NES NES/16/21 Item 8a (Enclosure) March 2016
NHS Education for Scotland
BoardPaper Summary
1. Title of Paper
Strategic Developments in NHSScotland - Consideration of recent publications of strategic importance: The National Clinical Strategy; the Chief Medical Officers Annual Report, ‘Realistic Medicine’; and the Review of Public Health in Scotland.
2. Author(s) of Paper
Caroline Lamb, Chief Executive
3. Purpose of Paper
To allow the Board an opportunity to consider and discuss the implications of these reports.
4. Key Issues
The last 6 weeks have seen the publication of three documents which are of strategic importance for NHS Scotland. These are:
The National Clinical Strategy – Launched in February 2016, this strategy highlights the significant changes in Scotland’s population and in the needs and demands placed on our health and social care services. It makes proposals for how clinical services need to change in order to provide sustainable health and social care services fit for the future.
The Chief Medical Officers (CMO) Annual Report – ‘Realistic Medicine’, published in January 2016, sets out to begin a discussion on some of the fundamental principles of how medicine is practiced today and how doctors can be hugely influential in improving care.
The Review of Public Health in Scotland – Also published in February 2016 this report draws attention to the complex and persistent public health challenges and makes a number of recommendations in relation to achieving a more strategic and coherent approach to public health.
5. Educational Implications
All these publications have important strategic implications for the future shape and direction of NHS Scotland. The National Clinical Strategy, along with the Review of Public Health and the Health and Social Care agenda are being described as the major ‘game changers’ in relation to moving to a different vision of the delivery of health and social care.
1 6. Financial Implications
None yet quantified for NES
7. Which of the 9 Strategic Outcome(s) does this align to?
This paper is presented to allow the Board an opportunity to discuss important developments in the strategic context in which we work.
8. Impact on the Quality Ambitions
The publications highlighted in this report are designed to deliver on all of the quality ambitions
9. Key Risks and Proposals to Mitigate the Risks
It is important that the Board maintain an awareness of developments in this areas so that we can ensure an appropriate strategic response.
10. Equality and Diversity
These publications have a strong focus on reducing inequalities.
11. Communications Plan These are Scottish Government publications and communications have been handled accordingly
12. Recommendation(s) for Decision
The Board is recommended to consider and comment on these publications.
NES March 2016 CSL
2 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
The Scottish Government February 2016 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
CONTENTS
02 Foreword
04 Preface
06 1. Executive Summary
14 2. Introduction: Why do we need to change? 16 a. Demographic changes in our population 19 b. The changing patterns of illness and disability 23 c. The relatively poor health of the population and persisting inequalities in health 25 d. The need to balance health and social care according to need 27 e. Workforce issues 33 f. Financial considerations 35 g. Changes in the range of possible medical treatments 36 h. Remote and rural challenges to high quality healthcare 38 i. Opportunities from increasing information technology (e-health) 41 j. A need to reduce waste, harm and variation in treatment
44 3. Primary and Community Care
61 4. Secondary and Tertiary Care
77 5. The need for “realistic” medicine
85 6. Conclusion
01 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
FOREWORD
Over the last ten years there have been significant changes in Scotland’s population and in the needs and demands placed on our health and social care services. In 2010, in the Quality Strategy, the Scottish Government set out its strategic vision for achieving sustainable quality in the delivery of healthcare services across Scotland, in the face of the significant challenges of Scotland’s public health record, our changing demography and the economic environment. In 2011, the Scottish Government committed to integrating health and social care, to address in particular the changing needs of our growing population of people with multiple complex needs, many of whom are older. This was followed in 2012 by publication of the 2020 Vision which provided the strategic narrative and context for taking forward integration and implementing the Quality Strategy, and the required actions to improve efficiency and achieve financial sustainability.
In 2015 the Scottish Government set out • Developments should be guided by the need for transformational change in evidence where available: evaluation NHSScotland to meet people’s health and of any changes should be considered social care needs by 2020 and beyond. The before making the changes. Scottish Government’s Draft Budget for • We will continue to provide caring health 2016/17 proposes significant new investment and social care services that will recognise in health and social care services to pursue the central importance of the role of ambitious reform. This National Clinical people using services, their carers, and Strategy is an important contribution to their community in providing support. This the provision of clarity on the priorities for allows people and communities to manage that reform. The Strategy is underpinned their own health more. A system that by the following set of key principles: seeks to build on this, rather than supply alternatives, is likely to improve population • Quality must be the primary concern – health and wellbeing, as well as the all developments should seek to ensure individual experience and outcome of illness. that there is enhancement of patient safety, clinical effectiveness and a • Services will be based around supporting person-centred approach to care. people, rather than single disease pathways, with a solid foundation of integrated health and social care services based on new models of community-based provision.
02 • Where clinically appropriate we will Scotland has a long tradition of providing continue to plan and deliver services at a high quality health and social care local level. Where there is evidence that services to our population and we believe better outcomes could only be reliably that we are well placed to achieve the and sustainably produced by planning transformational change required. services on a regional or national level, we will respond to this evidence to There has been extensive engagement with secure the best possible outcomes. clinicians, professionals and stakeholders in • The impact of health inequalities will the preparation of this draft of the National be minimised by ensuring equitable Clinical Strategy. However, we recognise it’s access to health and social care not the finished article and that we need support, removing barriers that make to engage further about it. The national people less likely to access care. conversation on “Creating a Healthier Scotland” provides the ideal opportunity for The Strategy makes proposals for how that engagement. So we will, through the clinical services need to change in national conversation, engage with those order to provide sustainable health and interests but also with the public whom social care services fit for the future. It health and social care services serve. sets out a vision that is both ambitious and challenging as a basis for further engagement with clinicians and the public.
Professor Jason Leitch Dr Catherine Calderwood Professor Fiona McQueen National Clinical Director Chief Medical Officer Chief Nursing Officer
03 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
PREFACE
At the beginning of 2015 Ministers decided The National Clinical Strategy has been built that it was appropriate to draft a National on a process of reviewing written evidence on Clinical Strategy that would develop further the organisation of healthcare, and seeking the 2020 Vision, and look towards a longer contributions and comments from a wide time scale, up to 2025-30. The National range of stakeholders, from within Government, Clinical Strategy would lay out a framework and from the wider NHS in Scotland. that would take account of several significant changes in Scotland, including the changing The National Clinical Strategy is, by necessity, demographic composition of our population, both high-level and strategic, and seeks to set the increased demand for health and social out a broad direction for change to help the care that will follow the advent of Health NHS in Scotland meet the challenges ahead, and Social Care Integration, and significant with its partners in local government and the technological changes in healthcare. third and independent sectors, who provide social care services. The development of the This Strategy has been developed by a small Strategy has taken place at a time when there team (Dr Angus Cameron, Elizabeth Porterfield are a large number of other reviews ongoing and Karen MacNee) who have been led and such as the Reviews of Public Health and of supported by an oversight group drawn GP Out of Hours Services. In addition there from across the service, and consisting of: are a number of NHS Boards reviewing their strategic plans, particularly in the context of National Clinical Director: development of Integration Joint Boards. The Professor Jason Leitch Strategy seeks to give a fresh perspective Chief Medical Officer: to these reviews and strategic plans to help Dr Catherine Calderwood a more uniform approach to future change Chief Nursing Officer: Fiona McQueen that is coherent across the whole system. Finance Director: John Matheson NHS Board Chief Executives: Robert In developing the strategy, care has been Calderwood, Cathie Cowan, John taken to engage with a wide variety of Turner (until July 2015), Jill Young staff across Scottish Government and NHS Boards, with a particular focus on clinicians NHS Board Chairpersons: Lindsay Burley, and their representatives. The engagement Jeane Freeman process has included meetings with Chief Senior Medical Officer: Dr Andrew Longmate Executives, Finance Directors, Directors Divisional Clinical Lead: Professor Craig White of Planning, Medical Directors, Nurse Directors, Chief Pharmacists, Area Clinical Forum Leads, Directors of Public Health, Chief Operating Officers, HR Directors, the Academy of Medical Royal Colleges, the
04 Scottish National Partnership Forum, eHealth how we need to shape change, and the advisors, the Royal College of Nursing, the principles underpinning that change. Royal College of General Practitioners, the Royal College of Surgeons and the British Having set out an agreed, evidence-based, Medical Association. In addition there clinical strategy that prepares us for the has been significant clinician engagement next 10-15 years, it will be important to with meetings open to all clinicians held in share that direction with the public to Edinburgh, Dundee, Aberdeen, Inverness, enhance understanding of the need for Fort William, Glasgow and Dumfries. adaptation and change, and to seek their support for the general direction. The The overwhelming impression from repeated current “National Conversation” provides an engagement with these groups is firstly a excellent opportunity to progress this stage. strong appreciation of the need for change and adaptation to improve the sustainability Following this, the hard work of implementing of the service, and to enhance the quality change along the lines laid out in the Strategy of care. Secondly, the engagement process must begin. This will take considerable has achieved a high level of support for all effort, as change within very busy aspects of the strategy as it has developed, organisations is always difficult. However, and there is particularly strong clinical the evidence laid out in this strategy support for the main messages around points to the importance of changing in a the development of general practice and changing world, and stresses the urgency primary care, the development of hospital with which this must be approached. networks to deliver services planned at a population level, and a need to enhance the I would like to end by thanking all those value to patients of services by addressing who so positively gave time and effort over-treatment, harm, waste and variation. to advising the group, particularly the team of librarians who carried out two This National Clinical Strategy sets out very important and extensive literature challenging but deliverable aspirations reviews to support this work. for Scotland’s future health service built on the basis of collaboration rather than Dr Angus Cameron. MB ChB. MRCGP. competition. It acknowledges the challenges MBA (Healthcare Management) facing healthcare services in Scotland – as in the rest of the developed world – in improving health and reducing health inequalities in the context of demographic change and increasing pressure on resources. It is ambitious and visionary and describes
05 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
1. EXECUTIVE SUMMARY
06 1. EXECUTIVE SUMMARY
1. 3. This Strategy sets out a framework for The health of the population of Scotland is the development of health services across poorer than in many other European countries, Scotland for the next 15 years. It does not but will continue to improve with national give prescriptive details of exactly what initiatives to support healthier lifestyle developments are required – it is designed choices, to support mental wellbeing, as well to give an evidence-based, high-level as addressing socio-economic, educational, perspective of why change is needed and employment and environmental issues what direction that change should take. It is that contribute to poor health. While these intended that the National Clinical Strategy initiatives will remain crucial to improving will provide a unifying direction to the range the health of the population, the National of service reviews currently underway, so Clinical Strategy is confined to the delivery of that the complex whole that is healthcare healthcare services to meet assessed needs. across the country can progress to a coherent, This is not to suggest that such initiatives comprehensive and sustainable high quality to improve the health of the population service. The Strategy also provides an outline are not important – they are essential, and of how the NHS in Scotland will change – must be progressed with determination. describing change that will be required to help the service adapt to changing circumstances. 4. Despite the success of the National Health 2. Service in Scotland, there are challenges that The National Health Service in Scotland is need to be addressed if we are to meet our a success story. It provides comprehensive aim of providing a world-class health service and universal healthcare, free at the point for the future. We know that the fact that we of need. It has successfully made progress all, on average, tend to live longer will result against many of the challenges to our nation’s in an increasing number of older people. health and healthcare. This is evidenced While many older people will enjoy better by steady falls in mortality from the “Big health than their predecessors did at an Three” – cancer, heart disease and stroke – equivalent age, they will still have significant and life expectancy is steadily increasing. health needs, and the overall impact will be More treatment is provided each year, a steadily increasing demand for health (and and waiting times have shown significant social) care. Much of this need will relate to improvement over the last 10 years despite long-term conditions – such as diabetes, increases in demand and activity. hypertension, cancer, sensory impairment, dementia and impairment of mobility. It is clear that for the next 15-20 years, demand for health and care services will increase.
