Out-of-Hospital Cardiac Arrest (OHCA) strategy: case study

3. Overview of the Scottish Approach to policy

This section provides a brief background to the Scottish Approach as a concept, and then describes how this has evolved in light of public service delivery in Scotland. The features of what the Scottish Approach is in practice are then identified. The background concludes with an overview of the OHCA Strategy as a case study of this approach.

3.1 The concept of the ‘Scottish Approach’

Since devolution a number of legislative and constitutional changes in Scotland have led to a narrative of divergence between the Scottish and United Kingdom Governments (Smith et al. 2009, Stewart 2013), one which posits “the potentially distinctive ways in which the Scottish Government makes and implements policy” (Cairney et al 2016, p 334). As civil servants and academics have observed these changes, the term ‘the Scottish Approach’ evolved as an overarching phrase to describe this potentially distinctive way of working.

3.2 The context of public service delivery in Scotland

The ‘Scottish Approach’ evolved in the context of the changing landscape of Scotland’s public services. In 2006 the-then Permanent Secretary to the Scottish Government ( SG), Sir John Elvidge, articulated a new vision for public services at a meeting with the lead of every public service organisation in Scotland. It was proposed that there were too many departments within the SG, as well as numerous fragmented public organisations. In early 2007 a proposal was put forward to reform the organisational structure of departments, and for public services to be reformed.

In a Parliamentary speech in early 2008, the-then First Minister Alex Salmond voiced:

“Looking at the landscape of Scotland's public organisations today, we see a confusing array of organisational roles, remits and functions. A complex system, which we risk being ever more concerned with talking to itself about procedure - instead of improving services and speaking directly with citizens to address their needs”. (Scottish Parliament 2008)

The Independent Budget Review ( IBR) echoed this sentiment, stating “For a small country, Scotland has a plethora of institutions, including 32 local authorities, 23 NHS bodies, 8 police forces, 20 universities, 43 colleges, and over 100 other public bodies” ( IBR 2010, p 4). In total, there were approximately 199 active public service organisations at the start of the 2007 parliamentary session (Scottish Parliament 2008).

Set against this backdrop, Elvidge argued that “In 2007 the Scottish Government embarked upon a more radical departure in the organisation of government, at the heart of which is the concept of a government as a single organisation. It is, one might say, the idea of ‘joined-up government’ taken to its logical conclusion” (Elvidge 2011, p 31).

The new vision for Scotland was to create a governmental system that was de-centralised, embedded within communities and brought citizens and services closer together. This end-goal was operationalised in 2007 when the SG introduced the National Performance Framework ( NPF). This drew on the outcome-based performance model used in the Commonwealth of Virginia in the United States. This framework catalysed the Government’s focus on the shared outcomes of policies. The roles of central and local Government evolved as a Concordat was negotiated between the SG and the Convention of Scottish Local Authorities in 2008.

Around the time of the revision of the NPF in 2011, which was also the second Parliamentary term for the SNP administration, the Christie Commission was formed to review the delivery of public services in Scotland. Although the Commission stated that “our system of public service delivery is in need of a significant transformation” (Christie 2011, p 2), they found areas of progressive working. “What distinguishes these positive approaches”, concluded the Commission, “is that they are grounded in people’s lives, and the lives of communities (of place and of interest). Typically, people, communities and services work together to decide priorities and how to achieve their delivery while the focus is on fitting services to people, not people to services. They also maximise all the resources and assets available, and the process itself builds the capacity of all those involved.” (Christie 2011, p 2)

These findings prompted the SG to identify four key objectives that would shape public service provision:

• Participation – public services are built around people and communities, their needs, aspirations, capacities and skills, and work to build up their autonomy and resilience
• Prevention – public service organisations prioritise prevention, reducing inequalities and promoting equality
• Partnership – public service organisations work together effectively to achieve outcomes
• Performance – all public services constantly seek to improve performance and reduce costs, and are open, transparent and accountable

The Government’s response to the Christie Commission served to cement the national vision. The NPF was further refined in 2016 and now sits with a 4 tier hierarchy. The overarching aim is defined in the Government’s Purpose. Five Strategic Objectives (wealthier and fairer, smarter, healthier, safer and stronger, and greener) describe how actions will be focussed. Sixteen National Outcomes describe what the government wants to achieve and a collection of 55 National Indicators enable services and citizens to track progress.

3.3 The features of the Scottish Approach in practice

The work described above offers a context for how Scotland’s public services were being developed. In 2011 Elvidge was invited by the Institute for Government to write about the first twelve years of devolved government in Scotland. Whilst reflecting on this progression, Elvidge used the phrase “The Scottish model of government” (p 31). As far as can be determined, this was the first time a distinctive Scottish approach was articulated, and it appears this was used to communicate two ideas. First, the Scottish model referred to his observations of what had previously been done. Second, this Scottish model was something on-going – a set of principles that should be used to guide future public service provision. This marks an important juncture, where there is a transition between the ‘Scottish Approach’ being spoken about as a concept, to something that gives the approach an identifiable set of features.

