Review of targets and indicators for health and social care in Scotland

Healthcare indicators

78. The effectiveness of health care in reducing premature mortality depends on preventing illness, detecting it early while still curable and providing effective treatment where possible.

Reduce premature mortality ( NPF)

Detect Cancer Early ( LDP)

Cancer Waiting Times. ( LDP)

Dementia Post Diagnostic Support – In development ( LDP)

Treatment Time Guarantee. ( LDP)

18 Weeks Referral to Treatment ( RTT) ( LDP)

12 Weeks First Outpatient Appointment ( LDP)

Early Access to Antenatal Services ( LDP)

IVF Waiting Times ( LDP)

Psychological therapies waiting times ( LDP)

79. Early detection is achieved through our screening programmes which are assessed by a National Screening Committee which advises all 4 UK governments. The proportion of people invited for screening who take up the invitation is reported. This should continue.

80. Waiting times for treatment involve a guarantee of 12 weeks as a maximum wait for treatment and a special arrangement for cancer cases to ensure they begin treatment within 2 months of referral. In addition, there is an 18 week guarantee for referral to treatment. These guarantees have an evidence base to support them (Appendix 2). However, there are clinical implications of these guarantees. The decision to offer treatment is often not straightforward. Surgery, for example has risks as well as benefits and, where these are finely balanced, patients will often wish to defer surgery or take time to consider their position. Indeed a recommendation of this review is that there should be greater use of decision support tools to help patients decide whether or not they want surgery. Evidence suggests that many patients wish to take time to think about this decision. In those circumstances, neither an 18 week or 12 week guarantee should apply. Furthermore, it can take time to investigate complex problems, diagnoses may not be obvious and it can be perfectly sensible to delay treatment until diagnosis is secure. These guarantees, therefore, cut across clinical judgement, and can interfere with patient choice.

81. Another problem with a fixed target is that there is a risk that patients with less serious conditions who may be close to breaching the target are treated before patients with serious conditions whose clinical priority for treatment is greater. The guarantee, in that case, comes before clinical priority. That should not be the case. While treatment time guarantees have an evidence base and to abolish them would run the risk of unacceptable and unsafe waits returning to the NHS, they carry with them the risk of affecting the standard of care and they may impact adversely on patient choice. So far as can be ascertained, Scotland is the only country which has both an 18 week RTT and a 12 week maximum wait for treatment. The 18 week guarantee should be dropped since it brings with it the possibility of altering clinical decision making. The 12 week guarantee, which is more likely to be applied after a clear decision to treat is finally made should be kept. However, there will always be legitimate reasons why treatment might be delayed for sound clinical reasons or by patients themselves. Given the many legitimate reasons why this guarantee is not met, it seems odd that it is legally enforceable. This seems to be a law which if not followed correctly has the potential to interfere with clinical judgement, patient choice and so do harm to patients. It would be helpful if guidance issued to Health Boards on this issue ensured that clinical issues which might delay treatment were given due priority. It would be more sensible to work across the NHS to understand better how patient flows through treatment facilities might be improved. This work is underway.

82. HAI and AMR targets/indicators have been extremely successful in reducing rates of C.diff and MRSA and should be part of the suite of indicators in the future. This will ensure that HAI and AMR remain a priority and continue to build upon the progress made to date.

83. Any set of indicators of quality in healthcare should contain a reference to and support for clinical audit. Clinicians in Scotland have a long tradition of auditing clinical practice. Most of these audits have emerged from projects set up by clinicians without formal management support. In recent decades, however, the importance for healthcare systems of ensuring high standards of clinical care means that clinical audits are more commonly centrally coordinated and funded. There are two key strands for clinical audit / data collection across NHS Scotland:

• Scottish Healthcare Audits

This current suite of nine clinical audits, which includes the Multiple Sclerosis Registry, Renal Registry, Scottish Stroke Care Audit and MSK audit, is managed and delivered by Public Health and Intelligence ( PHI). These programmes collect and report only Scottish data.

• UK Wide Audit Programmes

These are commissioned by Healthcare Quality Improvement Partnership ( HQIP) on behalf of the Department of Health ( DH), directed by priorities for NHS England and the Secretary of State/Ministers. The programme consists of three types of data collection – national clinical audits, clinical outcome review programmes (previously known as confidential enquiries) and Consultant Outcome publications. In total the programme delivers 50 individual clinical audits. Scottish participation in these audits has a number of potential benefits including the ability to benchmark against other nations and learn from a wider community of experience in leading improvement. In addition it offers economies of scale in delivery costs.

84. HQIP invite Scottish participation in these clinical audit programmes at appropriate points in the contracting process. At present Scotland have formal agreements in place to participate in 8 audits. These audits are:

• Medical and Surgical Outcome Review Programme
• National Mortality Case Record Review Programme
• Mental Health Outcome Review Programme: Suicide & homicide
• National Neonatal
• Maternity & Perinatal Audit
• Child Health Outcome Review Programme
• Maternal, Newborn and Infant Outcome Review Programme
• Perinatal Mortality Review Tool.

In addition through historical arrangements there are 6 clinical audits where Scottish data is collected, which include cancer and cardiac audits. However, no formal agreement exists and these are not funded centrally.

85. The Clinical Outcomes and Measures for Quality Improvement ( COMQI) group in Scotland has proposed the development of a prioritisation process to support an Audit Programme for Scotland. This proposal was brought forward recognising the need to have a clear, open and transparent mechanism for agreeing audit commissioning and participation. The process aims to assess the current audit landscape and consider quality/standard of Scottish Healthcare Audits through an Audit of Audits.

86. Improving the quality of the health care experience is based on a patient feedback scoring system and this indicator has been increasing since 2010. One aspect of the health care experience which is relevant to recent discussions on realistic medicine is the issue of shared decision making between clinician and patient. A recent Cochrane review ^[13] of the use of decision aids in planning treatment concluded: "Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values and they probably have a more active role in decision making and more accurate risk perceptions…There are no adverse effects on health outcomes or satisfaction." Such techniques are currently being assessed in Scotland and, should the assessment prove positive, they should be introduced.

87. Recommendations:

a) The current 12 week waiting time for treatment should remain. However, analysis should be carried out to confirm that Scotland's waiting times distributions continue to accord with clinical prioritisation. Consideration should also be given to taking the 18 week RTT standard out of the suite of LDP standards and for RTT to be a matter for local systems.

b) Patient confidence in clinical advice appears to be significantly enhanced when decision support tools are used in discussion about treatment options. A trial of their use should be carried out. If the outcome confirms the positive experience reported in other studies decision support systems should be introduced across Scotland.