07 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
5. 7. We continue to have an unacceptable degree As a result of the financial challenges of health inequality across Scotland, which being faced around the world, there will can mean that a person who is amongst the be constraints on what can be achieved most disadvantaged section of our society can with anticipated future resources. World expect to live at least 10 years less than those comparisons show that increasing expenditure in the least disadvantaged. This inequality is on health services does not always bring multifactorial. The solutions do not lie solely about proportionate improvements in health: with(in) healthcare but evidence indicates that more and more resource input may lead effective healthcare services, particularly in to more and more marginal improvements primary and community care, can significantly in health. This strategy proposes that a reduce the impact of these inequalities. continuous drive to deliver services of the highest quality and value is a more 6. important and appropriate way of managing We also know that the NHS in Scotland is at resources than an isolated focus on finance. present challenged by a number of factors. We have one of the most skilled workforces in 8. the world, and a proud tradition of education There are concerns shared across developed and training. Overall the numbers of doctors, countries that modern medicine, while dentists and nurses have increased, but providing enormous benefit to populations, we know that in many specialties there are can also cause harm to individuals. There challenges in employing the numbers of highly is also concern that on occasion medical skilled staff required to deliver sustainable practice can result in overdiagnosis, healthcare services. We know that many of overtreatment and waste. We know that the current experienced staff in the service this overtreatment probably co-exists with will retire in the next 10 years. While we undertreatment. If we are to continue to anticipate that the biggest challenge will be provide our world-class health service we in medical staff in general practice, and in must find a way of addressing these issues. hospital doctors, we know that there are also While the commitment to year on year pressures in a range of other professions. We increases in investment is important, this rely on a range of highly skilled staff that are strategy sets out the need for a new clinical crucial to the sustainable delivery of health paradigm that will ensure that healthcare services. We will face challenges to replace delivery is proportionate and relevant to these experienced people, particularly because individual patient’s needs and uses minimally of the time that it can take to train experts – disruptive interventions (including lifestyle and we recognise that the increased demand changes) wherever possible. In other words from an older population will require more the emphasis is on maximising patient staff and/or innovative technological solutions. value from the available resources.
08 9. 10. The strategy describes the rationale for an There are a range of changes that will support increased diversion of resources to primary transformation of primary/community care, and community care. Stronger primary such as the move to integrated health and care across Scotland should and will be social care from April 2016, and the new GP delivered by increasingly multidisciplinary contract in April 2017. We will build a greater teams, with stronger integration (and where capacity in primary care, centred around possible, co-location) with local authority practices, by enhancing the recruitment of (social) services, as well as independent doctors to general practice, by increasing and third sector providers. The aim of an the adaptation of technological solutions expanded health and social care team will be to increase access and improve decision to provide all current services, but also to: making, and by developing newer, extended, i) support self-management and independence professional roles within primary care, for everyone by supporting patients such as Advanced Nurse Practitioners, to fully understand and manage their Pharmacists and Allied Health Professionals. problems, promoting a focus on prevention, This will provide the range of skills needed rehabilitation and independence to meet the changing and complex needs of communities. With the advent of integration, ii) to provide care that is person centred and closer working between social work rather than condition focussed, based staff and healthcare staff, there will be on long-term relationships between effective and proportionate responses to patients and the relevant clinical team(s) health and social care needs. The planning iii) understand that the problems of multiple and organisation of care delivery for long-term conditions and the resulting loss individuals and communities will be based of independence result in complex needs around practices, with GPs increasingly taking – many of which are best addressed by on a role in dealing with complex cases, social interventions. We must not provide and providing expert assessments of new an overall system that defaults to medical cases. Transformation of the outdated and solutions (such as admission to hospital) complex dental system will meet the needs when the needs are predominantly social of younger people (who need to maintain a preventive focus) whilst ensuring that the iv) provide evidence-based interventions treatment needs of the older population are that reduce the risk of admission to met. An eDental programme will improve hospital, especially for the elderly the assurance, governance, efficiency and v) provide more community-based information on quality of services. We will services to replace some that have consider the mix of secondary/primary previously been provided in hospital care dental provision to ensure the most appropriate use can be made of each. vi) provide sensitive end of life care in the setting that the patient wishes.
09 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
11. need to ensure that patients experience timely The emphasis on primary care supports discharge without delay, supported when they the ambition of the Scottish Government’s return to their communities by responsive “2020 vision” to provide the majority of health and care services. We know that this care locally and to ensure “We will have a helps promote a prompt return to previous healthcare system where we have integrated levels of independence. As another example, health and social care, a focus on prevention, we intend to reduce the number of times anticipation and supported self-management.” patients are recalled to review outpatient There is evidence from around the world that appointments where this can be avoided. We systems with a strong primary care service can provide better alternative arrangements, tend to produce better overall outcomes for using modern technology to best effect, that people, a better experience of managing with will provide people with faster access to illness and disability, and a lower and more results, see them more rapidly when they proportionate use of resources. The potential are unwell, and disrupt their lives less. of prevention is seen, for example, by developments from the extended vaccination 13. programme now being provided by primary The other changes needed are in relation care, with, for example, dramatic reductions to the structures within secondary care. in gastroenteritis amongst children following There is now an overwhelming amount of immunisations against rotavirus. Primary care evidence that suggests that some complex, will be supported by evolving IT solutions and many less complex, operations are best to improve efficiency and safety of the care performed in more specialist settings. There delivered, as well as enhancing patient access is increasing evidence that teams more to services and participation in their own care. specialised in doing complex operations frequently get better outcomes for patients, 12. who tend to have fewer side effects, and This strategy also describes a number of typically spend less time in hospital. This changes that need to take place in secondary strategy sets out the evidence that some care settings. The first set of changes revolve services should be planned at a national, around processes. Acute hospital care can regional or local level on a population rather be highly complex and involves multiple than geographical boundary basis. This would processes. Despite considerable recent focus mean that, for some services, there would on processes within hospitals, we know there be fewer specialist inpatient units within is still much that can be done to ensure that a region. However, in order to ensure that we use available resources as effectively as services are provided as locally as possible possible, and improve outcomes for patients. (where clinically appropriate) the strategy The two aims are not mutually exclusive. proposes that most services would continue Across health and social care for example, we to deliver outpatient, diagnostic and day-case
10 surgery at most hospitals, as at present. By 14. developing networks of hospital services it It is essential to take forward planning and will be possible to deliver first class outcomes delivery locally, regionally and nationally. As from more specialist centres/services where noted above, planning in this way is not new evidence supports interventions concentrated but how this is achieved will need to change in such a way. However, within a specific to meet future needs. Planning and delivery specialty, not all interventions are complex, with geographical and/or other boundaries therefore by developing a planned delivery will no longer deliver what is needed; planning network, local access to all other services and delivering services for and across within that specialty would be maintained. populations, regardless of locality, is key. We These changes will be complex, but they must increase the collaborative working that are based on evidence of benefit and is the hallmark of the NHS in Scotland. It will have considerable potential to improve also be necessary to adopt a performance outcomes for patients while at the same management framework that supports service time maximising resources and clinical skills. planning at the most appropriate level. The commitment to an investment of £200 million for elective diagnostic and treatment 15. centres will support the changes in capacity The strategy describes the advances that can that will be required as a result of an increase be made by harnessing technology – with in surgical procedures – especially those that particular emphasis on digital technology, both are significantly age-related (such as cataract for clinicians and patients. It has enormous extraction, and knee and hip replacements). potential to provide training and clinical decision support, to support standardisation of processes where they should be standardised, and to improve safety and self-management. It has the potential to address some of the barriers to access inherent in living in a remote community, by enabling specialist input to augment local care via teleconsultations.
