider group of professionals including pharmacists, Allied Health Professionals (AHPs) and Health Care Support Workers (HCSWs) in primary, secondary and community care environments.

Access to diagnostic tests may be inconsistent across the country. There are national guidelines for diagnosing respiratory disease, which inform the use of specific tests including x-rays and CT scans, pulmonary function testing, blood tests and polysomnography (sleep studies). For people exhibiting symptoms of a respiratory condition, the route to diagnosis may not be straightforward. Along with wider health and social care policy, we understand that access to diagnostic testing needs to improve, but we also need to consider barriers to accessing health information and support.

During the COVID-19 pandemic, new diagnoses may have been missed. People were initially asked to stay at home, meaning some people will not have sought advice from their GP Practice due to fear of burdening the NHS. People identifying a cough when calling their GP practice may have been redirected to a COVID-19 testing pathway. Access to diagnostic testing has also been challenged because of reduced service capacity for pulmonary function testing in particular, as it is an aerosol generating procedure and therefore higher risk to carry out during the pandemic. It is critical that timely diagnosis is in place moving forward and consideration must be taken on how to tackle missed or delayed diagnoses as a result of COVID-19.

Upon diagnosis, people should then enter an appropriate treatment pathway, which is supported by safe, effective prescribing. Medicines for respiratory conditions are constantly evolving and we will work closely with medicines policy teams to ensure this Plan is linked with the update of the Quality Prescribing for Respiratory guide.

Commitment 2

We will improve and simplify access to appropriate diagnostic tests for respiratory conditions and explore the use of high quality, consistent spirometry testing and chest & lung CT scans.

Commitment 3

We will support the ongoing work within the Scottish Access Collaborative' disease-specific pathway projects and ensure developments are embedded within wider respiratory policy.

2.2 Pulmonary Rehabilitation

A critical part of the respiratory care pathway is access to pulmonary rehabilitation.

Pulmonary rehabilitation offers a structured exercise and education programme designed for people living with a respiratory condition. The programme encourages increased physical activity within the person's limitations. Throughout the programme, participants are offered advice about their own specific medications and how to use them, as well as information on diet, weight management and mental health support.

Pulmonary rehabilitation is one of the most effective forms of management for people living with respiratory conditions. 90% of people who complete the programme experience improved exercise capacity or increased quality of life^[8]. However, Chest Heart and Stroke Scotland (CHSS) estimates that only 2% to 21% of those who might benefit are being referred to pulmonary rehabilitation^[9]. Pulmonary rehabilitation is best established within treatment for COPD, however there is evidence of clear benefit in asthma, pulmonary fibrosis and bronchiectasis.

NHS Boards are expected to provide access to accredited pulmonary rehabilitation programs based on current clinical guidelines^[10]. In order to improve and widen access, we need to think differently and communicate the health benefits to a broader audience. Demand for the service will likely increase in the wake of the COVID-19 pandemic. During consultation of this Plan, many health professionals highlighted the need to work with community services in order to promote pulmonary rehab to more vulnerable groups.

Some NHS boards across Scotland have adapted to deliver pulmonary rehab virtually. Although this has been an excellent example of innovation, it is not regarded as a long-term solution by many people using the service. The social aspect of classes was highlighted as a huge benefit by many individual respondents during the consultation. The changes in lifestyle caused by the COVID-19 pandemic have meant that communication, meetings and social interactions over digital media are now commonplace, and more widely accepted by all age groups.

The Rehabilitation and Recovery Framework will support rehabilitation service development in the future. This work will be relevant to the implementation programme as it covers three target groups:

• Those that had COVID-19 and have extended rehabilitation needs
• Those that have had pre-existing health conditions that have been negatively impacted by lockdown restrictions
• Those that required ongoing intensive rehab as a result of services or treatment delayed due to COVID-19

Moving forward, we should consider best practice before and during the pandemic and consider how we can make future pulmonary rehabilitation sustainable. We must design pulmonary rehabilitation based on the needs of people and specifically aim to increase uptake in groups with the highest incidence of respiratory conditions.

Commitment 4

As part of the Rehabilitation Framework implementation programme, we will ensure everyone with respiratory conditions who would benefit from specialist, general and community rehab is able to access appropriate services and support.