Elvidge suggested in 2011 that the early Scottish model, based on the idea of government as a single organisation, was centred on 5 principles:

• An outcomes based approach
• A single government purpose, informed by broader objectives, measured by national outcomes
• A transparent system for tracking progress
• Single leadership roles for the central political and civil service pillars
• Role clarity for political and civil service teams to contribute to the collective objectives

Based on his observations of how the Scottish approach was evolving, Elvidge’s successor – Sir Peter Housden – expanded this approach. He offered a more practical explanation of what the Scottish model entailed. In a journal article published in 2014, Housden argued that the approach was underpinned by alignment and integration of public services, inter-connected patterns of working at local and national level and cross-sectoral working between directorates and organisations.

In addition, several specific elements define the model. Namely, that policies and interventions should be outcome-based. For example, it may serve no use to increase the number of training hours for a profession if the individual cannot secure a job (Housden 2014).

Another feature discussed by Housden is co-production. Co-production refers to a way of working where the service user and provider of the service come together to share dialogue about what is required in their context. A complimentary and reliant term is an asset-based approach. Here, services view individuals as assets and resources – active agents who can influence change within their lives, their family’s lives and the communities in which they live.

A discussion paper by the Carnegie Trust published in 2017 added to these original ideas (Coutts and Brotchie 2017). They argued that “It [the Scottish Approach] necessitates the production and use of system-wide evidence, rather than evidence focussing on an individual sector or programme” (p 2). This was supported by Cook (2017) who said “The term ‘Scottish Approach’ encapsulates a move within public services from top-down, service-led, reactive delivery, towards more personalised, preventative and collaborative ways of working” (p 1).

Lastly, the former Chief Researcher for the SG voiced three key elements of the ‘Scottish Approach’ (Ferguson 2015): assets or strengths of individuals and communities; co-production or policy developed with rather than done to people; improvement – local ownership of data to drive change.

As the SG has continued to evolve in light of political, social and constitutional change, so too has the Scottish Approach. As Cairney et al (2016) highlighted:

“Overall, the ‘Scottish Approach’: began in 1999 as a broad idea about how to govern by consensus in an era of ‘new politics’; developed from 2007 as a way to pursue a ‘single vision’, cross-cutting government aims, and an outcomes-based measure of success…and became, from 2013, a way to articulate, and measure the impact of, key governing principles (‘assets based’, ‘co-production’, ‘improvement methodology’) and address specific issues such as inequality” (p 339)

Pulling this research together (Figure 2), we can conclude that there are several hallmarks of the Scottish Approach which are regularly identified, albeit with varying degrees of clarity. There are 9 common themes that are frequently cited as features of this approach which should be used as a reference standard going forward (Figure 3a). These cross different ‘levels’ of government, policy and public service.

Figure 2: Visual timeline of the ‘Scottish Approach’ in the context of public service delivery in Scotland

These have been placed within a macro, meso and micro system for 2 reasons: (1) it creates a conceptual framework for the Scottish approach, serving to communicate the multi-level nature of governmental vision being translated into actions of individuals (2) part of the challenge when discussing the Scottish approach is the lack of standardisation, specifically the components of the model and what the terminology refers to.

Figure 3a: Conceptual model of the Scottish Approach

Situating the approach within a conceptual schema will anchor future discussions in a common language.

3.4 The OHCA Strategy as a case study of the Scottish Approach

As highlighted in the Introduction above, the SG published Scotland’s first OHCA Strategy in early 2015. It was recognised that the Strategy was “ambitious, important and achievable” (Scottish Government 2015a, p 41). Delivering measurable benefits would require a concerted effort from multiple organisations within different sectors. With this in mind, a Reference Group and a Strategic Delivery Group were developed, which engaged a wide range of stakeholders including:

Public sector:

- Scottish Government

- NHS

- Scottish Ambulance Service ( SAS)

- Scottish Fire and Rescue Service ( SFRS)

- Police Scotland

- Defence Medical Services

Third sector

- Save A Life for Scotland (national CPR learning campaign), British Heat Foundation, Chest Heart & Stroke Scotland, Royal Life Saving Society Scotland, St Andrew’s First Aid, British Red Cross, Trossachs Search and Rescue, Lucky 2 B Here

Academic

- Resuscitation Research Group, University of Edinburgh

Now approximately half way through the timeline of the Strategy, it is possible to study how the Strategy was designed and how the actions are being delivered. As of August 2017, >140,000 people have been equipped with CPR skills in a variety of settings ( http://www.savealife.scot/), including health and sport events, school CPR days and community engagement programmes. This has involved partner organisations providing CPR training as well as embedding resources within communities – equipment, personnel or knowledge – to contribute to a nation of lifesavers. This is complimented by the longstanding and on-going community CPR training work undertaken by the third sector groups.

Furthermore, the emergency services ( SFRS, Police Scotland and SAS) have piloted co-response models for emergency OHCA calls. This has involved deploying defibrillators on emergency vehicles in areas identified by SAS and SFRS, whereby Police and Fire Service staff perform CPR and defibrillation where necessary.

When considering the work of the Strategy in the context of the Scottish approach, it appears several elements may align with the principles of the model. For example, at the macro level public service bodies are integrating their work. At the meso level, cross-sectoral working is occurring between NHS, government and third sector groups. Lastly, at the micro level, partners are engaging with local communities and using the assets within these areas to help create a nation of CPR-aware citizens. This suggests that the OHCA Strategy may share some of the features of the Scottish Approach. The extent to which the development and delivery of the Strategy was – and continues to be – informed by the Scottish Approach is analysed in the Findings ( Section 4).