11 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
16. 17. The NHS will increasingly become an Acknowledging that the quality of services organisation that is driven by information. is related to the quality of our workforce, Currently a great deal of data is generated, the strategy describes the development of and use is made of it to support increasingly skilled staff, working effectively service improvement and performance in multidisciplinary and multi-organisational management. However as we become settings to deliver excellence in care. more able to draw conclusions from “big data”, we should be able to: 18. • make more informed decisions The strategy ends with discussion about and provide better coordinated a new clinical paradigm. This will be a and more personalised care longer-term cultural and clinical change programme that will need strong national • predict risk for individuals and thus focus clinical leadership. At its heart will be interventions more effectively/proactively a desire to provide proportionate and • collect and use more information on realistic care to fully informed patients, outcomes, especially those that matter most who are encouraged to understand options to patients, rather than clinical data such and choose treatment according to their as biochemical or other surrogate markers preferences. It will support an approach that uses lifestyle modification first before • assess outcomes from medications, more significant intervention. It will support and multiple medications, in different self-management where appropriate, and patient groups, thus developing greater encourage empathetic resilience building understanding of complex polypharmacy rather than dependency. This clinical paradigm • understand degrees of variation will identify interventions that are of limited in interventions across regions so value or may cause harm, and reduce their that any inappropriate clinician use. It will address waste and variation in driven variation is minimised clinical practice. We know that patients when fully informed tend to choose less • predict future needs more accurately interventional healthcare. As is the case • continue to drive continuous at present, we have a duty to ensure that service improvement. everyone is provided with enough information to equip them to become confident partners in decision making. Technology will play a key role in realising this change.
12 19. 20. Over the next 10-15 years there will be In summary, the clinical strategy scientific advances which have not been sets out the case for: anticipated at present, and these will change • planning and delivery of primary the way that we deliver healthcare. There will care services around individuals also be advances that are beginning to make and their communities an impact now. The most obvious example of this is the increasing understanding of • planning hospital networks at a genomics and its potential. Already we have national, regional, or local level developments that mean drug treatment can based on a population paradigm be tailored to individuals – so that fewer • providing high value, proportionate, patients may need treatment. It is hoped effective and sustainable healthcare that genomics will, in the foreseeable future, help stratify patients into low and high • transformational change supported risk, thereby reducing treatment for some by investment in e-health and patients and focusing it more effectively technological advances. for others. This may help some of the challenges created by high-cost but effective medications – we may be able to use them more wisely, with greater certainty of benefit.
13 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
2. INTRODUCTION
14 2. INTRODUCTION: WHY DO WE NEED TO CHANGE?
The current direction of travel for NHSScotland While this remains the central vision for has been set out by two documents. the Health Service in Scotland, we need to change so our health and care system can The Healthcare Quality Strategy for deliver it, adapting to changing demands and NHSScotland, set out an ambitious approach opportunities, and ensuring sustainability. to ensure that the National Health Service Without adapting and improving we will in Scotland could become one of the best not be able to realise the potential of health services in the world, with a world providing world-class care. The challenges leading approach to patient safety, and more we face are seen throughout much of recently, a determined approach to deliver the developed world, and countries are person centred care. The aspirations of trying to adapt healthcare services so that the Quality Strategy remain central to the they maintain a comprehensive supply day to day work of the Health Service. of high quality healthcare in the face of steadily increasing demand. The ability to More recently, the Scottish Government set sustain services that are able to meet the out the 2020 Vision, a high level description increased demand effectively will be a of the direction to be taken by the NHS key challenge for maintaining the delivery in Scotland. of high quality healthcare in the future.
Our vision is that by 2020 everyone is able Although this strategy argues the case for to live longer healthier lives at home or in change, it considers only the delivery of a homely setting. We will have a healthcare clinical services and how they can be planned system where we have integrated health to deliver the best possible outcomes for and social care, a focus on prevention, patients. It is acknowledged that there anticipation and supported self-management. is a need to improve the health of the When hospital treatment is required and Scottish population, by the development of cannot be provided in a community setting, a range of measures designed to address day case treatment will be the norm. Whatever the determinants of poor health – lifestyle, the setting, care will be provided to the educational, economic, employment, highest standards of quality and safety, with environmental determinants. The absence the person at the centre of all decisions. of discussion of these approaches does not There will be a focus on ensuring that reduce in any way the need for continuing the people get back to their home or community progress that has been made in recent years. environment as soon as appropriate, with minimal risk of re-admission. “The 2020 Vision.” Scottish Government 2010
15 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
In setting out a National Clinical Strategy f) Financial considerations it is acknowledged that there are many g) Developments of new treatments challenges facing healthcare services in Scotland. These challenges are substantial, h) Remote and rural challenges and thus it is essential that any Clinical i) Opportunities from increasing, better, Strategy is ambitious and visionary and sets and more joined up use of Information out challenging but deliverable aspirations Technology for a transformed future health service. There are multiple reasons why we need j) Reducing waste, avoidable harm and to evolve and adapt in the face of changing variations in treatment. circumstances. For any organisation, failure to adapt successfully to both external and In discussing these drivers it is important internal challenges will result in an increased to recognise, above all, the overriding risk of failing to comprehensively meet the need to maintain and enhance the objectives of that organisation. The main quality of care, and the outcomes that drivers for change are discussed in this care provides for our population. section. It is important to detail these at some length as a failure to understand the drivers A. DEMOGRAPHIC CHANGES for change will mean that change, which is IN OUR POPULATION always difficult, will not come about, and we will fail to be a world-class health service. Although Scotland lags behind some other European countries, life expectancy has been The main drivers for change are: steadily increasing. This is of course welcome, and is a measure of both healthier lifestyles a) Demographic changes in our population and improved clinical care. However, the b) The changing patterns of illness and significant consequence is that the average disability age of the population and the percentage of older people is increasing, and looks likely c) The relatively poor health of the population to continue to do so until at least 2030. and persisting inequalities in health d) The need to balance health and Current projections suggest that the social care according to need population of Scotland will rise to 5.78 million by 2037, and that the population e) The need to manage the skilled workforce will age significantly, with the number of in a way that makes best uses of their people aged 65 and over increasing by skills, allows further changes in roles, and 59%, from 0.93 million to 1.47 million. The provides sustainable services despite number of households headed by people the current recruitment challenges aged 65 and over is projected to increase
16 by almost 54% between 2012 and 2037. In is challenged by the increasing absolute contrast, households headed by someone number of the population over the age of 75. aged under 65 are projected to increase by just 3%. The number of households headed The impact of the increasing age of the by someone aged 85 and over is projected population can be demonstrated by considering to more than double over the same period, two particular conditions: dementia and cancer. from 77,400 to just over 200,000. Dementia Estimated and projected age structure of the Scottish population, mid-2012 and mid-2037 The increasing prevalence of dementia in an older population will have considerable consequences for the volume and type of health and social care that is 2012 Male required for the future. People with dementia have the greatest likelihood of using high cost unscheduled hospital care for extended periods of time.
A recent estimate carried out by Alzheimer Scotland suggests that there were 89,000 people with dementia in Scotland in 2013. Of Source: NRS 2014 that number, between 50-65% have a formal diagnosis (depending on which prevalence Whilst an older population will require more model is applied). Approximately 3,200 are healthcare, it is possible to point to recent under the age of 65. The rates of dementia are changes that have altered the rates of need strongly related to age. There is evidence that for treatment. For example the rate of hip the true prevalence, rather than the number fracture per thousand of the population over of cases actually identified and diagnosed, at 65 seems to be decreasing, although because age 65-69 is around 1.8% in men and 1.4% in of the absolute increase in the population women. The prevalence increases rapidly so over the age of 65, the actual number of hip that 20.9% of men aged 85-89 have dementia, fractures is increasing and is likely to continue with around 28.5% of women of the same to do so. Likewise the rate of bed day use per age having the condition. While the majority 1,000 of the population over the age of 75 of people with dementia manage to live at has decreased significantly (primarily due to home, with input from relatives and informal reduced average length of stay) from 5,421 carers, the disease is steadily progressive in 2009/10 to 4,815 in 2013/14 – a reduction of 11%. Inevitably, however, this falling rate
17 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
and it is almost inevitable that health and New cancer registrations in Scotland, social services will require to provide 1989-2013: number of cases and age significant input as the illness progresses. standardised rate (European Age Information Services Division The figures above indicate how the scale of Standardised Rate – using ESP20132)
the problem will increase as the proportion Figure 3. New cancer1 registrations in Scotland, 1989-2013: of older people in the population increases. number of cases and age standardised rate2 (European Age Standardised Rate – using ESP20132)
Cancer 18000 900 16000 800
14000 700 Over the last ten years, age-standardised
incidence rates of cancer in Scotland have 12000 600 fallen by 4% in males but increased by 7% in 10000 500
8000 400 population Males - cases females. However, excluding non-melanoma 6000 Females - cases 300 Males - rate skin cancers, the actual number of cancers 4000 200 Rate of registrations per 100,000 Number of registrations Number Females - rate diagnosed in Scotland has increased over 2000 100 the last 10 years from 27,095 cases in 0 0 1989 1993 1997 2001 2005 2009 2013 2003 to 31,013 in 2013. This is likely to be largely due to an ageing population. Source:Source: Scottish ScottishCancer Registry Cancer Registry 1 All cancers excluding non-melanoma skin cancers (ICD-10 C00-C97 excl C44) 2 1The All European cancers Standard excluding Population (ESP), non-melanoma which was first used in 1976, skin was cancersrevised in 2013. Figures using ESP1976 and (ICD-10ESP2013 are C00-C97 not comparable. excl The European C44) Age Standardised Rate (EASR) is calculated using ESP2013 and 5 It is estimated that up to one in two people in year age groups 0-4, 5-9 up to an upper age group of 90+. 2 The European Standard Population (ESP), which was first Scotland will be diagnosed with some form of For bothused males in 1976,and females was inrevised Scotland incombined, 2013. Figureslung cancer using is still ESP1976 the most common cancer during their lifetime. This does however cancerand overall ESP2013 (Figure 4),are with not 5,124 comparable. cases diagnosed The in European2013 (17% of Age all cancers), comparedStandardised to 4,697 cases Rate (15%) (EASR) of breast is cancercalculated and 3,8 using12 cases ESP2013 of colorectal and cancer 5 include cancers that will have no detrimental (12%).year age groups 0-4, 5-9 up to an upper age group of 90+. impact on life expectancy, such as indolent prostate tumours. It is estimated that there This increased incidence, and increased are 176,000 people in Scotland who have been prevalence, will have a very significant diagnosed with cancer over the last 20 years impact on the services that we will be and who are still alive. This is approximately required to deliver in the future. Medical 3% of the population of Scotland. technology has developed significantly, and recurrences of cancer are now treated more aggressively (and more successfully) than before. These increases in demand, along with the rapidly changing range of investigations and treatments as we develop greater 6 understanding of cancer treatment, means that we must have a service that is able to adapt promptly to developing technology. The careful scrutiny of treatment developments,
18 the development of an evidence base, and the B. THE CHANGING PATTERNS OF need to adapt to changing treatments requires ILLNESS AND DISABILITY ongoing planning of cancer services across the population. The next steps will be outlined in It has been recognised for at least the a cancer plan to be published in Spring 2016. last 50 years that the pattern of illness experienced by the Scottish population These two examples indicate how we will has changed significantly from acute need to build capacity in both our social care life-threatening illnesses, towards long- and healthcare services to meet the increasing term conditions and disability. demands that will develop as our population grows older. These changes will require us In 2014, 46% of adults had one or more to adapt current health and care services so long-term conditions. The prevalence of long- that they are aligned to address the burden term conditions increased with age, from a of ill-health in our population. We will need quarter (25%) of adults aged 16-24 to three- to focus on preventing illness, delaying quarters (77%) of those aged 75 and over1. progression or exacerbations, supporting Long-term conditions are generally defined self-management where appropriate, and as conditions that have been present for at providing health and social care safely, least 1 year and are unlikely to be cured. The effectively, equitably and sustainably, aiming significance of long-term conditions is that to return people to a state of maximum health they are very likely to persist for the rest and independence for as long as possible. of the individual’s life, resulting in ongoing need to manage the condition or conditions.