2.3 Mental Health Support

Diagnosis of a respiratory condition can have a profound effect on mental health and wellbeing. Unlike other disease groups such as cancer, there is currently no specific pathway for mental health input for a new respiratory diagnosis. Some health boards complete a mental health psychological assessment during pulmonary rehab, however this is not consistent. Within other condition specific pathways, there are examples of good practice such as the 'holistic health assessment' used by some cancer services. This includes not only a mental health assessment, but considers wider factors including finance, employment and relationships.

A new diagnosis of IPF for example, can have a lower life expectancy than some forms of lung cancer. There is no way to stop IPF and there is currently no cure. This can be an extremely traumatic time for people and their families, and access to mental health support is difficult to navigate for a condition like IPF. People who have a new diagnosis of a respiratory condition, or have lived with their diagnosis for some time commonly have feelings of anxiety, low mood, and depression. During the COVID-19 pandemic, many people reported heightened anxiety and depression.

We know that the Pandemic has increased demand for mental health services and the impact of this is likely to be long lasting. This may mean there is reduced capacity within the system to create condition-specific responses, so we must continue to link with developments happening across other areas. We will not accept that patients should have to wait for prolonged periods to receive the support and treatment they need from mental health services.

The Scottish Government published the Mental Health Transition and Recovery Plan in October 2020 in response to the pandemic and recognised the need to integrate our response to mental and physical health. We will continue to place clinical and strategic priority upon achieving parity between and across mental and physical health.

Commitment 5

We will work with people living with respiratory conditions to better understand the barriers to accessing appropriate mental health support; and collaborate with policy and health & social care teams to determine opportunity for improvements.

2.4 Transition from Child & Young People Services to Adult Services

Children can be diagnosed with several lung conditions, however the most common is Asthma. One of the most important aspects in the management of asthma is the period of transition from childhood to adulthood.

If children receive a respiratory diagnosis in early life, their care is provided by a paediatric team. The transition to adult services occurs at different stages dependent on the young person, their diagnosis, and the infrastructure of the paediatric and adult services within their region. This transition period occurs for all long term conditions and can be a challenging time for young people and their families or carers.

During adolescence, care can become fragmented due to transition from paediatric to adult services. Changes in priorities for young people can lead to disengagement from clinical services; feelings of independence can also be accompanied by feelings of resistance towards therapies.

To ensure a positive transition, both teams should work together to create a person-centred plan, and ensure this is done in partnership with the young person and their family or carer.

Commitment 6

We will work with key partners to understand and improve pathways for a good transition from children and young people services to adult respiratory services, and ensure all young people with long term respiratory conditions go through a dedicated respiratory transition service.

2.5 Palliative Care

Palliative care is about improving the quality of life of anyone facing problems associated with life-limiting conditions. It includes physical, emotional and spiritual care and can be delivered in any setting.

It can be difficult to determine how lung disease will progress, particularly for people with multiple other conditions. Therefore the palliative and end of life care needs of these people should be assessed as early as possible, to help staff and loved ones to appropriately coordinate care and support. The Scottish Palliative Care Guidelines^[11] reflect good practice in the management of those with life-limiting illness and are designed for healthcare professionals from any care setting who are involved in supporting people with a palliative life-limiting condition.

It is important to understand that starting a palliative pathway does not mean that the disease will no longer be actively managed. Person-centred palliative care takes account of changing preferences and priorities of people with advanced illness and their carers to help staff and loved ones to appropriately coordinate care and support.

Anticipatory care planning (ACP)

Some respiratory conditions can progress rapidly. In such instances, it is particularly important for healthcare professionals to have early care planning conversations with people and their loved ones about their care wishes for the future.

This person centred approach, known as Anticipatory care planning, is a proactive approach to care, where people are supported to have meaningful conversations with their families, friends and healthcare professionals about the things that matter most to them – particularly in the context of their treatment or care. This can include conversations about what to do if there is a sudden deterioration in their health. Individuals can be supported to make an anticipatory care plan with their health professional outlining the types of care and treatment which would be and which would not be appropriate in these circumstances.

Commitment 7

We will work with the NHS, clinicians and the third sector to ensure provision of best practice palliative care for people with a lung condition as they near the end of life and support wider roll out of Anticipatory Care Plans.

Priority 3 – Supporting Self-Management

Every day, people with long-term conditions, their family members and carers make decisions, take actions and manage a broad range of factors that contribute to their health. Self-management is the process each individual develops to enable them to manage their own condition. Self-management does not mean people are left to manage their condition on their own; it requires a strong partnership with health professionals and access to a wide range of support networks.