A significant number of long-term conditions are preventable with appropriate lifestyle choices, indicating the need in Scotland for continued work on influencing changes in lifestyle choices and thereby developing a healthier population for the future.
1 Scottish Health Survey 2014
19 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
Long-term Conditions:
• People with long-term conditions • People living with a long-term condition are twice as likely to be admitted are likely to be more disadvantaged to hospital and will stay in hospital across a range of social indicators, disproportionately longer than people including employment, educational without them. opportunities, home ownership and income. Someone living in a • Account for over 60% of hospital bed disadvantaged area is more than twice days used. as likely to have a long-term condition as someone living in an affluent area, is • Most people who need long-term more likely to be admitted to hospital residential care have complex needs because of their condition, and will be from multiple long-term conditions. more likely to develop the long-term illness at an earlier age – a difference of • People living with long-term conditions as much as 10 years. are also more likely to experience ISD psychological problems.
20 Longstanding illness by Scottish Index of Multiple Deprivation (SIMD) quintiles, 2014
Type of longstanding illness SIMD 2012 quintiles Least Most 2 3 4 deprived deprived Neoplasms & benign growths 2% 2% 3% 2% 3% Endocrine & metabolic 9% 7% 11% 10% 11% Mental disorders 6% 6% 7% 8% 15% Nervous System 4% 4% 5% 5% 5% Eye complaints 2% 1% 2% 3% 2% Ear complaints 1% 1% 2% 1% 2% Heart & circulatory system 11% 10% 14% 13% 17% Respiratory system 7% 7% 8% 10% 11% Digestive system 4% 5% 6% 6% 8% Genito-urinary system 2% 3% 2% 3% 2% Skin complaints 1% 2% 3% 2% 2% Musculoskeletal system 15% 14% 17% 20% 23% Infectious Disease 0% 0% - 0% 0% Blood & related organs 1% 1% 1% 1% 1% Other complaints 0% - 0% 1% 0% No longer present - 0% 0% - - Any longstanding illness 42% 41% 46% 50% 55% Source: Scottish Health Survey
21 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
It should be recognised that although long- term conditions are often thought to be associated with older age, the absolute number of long-term conditions experienced by the under 65s in the population is greater. The clinical significance of long-term conditions is very varied, ranging from illness that can be considered more of a risk factor (such as hypertension and osteoporosis) to those that cause increasing disability (such as osteoarthritis, chronic obstructive pulmonary disease, heart failure, macular degeneration and hearing loss). While it is Source: Barnett et al, The Lancet 2012; 380: 37-43 possible to provide secondary prevention to reduce the rate of progression of many The chart above shows how there are long-term illnesses, and to decrease the increasing numbers of long-term conditions episodes of exacerbations, the combined found in older people. The accumulation impact of multiple long-term conditions is of multiple long-term conditions results to cause a progressive, cumulative disability in progressive loss of independence and that severely threatens the quality of life, increasing need for social support. and creates a need for greater and greater social support. While it is recognised that, overall, the majority of the support is provided by family and other carers, it is inevitable that there will be an increasing demand on health and social care services.
It is essential to recognise that the accumulation of long-term conditions and related disability results in increasing needs that may be complex, and may require social care and support more than clinical solutions. This has been one of the main drivers behind the recent integration of Source: Barnett et al, The Lancet 2012; 380: 37-43 health and social care across Scotland – to This chart shows how the population that is ensure that people in need have appropriate most deprived develops long-term conditions at help that addresses their needs – which an earlier age – developing long-term conditions may not be predominantly medical. up to 10 years earlier than the least deprived.
22 In conclusion, the increasing prevalence of example, by the significant improvements long-term conditions, and the complex needs brought about already by the nursery that arise from multiple long-terms conditions school tooth brushing campaign, which has will drive increasing demand for health and substantially reduced dental decay and social care for the foreseeable future. The fact the need for fillings and extractions. that there will be more people with multiple conditions in future means that clinicians will The use of the rotavirus immunisation increasingly need to work in teams across in children has dramatically reduced the specialisms and will need to be supported incidence of diarrhoea and vomiting, and in that by improved information exchange thus reduced the number of admissions to and clinical decision support systems. hospital. The ban on smoking in public places is bringing about an increased reduction in C. THE RELATIVELY POOR HEALTH OF the number of smokers, which will impact on THE POPULATION AND PERSISTING the demand for many aspects of healthcare. INEQUALITIES IN HEALTH £1,762,621 £1,762,621 £2,000,000 £213,380 £- £- While the health of the Scottish population 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 -£2,000,000 -£1,217,255 is improving, and life expectancy has -£2,048,836 -£2,880,417 -£4,000,000 -£3,276,469 -£3,672,522 -£4,201,809 also improved, we lag behind some other -£4,731,097 -£6,000,000 European countries across a wide range -£8,000,000
Cost of toothbrushing in nurseries of population health measures, including Costs / Expected savings -£10,000,000 Costs / Expected savings resulting from actual and anticipated dental treatments dental and oral health. This alone makes -£12,000,000 the case for renewed efforts to have a comprehensive public health approach across The chart above shows how the investment all sectors of Government (and the third of £1.7 million annually on a toothbrushing sector) as many of the long-term conditions campaign in Nursery Schools has led to a described above can be significantly significant drop in the need for fillings and reduced by improvements in lifestyle, extractions – showing improvements for education, wealth, employment, environment, patients, and reduction in overall costs. social cohesion and mental wellbeing. Although a relatively crude measure of health This clinical strategy does not focus on the inequalities, the inequalities across Scotland prevention of ill-health, but that does not can be demonstrated by consideration of life in any way indicate a lack of importance expectancy, and healthy life expectancy. of public health initiatives. As well as the obvious benefits to individuals, they can be shown to effectively reduce demand for healthcare. This has been evidenced, for
23 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
Life expectancy (LE) is an estimate of how Males – Males – Female – Female – many years a person might be expected to Least Most Least Most deprived deprived deprived deprived live, whereas healthy life expectancy (HLE) Life Expectancy 81.7 71.3 84 77.2 is an estimate of how many years they (years) might live in a “healthy” state. HLE is a key Healthy Life 69.1 48.3 71.9 51.5 summary measure of a population’s health. expectancy (years) Expected years 12.6 23 12.1 25.7 • The most recent annual estimates for of “Ill health” Scotland are for boys born in 2013 to live 77.1 years on average, 60.8 of these in a Source: ISD “healthy” state. Girls born in 2013 would be expected to live 81.1 years on average, • LE is significantly worse (lower) in Scotland 61.9 of these years being “healthy”. than in the UK as a whole, for both males and females. HLE is significantly • Underlying trends in both LE and HLE worse (lower) in Scotland than in the at birth show a general improvement UK for males, but similar for females. in Scotland over recent years. • Scotland has one of the lowest LEs in • The gap between LE and HLE (the years Western Europe. International comparisons expected to be spent in a “not healthy” state of HLE are hampered by the lack of during the average lifetime) has been fairly consistent health measures. However, on constant for females between 1980 and the basis of a related indicator, healthy 2008, but tended to increase for males. life years (HLY), it would appear that, • There are considerable variations in LE and in comparison with many European HLE at birth in Scotland among different countries, Scotland fares badly for males geographical and socio-economic groupings. but compares better for females2. Men living in the most affluent parts of Scotland can expect to live 10 years longer than those in the most deprived areas. Differences in healthy life expectancy are even starker with a gap of 20 years for men living in the most and least deprived areas. As shown in the table below, even the most advantaged section of the population can anticipate a significant period of “Ill health” – with the most disadvantaged likely to experience approximately twice the number of years of ill health: 2 Source: Information Services Division.
24 D. THE NEED TO BALANCE HEALTH AND social care that, for many of our older people, SOCIAL CARE ACCORDING TO NEED admission to an acute hospital is too often the fall-back option, when it is possible that As referred to above, the development their needs could have been satisfactorily met of multiple long-term conditions leads to by enhanced support and care input within increasing loss of independence, and the their home and community. This is important. development of complex needs that cannot Not only does avoidance of admission, where be met solely by health services. For many possible, provide a service that is preferable older people who have increased restrictions to most people, it can be associated with on their life, perhaps from combinations less unintended harm from treatment, less of multiple long-term conditions such as confusion and dependency, and, of course, sensory loss, poor mobility, chronic pain, less need to continue to increase capacity social isolation and mental health issues, in our hospitals over the coming years. the need for rehabilitation, social support and integration into local communities may 2011 2012 2013 2014 have greater immediate importance to them Emergency 534,178 547,673 551,524 554,893 than the provision of medical care. The inpatient discharges implementation of Health and Social Care Routine 447,989 448,263 469,543 518,743 Integration will mean that we are better inpatient placed to ensure that there is an appropriate discharges balance between health and social care Day case 443,109 453,520 459,919 451,281 services. This is important to prevent health discharges services being used as the “default” when Source: ISD Scottish Hospital Activity social support might be more appropriate (as happens with a number of avoidable hospital The steady rise in unscheduled admissions admissions, particularly in older people). shown in the table above is likely to continue unless health and social care Admissions to hospital systems adapt. The rate of unscheduled admissions in the elderly population will Analysis of admission trends show that across increase most. Currently admissions in this most age groups, the rate of admission to group of patients are partially driven by hospital is relatively steady. However in a lack of health and care services in the the over 75s, and particularly in the over community that are able to rapidly escalate 85s, the number of admissions is driven the levels of care during an exacerbation of by an increasing rate of admissions in illness to maintain them in their homes. those age groups, along with the increasing numbers of patients in these age groups. There is evidence from across health and
25 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
There is evidence from a range of settings ready to leave hospital. This figure suggests that it is possible to treat a proportion of that there is very considerable potential to these people in their homes, and provide relieve pressure on hospitals by continuing similar outcomes, with a better experience, the improvement in addressing discharge and less impact on their independence delay. It must be considered an urgent priority than if they are admitted to hospital. to ensure that any barriers to discharge for these patients are removed and support Hospital discharge provided for them to leave hospital. This improves their experience of healthcare, and The ability to discharge people from hospital also potentially frees up resources (beds and can be delayed by an inability to promptly staff) for use by other patients in need. organise suitable support packages for them, resulting in a worse experience for We also know that the vast majority of the individual, the potential for further people, if asked, declare a desire to die at loss(es) of function, delays in admitting other home. Currently in Scotland over 50% of patients, pressures within hospital systems deaths occur in hospital, and people may and increased but potentially avoidable (though by no means always) experience a use of resources within acute hospitals. depersonalised death that is distressing for them and their relatives. We need We are committed in Scotland to tackling to ensure that we have the capacity to delays in discharging people from acute support individuals and their families hospital beds – a key driver for integrating to stay in their own homes, or return to health and social care. Delayed discharges them when this is their explicit wish. in this context are defined as patients who are still in hospital more than two weeks The conclusion from this section is that after they have been declared medically fit we know it is better for people to be for discharge. In the census in October 2015 supported to stay in their own homes and there were approximately 1,280 such patients. communities for as long as possible, as This figure is a reduction of 7% from the independently as possible. We also know same time the preceding year. However the that demand for inpatient hospital care will Information Services Division notes that in increase significantly to an unsustainable September 2015, a total of 48,000 bed days level unless we fundamentally shift the were used by patients whose discharge had balance of care from acute hospital services been delayed. Again this is an improvement to comprehensive and responsive primary, on the situation from the preceding year, with community and social care services, along an 8% drop. However, this figure suggests with comprehensive approaches to improving that on average, 1,578 beds across Scotland public health and the ability of patients to are occupied by patients who are clinically self-manage their long-term conditions.
26 There is a need to prioritise investment While the total NHS workforce has grown to carefully to optimise the effectiveness of an all-time high of 161,0003 (138,000 WTE), services. In order to improve outcomes that in itself will not meet the challenges and reduce the pressure of unscheduled we face such as increasing demand admissions to hospital, it will be necessary for healthcare. We need to do more to to appropriately prioritise investment in maximise the contribution from the whole primary health and social care to allow healthcare workforce, and be prepared alternatives to admission to be developed to change the way we deliver services. where it is clinically appropriate to do so. This may include investment in hospital-based We do not underestimate the challenge services that could reach out to communities these changes will mean for our workforce. – such as community facing geriatricians. Through Everyone Matters4 the Scottish Government set out a clear workforce vision However, the increased proportion of and plan which was co-produced with NHS older persons in the population will result staff. We will support our workforce to in an increase in the need for a range of make those changes through the priority procedures – especially those that are areas identified in that plan. These are: age-related, such as cataract removal and • Healthy organisational culture joint replacement. Demand assessment for these operations has been carried out, as • Sustainable workforce a result of which the Scottish Government • Capable workforce has allocated £200 million over the next 5 years to increase elective capacity • Workforce to deliver integrated service across the country, particularly where • Effective leadership management. population projections suggest most need. Evidence from the Golden Jubilee National Alongside the strong partnership working Hospital shows that a concentration of approach that is well established in high volume procedures results in lower NHSScotland, this collaborative approach complication rates, reduced length of will be vital in creating the sustainable stay, and effective, standardised care. workforce we need for the future.
E. WORKFORCE ISSUES
A sustainable health workforce which is motivated, adaptable and highly trained is crucial to delivering high quality healthcare in the changing health landscape and to meet our vision for health and 3 ISD Workforce Numbers: Published December 2015 social care by 2020 and beyond. 4 Everyone Matters, The Scottish Government, June 2013
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Challenges In addition gaps in the workforce among care workers make it difficult to start In common with many healthcare systems care packages timeously, with the result in the developed world, NHSScotland faces that patients remain in hospital after a challenge in maintaining a suitably trained they have been determined to be fit to workforce over the next 5-10 years. For be discharged from hospital. As we move certain professions and in certain regions, it to integration of health and social care, it can be extremely difficult to recruit the right is important that we plan for the wider staff in the right quantities. International workforce employed across health and shortages of key specialties are by their social care, ensuring that the important nature difficult to address in a Scottish contribution of care staff is recognised, context alone. Adding to these challenges and that these roles are as attractive as are the differing roles played by Scottish possible for potential care workers. Government and NHS Boards; the complex interactions around workforce planning; Achieving the right balance and individual circumstances applying to professional groups, service plans and policy Securing the right workforce within the clinical development. We also need to bear in mind environment, and balancing this against the that the medical workforce in particular diverse needs of patients can be extremely has an older age profile than most other difficult. Complex illnesses, and the pace of employment sectors, and it is likely that change in technology may mean patients a higher proportion of those over 55 may require specialised staff who can provide the choose to retire over the next few years. highest quality high technology care available when such specialised intervention is required. Self-evidently, gaps in the medical training However, patients with multiple conditions establishment and workforce are likely to may need clinicians with broader based skills adversely affect the quality and sustainability who can provide more generalist care. of services provided to patients. Within the medical workforce, gaps in particular This complex and almost infinitely specialties and in particular areas could create variable clinical environment means that risk to the sustainability of services. Using there is no one solution to the challenge expensive alternatives such as locums can of sustainability. However we do know help address the current needs of the service, that too much medical specialisation has but in a way that is unsustainable, and a often led to disjointed, disease-focussed poor use of resources. It also demonstrates care for patients with multiple conditions, the need to better match our workforce often provided within hospital rather capacity to overall demand in a sustainable than community settings, and frequently and affordable way which anticipates the requiring referral to multiple specialists. The challenges for healthcare in the future. tension between specialist and generalist
28 approaches applies particularly to doctors • Value the contribution of all disciplines (and was recognised by the Greenaway to addressing patient needs 5 Report on the training of doctors in the UK ). • Have excellent generic skills, such as listening, communication, leadership It is right that Scotland should make a full and improvement skills contribution to UK-wide developments on medical training. But we also seek to • Engage in life-long learning, recognising the achieve an optimum balance for Scotland pace of change in health and social care – though broadly in favour of more • Remain flexible, able to adapt to generalist approaches – through the Shape changing technology and patient need. of Training Transitions Group, which is best placed to respond to challenges of Building our approach to sustainability – if necessary, by making sustainability and risk adjustments to medical training intakes. To deliver a sustainable workforce supply Although there is a demonstrable need for we need to ensure sufficient supply into doctors of all roles to have a wider generalist training, maintain those numbers through approach (to match the multiple combinations the pathway of training and retain a of illnesses in their patients) we argue in this high proportion of those qualified staff strategy for services to be planned across within NHSScotland, as well as attracting populations, with specialised centres for high quality staff from elsewhere. complex interventions, staffed by clinicians with specialist skills. There will be considerable Even relatively few gaps in supply can planning and judgement required to develop create significant service challenges for a sustainable balance of medical, and wider Boards, particularly if compounded by clinical, workforce to provide the best possible difficulties in recruiting suitably skilled outcomes across all ranges of complexity. short-term locum cover. So maintaining that supply, and using the supply in the most What we expect effective ways, is a key area of focus for now and the future to mitigate those risks. Our expectations in Scotland are that, regardless of which profession is delivering At the same time, making fundamental changes high quality services in our NHS, it should: to ensure the delivery of high quality services • Combine generalist as well as specialist skills in future, will mean using our understanding of risk to improve and develop more • Work effectively in teams sensitive models of supply and demand, with gap analysis providing risk-based intelligence which informs recruitment 5 The Shape of Training Review: Securing the future of Excellent Patient Care: Review group led by Prof David Greenaway decisions and education requirements.