There are a variety of evidence-based, effective mechanisms for people living with respiratory conditions to manage their own condition. People need to first feel confident in their own knowledge and skills. Healthcare professionals play a crucial in empowering their patients.

Self-management techniques are well established within long-term conditions and during the COVID-19 pandemic, they became more important than ever. With access to hospital and community services disrupted, people were forced to take a different approach to manage their condition. People living with respiratory conditions raised many positive examples of self-management during the pandemic and it is important to share these examples and build into wider service delivery.

3.1 Unpaid Carers

Unpaid carers play a vital role in supporting their loved ones. A carer is anyone who looks after a friend, family member or neighbour due to old age, physical or mental illness, disability, or an addiction (this does not include paid care workers or those who are volunteering). There are around 700,000-800,000 people in Scotland who look after someone else.

'Looking after' can mean helping with things like shopping, domestic tasks, emotional assistance and personal care - all of which are difficult.

Many people living with a respiratory condition rely on support of a paid or unpaid carer. Family members, friends and neighbours providing these roles should be supported so that they can continue to care, if they so wish, and have a life alongside caring.

Support for those looking after someone comes from the Carers (Scotland) Act 2016. The Act extends and enhances the rights of carers in Scotland to help improve their health and wellbeing. We will continue to support people living with a respiratory condition and their carers to access appropriate support and resources. We will work with third sector organisation to help ensure carers of people with respiratory illness are aware of their rights and how to access support.

Commitment 8

We will work with key stakeholders to help ensure carers of people with respiratory illness are aware of their rights and how to access support.

3.2 Peer Support

People living with a respiratory condition can feel isolated and alone. During the COVID-19 pandemic, many people took swift action and began shielding before the shielding advice from the Scottish Government was issued. Although this decisive action protected many from contracting the virus, it has increased the feeling of isolation.

Peer support is regarded as a very effective tool in improving the mental health and resilience of people with long term conditions. There are many examples of successful peer support programmes throughout Scotland, including Breathe Easy Groups and various singing clubs. We will continue to monitor progress of these groups and ensure we build in peer support to wider pathway development.

3.3 Digital & Innovation

There are many digital and paper based tools available to support people with long term conditions and during the COVID-19 pandemic these provided a lifeline for many. There are specific apps designed for people to manage their COPD, which provide guides on inhaler technique and allow people to track their medications and exacerbations.

The Digital Health & Care Institute (DHI), in partnership with many stakeholders including those within private industry, continue to test, develop and roll out digital solutions including the monitoring of COPD from home. DHI continue to progress the digital transformation agenda in Scotland and ensure NHS and clinical teams are supported to access innovation pathways and test beds where they feel there may be an opportunity to transform the way their patients access treatment and care.

For people living with asthma, there are many apps and online tools. The DHI has written a joint position paper with Asthma UK, and produced a project report containing recommendations for a future vision of asthma care^[12]. We will continue to track developments within the digital and innovation space that may be relevant to respiratory care.

Commitment 9

We will work in partnership with key stakeholders including the third sector and DHI to ensure people with respiratory conditions have access to tools, resources and information that support them to manage their own condition.

Priority 4 – Consistent Access Across Scotland

We know that incidence and mortality rates of chronic diseases are higher in disadvantaged groups and areas of social deprivation. This is a complex problem with a range of causes; however we do know that these areas often have a higher rate of smoking, cold homes and fuel poverty.

In these areas, it is important to take a public health approach and design services based on the needs of specific communities. Third sector organisations play a critical role in developing and delivering community-based services that can reach people who often fall through the gaps of traditional healthcare services.

In order to provide the best respiratory care for all people in Scotland, we first need to understand what level of need exists. The rate of undiagnosed asthma and COPD is thought to have increased in 2020 due to the pause of some services. We are committed to improving access to meaningful data, which display the level of respiratory disease in Scotland and help us to understand where people's needs are not being met. We want to understand the variation across Scotland at a national, regional and local level.

Across Scotland, people struggle to access support services. In order to improve this, we need to work together with Health & Social Care Partnerships, local councils and the third sector to understand the barriers people are facing and identify improvements that will lead to meaningful change

This Plan is focused on the delivery of best care for all. A particular focus is needed in supporting people that experience barriers to accessing the appropriate care. We know that specific barriers to access exist; including restrictive working hours, childcare, transport issues, literacy issues and lack of digital infrastructure.

4.1 Meaningful Data

The Atlas of Variation was developed by ISD Scotland and is used to identify clinical intervention done at individual health board level. This data and can help us to understand if there is overuse or overtreatment across specific disease group. It is now well understood that the impact of medical intervention when it was not necessary can cause greater harm to the patient than doing nothing. The Realistic Medicine approach shifts away from unnecessary and avoidable medical treatments and instead focuses on what can be done to keep people well.

Data from the Atlas of Variation can help to inform targeted improvements specific to different areas of Scotland. It is important to consider the wide ranging landscapes in health boards across Scotland and support service development that is most suitable for each area.

High quality data is important to the NHS as it can lead to improvements in care and safety. Quality indicators can play a role in improving services and decision making, as well as being able to identify trends and patterns

and evaluate services.

Commitment 10

We will build on the data within the Atlas of Variation and work towards a core respiratory data set, in order to understand areas for improvement.

Priority 5 – Workforce

The skills required for treatment and care of respiratory conditions are vast and wide ranging. People living with conditions like COPD will come into contact with a range of health and social care professionals on a regular basis. It is important that the we build capacity and capability across the NHS and wider social care sectors to ensure the growing need in Scotland is met.

The COVID-19 pandemic has caused significant strain on our health and social care workforce. Staff were redeployed to new areas, and others had to step away from frontline roles entirely in order to shield. Over the course of the pandemic, the level of sickness has remained higher than normal and we know that this may continue due to Long-Covid and a variety of other factors. Not only were staff contracting the virus and subsequently taking time to recover, but many staff have also reported increased stress and anxiety.

Moving forward, it is important that all services consider the challenges of staff recruitment and retention; and also consider new and innovative models of care to build resilience across the NHS. In many specialities, nurses, Allied Health Professionals (AHPs) and Pharmacists take on Advanced Practitioner roles and are trained to a very high level. These roles protect sustainability within teams traditionally led by one consultant. As the medical workforce is strained, it is important to recognise the wide range of skills available to respiratory departments and build this into future planning.

5.1 Medical Staffing

Medical training is managed at a UK level. The issues within medical staffing are not limited to respiratory services. We know that many rural areas of Scotland find it difficult to recruit to consultant posts and there are several initiatives within Scottish Government and beyond that aim to tackle the sustainability of the medical workforce.

The Shape of Training^[13] review proposed an important evolution in the development of specialties and their role within provision of healthcare, particularly in the acute sector. The Review highlighted the need to construct pathways for more generalist consultants. There is also a need to consider the role of respiratory physicians and the potential increased demand from COVID.

NHS Education for Scotland (NES), BMA and other key stakeholders are working collaboratively to explore innovative ways of encouraging applications at consultant level in Scotland. We will continue to work closely with medical recruitment programmes and also support data collection to ensure we understand the unmet need across Scotland.

5.2 Transformation of Nursing Roles

The diversity of the specialist respiratory nurse role across Scotland is not underestimated. Community nursing teams including General Practice nurses district nurses, care home nurses, specialist community nurses and prison health nurses play a key role in supporting people with respiratory conditions. Their remit is broad and they are key to preventing exacerbations through early intervention and supported self-management.

Person centred care including management plans and instruction in the event of any exacerbation are often a key role of respiratory nurses . Like GPs, Practice Nurses are experienced in supporting people to manage their condition. Practice Nurses tend to be a consistent member of a person's care team through regular check-ups and annual reviews prioritised by clinical need.

The Scottish Government's Transforming Nursing, Midwifery and Health Professions (NMAHP) Programme's aim is to ensure consistent, sustainable and progressive NMAHP roles and career pathways, which will see an appropriately skilled workforce contributing to new models of care. The Transforming NMAHP Roles Programme aims to shift the balance of care, by reducing unscheduled care, unnecessary admissions and supporting people to be at home.