29 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
Much positive work is already being done We recently announced an increase of with NHS Boards and others to obtain better 100 in GP specialty training places and an intelligence about why and where vacancies enhancement of the GP returners scheme to occur in order to improve consistency in encourage GPs who are not currently working Board reporting of vacancies, which will: in NHSScotland back into the service. In addition we are working with our universities • inform more effective workforce planning on a number of actions that will increase • further develop and use mandated the number of medical undergraduates and workload and workforce planning tools broaden the range of people entering medical • improve data in areas such as midwifery, education to ensure that all of our young neonatal nursing and community nursing people have the opportunity to develop their skills through a career in NHSScotland. • aid profiling the GP and consultant workforces so there is a consistent Transforming roles evidence base to underpin decisions on future numbers. As demand for health services increases, we need to ensure future models of service We are extending this work into health delivery and workforce configuration are and social care integration to develop optimal. Ensuring a sustainable workforce common datasets where that is appropriate, means maximising the contribution of all to ensure Integration Joint Boards are healthcare professions, so that our staff work fully equipped to plan and provide at the top of their professional capability, integrated services across Scotland. but without adding to a loss of continuity of care or increasing the complexity of care. While we need to accelerate this work, It means further investment in a mixed we are not starting from a zero baseline. economy workforce, and crucially, it means In medicine, supply and demand issues transforming roles so they are of more direct in the education and training pathway benefit to Scotland’s NHS patients in different are particularly complex and planning for healthcare settings. For example, further future service need is challenging given the training allows experienced nurses to deliver duration of medical training (a minimum of advanced practice; pharmacists with extended 10 years for GPs and 15 years for hospital roles can provide care, especially for patients specialists). We are developing an increasingly with long-term conditions; allied health sophisticated understanding of supply and professionals can develop increased skills demand issues and other factors influencing to deliver professional care autonomously; the choices made by medical undergraduates and physician associates are a recent and and junior doctors, which is enabling us to welcome addition to multidisciplinary clinical target increases for particular specialties. teams. The primary care workforce is the one
30 which we most need to develop and grow in next five years and the fact that GP specialty order to achieve the capacity and workforce training places are difficult to fill. These transformation that is required, and specific issues are common across the whole UK. reference is made to that later in this chapter. The Scottish Government is taking measures Our ultimate aim remains to have sufficient to increase the supply of newly trained GPs, numbers of the right staff in the right location with the recent announcement of an extra 100 with appropriate skills, delivering patient GP training posts across Scotland from August care of the highest possible quality. Much 2016. This potential increase in capacity is excellent healthcare is already delivered accompanied by renegotiation of the GMS by multidisciplinary teams. This has been (GP) contract (due to be implemented from shown to be highly productive and delivers April 2017) which will provide a role and safe and effective care with improved career structure that is more attractive. outcomes for patients. We will continue to build on this model going forward. Concerted action is also needed to make GP careers more attractive, and there are a General practice number of actions which are being considered or are already in train to address this. The number of GP vacancies within These include giving medical students the independent contractor practices is difficult opportunity to spend more of their training to define precisely, though ISD collects data in primary and community care settings, on numbers of GPs, and the biennial Primary presenting a more positive view of general Care Workforce Survey is underway. There is practice, and extending the range of career however considerable evidence of a significant opportunities for GPs. Such opportunities recruitment challenge in general practice include the new one year GP fellowship to across Scotland, with some areas finding it provide them with the enhanced skills to more difficult to recruit than others. This has work in the new community-based models. had multiple impacts, including a number of practices relinquishing their contracts, The renegotiation of the GP contract is a requiring Health Boards to deliver a directly key enabler to increase the attractiveness of managed GP service for a period of time the profession, removing bureaucracy and until new arrangements are put in place. enabling GPs to spend more time on the type of patient care that provides the greatest The sustainability of the GP workforce benefits to patients, whilst providing higher continues to be affected by the existing short- levels of job satisfaction to the doctors. fall in GP numbers, the trend towards flexible working, the high proportion of GPs over the age of 55 who are likely to retire in the
31 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
For the future, general practice will require with a client should prompt contact with a different approach. The role of the GP will a healthcare professional. evolve to be the expert medical generalist, working with larger teams, and supported The provision of an appropriate level of by a wider multi-professional team able to support for patients in the community deliver much greater clinical care, working (aiming to help rehabilitation and re- in a way that utilises their particular enablement) requires a continuing expansion skills. The impact of the clinical team will of the primary care workforce. This will be enhanced by collaborative working be a central role of the newly formed with social care staff, and increasingly Integration Joint Boards. However, given by signposting patients to third sector the resource constraints, it is likely that a organisations that provide significant shift from investing in hospital care will be community-based support for patients. required, with a more significant move to investment in primary and community care. The development of the wider primary care team will be trialled in a number Conclusions of areas through new ways of working. Important issues to be determined by Healthcare will increasingly be delivered by the trialling of newer models will include teams of professionals united by common how continuity of care for patients can professional values, with effective clinical be optimised in wider teams, and how leadership. the increased range of professionals can be integrated to work with the existing Recognising the current and future challenges practice-based structure of primary care. in recruitment of highly skilled staff, we need to continue planning of training and The development of a highly skilled and recruitment for all types of clinicians to effective mix of professionals in primary care ensure that we can have the capacity to will require development of targeted training deliver the services that will be required for nurses, pharmacists and allied health care in the future. Enhanced capacity has to professionals, so that they are able to develop be planned early to deliver the health and the extended roles that will be required to social care workforce that will be required practice more autonomously in the in the future, particularly given that training primary/community care services of the future. for some professionals takes years. A new GP contract must provide a professionally It will be important for primary care satisfying career path to attract a greater professionals to be prepared to offer some proportion of doctors into primary care. basic training to relevant social care staff, with particular emphasis on what developments
32 However, increasing the numbers of staff early in disease to prevent progression alone will be insufficient. We have the (avoiding the added patient burden of potential to deliver care in different, and more intensive interventions), it is provided potentially better ways, by fully utilising safely to avoid harm, it is proportionate to the many skills found across the wide the patient’s needs (avoiding the waste of range of disciplines (supported in some providing outcomes that are not relevant to settings by innovative use of digital the patient), it is provided consistently and technology). NHSScotland has already reliably (avoiding unwarranted variation). invested significantly in a mixed economy workforce and recognises the benefit of Looking ahead, there are various issues that new roles in the healthcare setting but will specifically impact on the health also recognises the need to do more. resources available: • The estimated annual percentage change in The workforce challenges we describe the volume of demand for healthcare (and are not exclusive to NHSScotland and cost) as a result of anticipated demographic dealing with them requires action by changes over the period to 2030, and individuals, Health Boards and other increased life expectancy, is projected to bodies and Government. This should be at least one per cent per annum. In reflect our particular circumstances and the absence of change, this equates to an build on our well established models of increase of up to £120 million per year. collaboration and partnership working. • The projections for increased costs F. FINANCIAL CONSIDERATIONS of medicines suggest a further 5-10% increase on current spending per year. This is a clinical strategy which provides the • Staff costs are approximately 65% of rationale for change in the delivery of high total costs, and are projected to continue quality and sustainable clinical services. To be to rise as a result of pay structures, successful it must also be underpinned by a National Insurance and Pension changes. sustainable financial strategy, with a primary focus on the value of healthcare services. This all requires to be delivered within the context of the toughest public expenditure Value-based healthcare is an established conditions we have faced. The Scottish approach to improving healthcare systems Government’s discretionary budget will across the world – the central argument be around 12% lower in real terms in is that higher value healthcare is not 2019-20 than it was in 2010-11. Despite necessarily provided by higher inputs. What this pressure, health spending continues matters more is that care is provided to be protected, with health resource spending in Scotland set to rise to a record level of £12.4 billion in 2016-17.
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Evidence shows that the relationship between healthcare expenditure and health outcomes is non-linear. If it were, any Cash Terms (£billion) additional euro spent on healthcare would Real Terms (£billion) result in a corresponding improvement in the population’s health status (measured, for instance, in terms of healthy life Source: Scotland’s Spending Plans and Draft Budget expectancy). In reality, the greater the 2016-17, Scottish Government, December 2015 expenditure, the lower the marginal improvement in health status as a result of Investments in 2016-17 include: £250 its increase. million investment to be directed to health and social care partnerships, to ensure Countries also vary significantly in their improved outcomes in social care; £45 million ability to translate a similar level of improvements to primary and community resources into health outcomes. care, to support the development of new International comparisons show that the models of care; and £200 million over the same amount of per capita healthcare next five years for the development of a expenditure can be associated with very new network of diagnostic and treatment different health outcomes even after taking centres, enabling faster treatment and into account the differences in lifestyle and addressing demographic pressures. socio-economic realities among countries. It is not only how much money is spent, This strategy is primarily about improving but also how it is spent, that determines the value delivered by, and from, health a country’s health status. Present budget services. Improving value by providing constraints should therefore be used as reliable care that is proportionate to an opportunity to improve the value and need, is safe, effective, person centred effectiveness of healthcare spending. and sustainable will increase value for patients, and is likely to stabilise costs. “Investing in health” European Commission Staff Working Document: Feb 2013
34 G. CHANGES IN THE RANGE OF in future treatments may be constrained. POSSIBLE MEDICAL TREATMENTS There is evidence that some advances are only very slowly taken up across the Health The pace of change as a result of medical Service. This natural conservatism with advances is considerable. It is not just the respect to new treatments can have benefits change in the actual treatment that will alter as there are examples of treatments that the services that we can offer, it is change have been withdrawn after early experience in the way that services are delivered, and has revealed previously unsuspected safety challenges to accepted practice. For example, issues or unpredicted harms. However we 10 years ago it was considered normal and need to ensure that new advances are taken acceptable for patients to remain in hospital up promptly across the whole of Scotland, for up to 10 days after hip replacement. especially if they result in significant increases Since then, work has been done to reduce in the value of treatment to patients, and the physiological impact of anaesthesia and improved outcomes, or reduced costs. The operation, and speed recovery. Progressive role that Healthcare Improvement Scotland work has shown that better outcomes can be has taken in this respect has ensured that obtained with a concerted effort to reduce cost-effective and proportionate use is length of stay, and it is now not unusual for made of new technology (for example, patients to be discharged within 48 hours the consortium formed to advise on the of hip replacement. Likewise there has use of the novel anti-coagulant agents) been a continuing increase in the amount but there are further opportunities to of day-case surgery, and, especially in improve decision making and treatments. gynaecology, a significant move to provide traditional day-case care in outpatient In summary, we need to ensure that any clinics – improving the service to patients, new developments in Scotland deliver maintaining or improving outcomes and proportionate improvement in value in relation providing a higher value service at less cost. to their costs. That value should always be related to patient experience and outcomes. Scientific advances will continue to provide the means to improve outcomes, but We should focus as much on different and many of these advances will come with better ways of delivering current services considerable cost and complexity, and as we should on new technology and may require more total resource than the medicines. Medical and technical advances treatments they displace. We will need to can be marginal in their impact; service ensure that we have a health service that improvement can be transformational. assesses improvements in outcomes against increases in resource input, and is as efficient as possible, otherwise our ability to invest
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We require a continuing national approach lead to difficulties in providing high quality to support service improvements – as has emergency care – issues which have been been seen with the increased understanding significantly addressed by the establishment of improvement science with the Scottish of the flight based medical retrieval services. Patient Safety Programme. We require to support widespread clinical leadership – There are other key ingredients to the from multiple professions – to ensure that provision of effective emergency care – the we have a Health Service that is rapidly ability of well-trained local clinicians suitably able to adapt to changing technology, and equipped to respond rapidly to emergencies, better ways of delivering current services. and the ability to transport selected patients rapidly to definitive care. Due to the low rate H. REMOTE AND RURAL CHALLENGES of emergencies in sparsely populated remote TO HIGH QUALITY HEALTHCARE locations, clinicians there may infrequently be called upon to provide emergency care, Scotland has a population of just over five leading to reduction of any skills that have million, and covers a vast area, much of been acquired. For this reason, it is necessary which is sparsely populated. Rural Scotland to consider further development of remote accounts for 98% of the land mass and clinician support from specialists so advice approximately 20% of our population live can be obtained rapidly via phone or internet, there6. A significant proportion of areas are given the much broader range of skills remote from centres of significant population required of clinicians in rural areas. This may and thus physical access to services. Rural augment the broad range of service initiatives populations continue to grow at a faster rate that are found across rural Scotland – often than the rest of Scotland and have higher based on local solutions using local resources levels of older people, which increases and skilled healthcare professionals. demand for core services. Furthermore many rural households suffer from deprivation A number of innovative ways of delivering with “extreme fuel poor” rates around healthcare in rural areas are being developed double of those elsewhere in Scotland. and tested with Scottish Government support. Working with NHS Boards we are developing The co-ordination and delivery of health networks between rural and urban hospitals. and social care in remote and rural areas These networks will support doctors working presents very significant challenges. There are in rural areas to maintain and develop their insufficient populations to sustain specialist skills – ensuring that patients receive safe hospital services and distances and limited care. In some areas this will involve rotating public transport links to acute hospital care staff between rural and urban hospitals to can result in long travel times. This can ensure that we continue to provide services close to communities. This work has already 6 National Statistics, Rural Scotland Key Facts 2015
36 delivered early success in supporting the improved connectivity in rural areas has been delivery of general surgical services in Fort identified as a priority by the Rural Parliament William’s Belford Hospital. Working with and is important, not just because of the NHS Highland, a network between Caithness potential improvements in the provision of General Hospital and Raigmore Hospital in healthcare, but because of the wider issues Inverness is being put in place which will for more remote communities relating to involve rotating staff between the two education, business and social integration. hospitals. This will support the delivery of the majority of surgical care and all out-patient Delivering routine health, dental and social care close to the community in Wick. The care, can be difficult due to the challenges Scottish Government is also supporting an of recruiting and retaining clinicians and care enhanced training programme for GPs who professionals to rural communities. Potential will be able to support the general medical barriers include: social and professional services delivered in Caithness General. isolation, limited spouse employment opportunities, reduced educational Another initiative implemented by NHS opportunities for children, the demands of Highland with SG support is ‘Being Here’, providing very broad emergency and non- (2013–2016). This programme has explored acute services, increased on-call duties, lack of new healthcare approaches to tackle suitable housing, and difficulties in obtaining challenges of primary care delivery in continuous professional development. rural and remote areas. New multi-practice models for GP provision are being tested The ability to attract young professionals in West Lochaber, Isle of Islay, Mid Argyll of all disciplines to more remote and rural and in Campbeltown for 24/7 care by the environments is a more general issue – community hospital, local GPs and the Scottish suggesting that to be successful, recruitment Ambulance Service working together. campaigns should be multi-faceted and relate to more general community development as Remote rural practices face particular well as considering opportunities for multi- difficulties with mobile phone coverage and professional working across communities. broadband connectivity – important given that there are more branch surgeries in To tackle the barriers to recruitment and rural areas. However, new technologies can retention of staff, including GPs, the ‘Being create real opportunities in both treatments Here’ programme has helped deliver an and access to services. Installing telehealth ambitious and creative recruitment exercise facilities in the ‘Small Isles’ Medical Practice aimed at attracting health professionals on Eigg – with links with other islands being to live and work in remote and rural developed too – is enabling patients to access areas. With a new micro-site and targeted improved virtual face-to-face consultations advertising campaign, a number of remotely with their GPs. Support to encourage successful appointments have been made.
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The benefits of adopting community resilience There have been some notable successes models are also being realised, with the within the NHS in Scotland as a result of appointment of local residents to posts of investment in IT systems, with direct positive rural health and care support worker and impacts on the working conditions for staff first responders. The importance of using and the quality of care for patients. For all community assets, and developing care example Scotland was amongst the first that anticipates and reduces the risk of countries in Europe to establish a national acute illness, is particularly acute in rural PACS (Picture Archiving System) which areas, where arguably there is the greatest means that digital x-ray and scan images need. In the Small Isles the benefits of can readily be viewed at a distance on any adopting community resilience models are computer that is connected to the network. being realised, with the appointment of local There has been significant effort in digitising residents to posts of rural health and care and back scanning records to ensure that support workers and first responders. these are available electronically. Clinical portal development has facilitated electronic I. OPPORTUNITIES FROM INCREASING information sharing across hospitals within INFORMATION TECHNOLOGY (E-HEALTH) NHS Boards providing staff with easy access to essential patient information and history, Modern clinical IT systems can help to make and is increasingly being made accessible to care more efficient, safer, more person- GPs and staff in the community. The electronic centred, and more cost-effective. They patient management system (PMS) optimises offer considerable potential to redesign and patient flow through hospitals by automating standardise healthcare processes to meet processes helping to make our hospitals more healthcare practitioner and patient needs. efficient and reduce unnecessary discharge When applied in the right settings IT systems delays. Transitions and referrals are managed can deliver efficiencies and free up much electronically. Electronic discharge information needed resources for frontline services. is sent automatically to GPs allowing them to plan transitions back home or to a community The last 10 years have seen an acceleration in setting with patients and their families using innovation in IT with increased connectivity the most up to date information. Electronic and mobile communication, and massively referrals help to reduce the time patients wait more powerful data capture, storage and to meet with a specialist. Application of the processing capacity. As a result, clinicians latest IT innovations mean that our newest are increasingly reliant on IT systems and hospitals are paper-light; pharmacy and technology in their daily work and ensuring laboratory services, which have previously that IT infrastructure is resilient, secure been bottlenecks in the system, are fully and meets their needs is essential. automated and the latest technologies