Respiratory specialist nurses can work across the primary and secondary care divide, can utilise skills and expertise across a number of different disease processes, but may also specialise in the specific diseases this is underpinned by level 11 education. Respiratory specialist nurses can fulfil a number of extended roles:

• Assessment of airways diseases, including inhaler technique
• Assessment and prescribing medication
• Carrying out and interpreting spirometry
• Airway clearance techniques
• Support and follow up of people receiving monoclonal antibody therapy for asthma
• Initiation and ongoing support for people on CPAP and NIV therapy for OSA and Obesity Hypoventilation
• Cognitive behavioural therapy for anxiety and depression in respiratory illness
• Assessment and provision of long term oxygen therapy
• Palliation of symptoms
• Anticipatory care planning
• End of life care

We will continue to monitor wider developments across nursing roles and ensure appropriate workforce planning is considered to meet the needs of people living with respiratory disease.

5.3 Multi-Disciplinary Teams

Allied Health Professionals (AHPs) play a significant role in the treatment and care of respiratory conditions in Scotland. The development of more advanced roles means we are seeing more AHP-led services.

Rehabilitation is a core part of managing a respiratory condition and we know that early and regular rehab can have a significant impact on the outcomes of respiratory conditions. Traditionally, physiotherapists provide specialised pulmonary rehabilitation, however we know that workforce challenges mean we must work towards more sustainable models of pulmonary rehab with a wider workforce. The Rehabilitation & Recovery Framework has provided an opportunity to test new, innovative models of rehabilitation across the whole sector.

As with nurses, people living with respiratory conditions will come in to contact with many types of AHPs. Physiologists play a key role in providing diagnostic tests and supporting medical teams with ongoing management of conditions. Dieticians, occupational therapists and radiographers are commonly involved in the care of respiratory conditions. All of these professional groups face the same challenges of recruitment, retention and sustainability.

Access to specific professional services can vary across Scotland, and the specific tasks they perform vary from hospital to hospital. It is important to consider the wide range of AHP skills we have available and build these into a more holistic respiratory service models.

Pharmacists are also becoming well established within the respiratory pathway. During the consultation of this plan, many people reported the huge benefits they found when able to have a conversation with a pharmacist.

As part of the roll out of the 2018 GMS Contract, many GP practices now have a pharmacist within their team. Many respiratory patients also have other health conditions which means a complex range of medicines to take every day. A Pharmacist is able to spend more time reviewing a person's medication and they can spot potential interactions or risks.

Commitment 11

We will support wider workforce planning activity to develop innovative, sustainable workforce models within respiratory services.

5.4 Increasing Respiratory Skills

Presentation of respiratory conditions are common across all areas of health and social care. A baseline level of respiratory knowledge would build resilience in the workforce and would also improve the journey for people with respiratory conditions accessing services out with their speciality team. This would include training on the use of specific equipment and interventions.

We recognise the importance of including wider sectors within workforce planning. There is vast support available within the third sector and we should consider opportunities of developing pathways and partnerships with organisations such as Chest Heart Stroke Scotland and Asthma UK and the British Lung Foundation.

Chest, Heart, Stroke Scotland have rolled out a Scottish-Government funded Hospital to Home programme to support people in the transition period after leaving hospital. The Hospital to Home service enables people to manage their own condition, with support, from home. The service provides one to one support upon referral for people with respiratory conditions.

In Scotland COPD accounts for highest number of emergency bed days^[14] annually. We know that an increase in the life expectancy of the population will lead to increased demand for NHS services as people aged over 75 are the most common patient group seen in hospitals. This adds further to the challenges of how to manage the condition more effectively as older people are likely to have a more complex disease profile.

Emergency admissions for people with COPD and other respiratory diseases can cause significant stress and anxiety. We recognise the importance of supporting the work in Unscheduled Care to increase knowledge and skills of managing exacerbations of conditions such as COPD. This work also incorporates increased training and skills for GPs and other primary care staff to ensure exacerbations are prevented or managed at home.

Commitment 12

As clinical guidelines evolve, we will work with key partners, including NHS Education (NES), to ensure relevant and consistent training is made available to a wider group of healthcare professionals and third sector services, across Scotland.

5.5 Social Care

The recent Review of Adult Social Care^[15] identified areas for improvement within social care services in Scotland. The report suggests we need to 'shift the paradigm' from old thinking to new thinking; including collaboration instead of competition and enabling rights instead of managing need. The report made 27 recommendations after a significant period of engagement.

We know many people living with a respiratory condition have regular contact with social care staff and may have been following complex pathways within the system for many years. We will ensure any key learning from the transformation of social care is shared with the respiratory community and incorporated into the implementation programme.