38 are being used in diagnosis and treatment systems to ensure patient safety; and work where appropriate. Within community and is in hand to do so. Electronic reconciliation GP services, the national procurement and of medication records is required between implementation of two IT systems for general hospitals, GP systems, and community practice across the whole country has led to a pharmacists to ensure that a common up to dramatic improvement not only in the support date electronic medication view is available. for GPs but also in the sharing of summary Improved electronic information sharing patient data from primary care with the is required between health and social care wider health service in particular providing providers and their third sector partners to essential medications and allergy information ensure that the patient receives the right to the emergency and unscheduled care level of care based on all the information services. Scotland has a country-wide available. Electronic systems will increasingly network to connect all points of care which need to support cross boundary working has recently been expanded to support more as we concentrate and integrate resources integrated health and social care working to deliver the best available care, and across public and third sector partners. The support mobile access to meet patient secure email system – nhs.net – has allowed and clinicians’ needs. All developments extremely effective email communication will require greater interoperability within the service. The introduction of real- between systems, common standards for time management information systems recording and sharing information and have made performance management and local data sharing agreements based on the financial management much more effective nationally agreed SASPI (Scottish Accord and have helped NHS Boards to manage on the Sharing of Personal Information). capacity and resource across the service. There are great opportunities for NHSScotland Yet the adoption of some clinical IT systems to put its valuable data resource to better across the NHS has been variable and has use. Given that NHS IT systems are so not kept pace with clinicians’ expectations. comprehensive, there is the possibility of We are not planning to develop a single analysis of vast amounts of data to identify comprehensive electronic patient record in and study health and treatment trends in the short to medium term, however more almost the entire population. Examples such work is required to digitise paper records as the Farr Institute are beginning to build and case notes, share summary information between services and partners, and manage workflow across boundaries. The current limited use of electronic hospital prescribing and administration systems needs to be extended to replace existing paper based
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capacity in health informatics research tapping their healthcare that match their preferences. into electronic health data and combining this The provision of online information from with other forms of research and routinely accredited sources is in place with the collected data. If done in a way that respects development of digital resources such as data privacy and confidentiality, it should be NHSinform. However, the current range of possible to use NHS-held data much better public online health information resources to guide decision making in complex clinical needs to be consolidated and personalised. and population health contexts. Growing Telecare use is already well proven and evidence suggests that health informatics data is key to supporting patients in their own can be particularly powerful when combined home but its use is variable and support with a patient’s own recorded information is being provided to roll out best practice and clinical record to target treatment and across Scotland. Telehealth is increasingly achieve the best health outcomes. Further, understood to be beneficial to patient self- presenting the combined data visually can management and assisted living when applied support clinical co-management practice and in the right circumstances and current work sharing the anonymised information amongst is focused on integrating solutions within a interested professional and patient peer home based model of care. More advanced groups can support continuous improvement digital services including eConsultation, and across services. The Scottish Government and home monitoring and video conferencing NHSScotland are in the process of developing telehealth solutions could support GPs a Health & Social Care Information Strategy and enhance capacity within community to ensure we take full advantage of existing hubs over time but will require greater and future opportunities in this respect. commitment to change management and process redesign. Growth in this area will Patient online access to their medical data is require a commitment to innovation and still only possible in Scotland in very limited support for our local SME market. Scotland circumstances, although patients have a legal is ideally placed to lead in this fertile ground, entitlement to view their records if they given its already strong connections between wish. Most people are currently unable to industry, academia and service providers, access their notes online, book appointments and its track record in telecare and telehealth electronically, view test results or order innovation. The Digital Health Institute repeat prescriptions. This functionality exists was established to encourage and support with the current GP IT systems but requires market growth and ensure that we make local support and some change management the best use of locally grown innovation. within GP Practices to deliver. Good quality information can help patients and carers to achieve higher levels of self-management, and make realistic and informed choices about
40 Plans are in place to significantly improve J. A NEED TO REDUCE WASTE, HARM the situation with patient access in Scotland AND VARIATION IN TREATMENT within the next few years through the creation of a patient portal. This will give There is evidence of unmet need from access to a summary electronic patient undersupply or underuse of some services. record, personalised health information and However at the same time there is digital services for every citizen in Scotland. evidence of oversupply of some services As well as making the health service more or interventions, including some that are accessible to those who are digitally literate, of limited value. The Academy of Medical this IT development will be an important tool Royal Colleges published a document7 in for health improvement, self-management November 2014 that suggested that ‘20% of and co-production of care plans by citizens. mainstream clinical practice brings no benefit It is therefore a crucial element of realising to the patient: Most waste in the NHS lies our overall vision for increasing person- within clinical practice and models of care.’ centred, integrated care in the community. Continued investment in IT improvement will There is some concern voiced by clinicians be required to support transformed, more regarding the increased use of investigation person-centred services, to enable better and treatment. Their concerns centre on informed decision making, to ensure that rapidly increasing levels of diagnostic tests, clinical records are made readily accessible polypharmacy (the use of multiple drugs– wherever people are treated and ensure that this may be of benefit, but, especially in infrastructure remains resilient and secure. the older person, multiple drugs may give rise to excessive side-effects and drug- There is a great opportunity to ensure IT drug interactions), interventions at lower systems are in place that will make the NHS thresholds, and clinical variation that is not safer, more efficient in delivery of services, reasonably explained by patient need. more easily accessible and provide the ability to collect and analyse data to guide service planning and treatment decisions. These needs have been identified and a series of plans are in place to address them in the context of the Scottish eHealth Strategy.
7 Academy of Medical Royal Colleges: Protecting Resources, promoting value: A Doctor’s guide to cutting waste in clinical care. November 2014
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There are examples of poor understanding SUMMARY OF CURRENT CHALLENGES of risk by patients and clinicians alike that Like many other health services, the results in more treatment being used than NHS in Scotland is facing a series of a person would choose if fully informed challenges which can be summarised as: and involved. This suggests that people • increasing need for support from an are not always full partners in decision ageing population with increasing making, and so unable to choose treatment levels of multi-morbidity strategies based on complete information and their own preferences. If we are to • multi-morbidity arising approximately a support people having an increased voice in decade earlier in areas of deprivation their treatment choices, and support them • a need to improve care and outcomes in self-management, we need to improve via an expanded, multidisciplinary and communications with patients, to increase integrated primary and community care health literacy (the understanding of health, sector, despite current workforce constraints healthcare interventions, and their likely impacts). Initial work has been developed • a need to increase co-production by the Scottish Government on improving with patients and carers, create heath literacy, which needs to continued. high-quality anticipatory care plans and to support people in health This must be addressed because of the improvement and self-management harm that may result, along with stemming • a need to embrace the changes required the waste of providing a service that is not for effective integration of health and desired. There is a need to develop targets social care, and ensure that it makes that focus on outcomes rather than process, a transformational change in the and use data on patient outcomes instead of management of patients despite the biochemical or physiological measurement. current demand and supply challenges The current clinical paradigm needs to adapt also faced by social services so that there is an increased focus on realistic • a need to reduce the avoidable and proportionate interventions (to maximise admission of patients to hospital benefit and to minimise patient harm) and an whenever alternatives could provide even stronger participation of well-informed better outcomes and experiences people in decisions about their care. • a need to dramatically reduce the problem of discharge delay and thereby the risk of avoidable harm and adverse impact on the maintenance, or re-establishment of independent living
42 • a need to make better use of information quality, life expectancy in Scotland has and make better informed decisions about not improved in line with other European both individual and collective care countries, and significant health inequalities remain between the most affluent and • a need to ensure that services become the most disadvantaged communities. sustainable in the face of considerable workforce and financial constraints by giving careful consideration to planning of more highly specialist provisio • a need to provide healthcare that is proportionate to people’s needs and where possible preferences, avoiding over- treatment and over-medicalisation, and at the same time prevent undertreatment and improving access to services in others • a need to provide services of greater individual value to patients • a need to move to sustainable expenditure so that we maintain high quality services and can also avail ourselves of medical advances as they arise, and • a need to integrate the use of technology into service redesign and to consider how IT could transform service delivery and help meet future challenges.
The NHS in Scotland is a highly valued public service that has significantly improved in recent years – as evidenced by falling death rates from heart disease, stroke and cancer. More people are being treated than ever before, and waiting times have dramatically decreased. The quality of healthcare in Scotland is high, and the work on patient safety, person-centred care and digital health has made us world leading in these areas. Despite the progress in improving
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3. PRIMARY AND COMMUNITY CARE
44 3. PRIMARY AND COMMUNITY CARE
The majority of healthcare is delivered within more person centred care that is holistic the primary care setting, with the provision of and less focussed on task delivery. The around 25 million face-to-face consultations long-term relationships allow for supported in GP practices each year. Across the world it self-management in a context that is most has been shown that effective primary care, appropriate to the person’s preferences with universal coverage, can significantly and needs, across the full range of health improve outcomes for patients, and deliver problems – primary care is the last home of the most cost-effective healthcare system. true generalists, and is able to address health The integration of health and social care from needs in a model that combines a bio-medical April 2016, and the development of a new approach within a psycho-social context. GP contract by 2017, offer an opportunity to modernise primary care. Primary care includes General practitioner recruitment is four professional groups of independent challenging at the present, and will be for the sub-contractors – medicine, pharmacy, next 5-10 years, with GPs known to be due dentistry and optometry and all need to to retire within that timescale. In addition work in close association with community to seeking to attract doctors into general care for the benefit of the whole population. practice, expansion of capacity in primary care is required. Other professionals have The current arrangement of universal shown that, with appropriate training, they registration of the population with a particular can more appropriately deliver many of general medical practice, and the maintenance the roles within traditional general practice, of the practice as the local point of access and provide service of equal or improved for most care will remain a key element quality. The rise in the number of practice of an effective primary care system. The nurses in the last ten years has shown that similar approach in terms of NHS dentistry they are able to take on a great deal of will also continue. This approach enables care and treatment, with particular benefit the provision of local healthcare, with a to people requiring ongoing management personalised and incremental approach of long-term conditions. Advanced nurse to investigation and referral, based on practitioners have also been recruited to assessment of need, and helps to stream practices (and other primary care settings, people into the most appropriate services. such as Out of Hours Services), and have shown that they are very able to deal It is essential to recognise the importance with a wide range of presentations in of long-term relationships between patients general practice, and are able to treat most and small teams within primary general presentations with clinical autonomy. More medical and dental practices. These long- recently, pharmacists have been shown to term relationships allow for the delivery of have a useful role in providing excellent
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pharmaceutical care, especially in patients immediate concerns relating to day to day on complex combinations of medications. life – benefits issues, housing problems, family stresses, unemployment etc. The aim must Substantial contributions are made to the be to support people to access the services primary healthcare of people by a wide range and organisations that can most appropriately of healthcare professionals – district nurses, help them to address these problems, so health visitors, midwives, community mental that proportionate self-management of health teams, counsellors, social workers, link illness can become a reality for all patients. workers and benefits advisors. This is not a comprehensive list of professionals that General dental practices will continue to be are found in practices, or associated with the main providers of NHS dental care, with practices, across the country – what it does the increasing development of new roles to demonstrate however is the emergence of meet population needs – increased input from teams, with a wide range of professionals, dental nurses, hygienists and dental therapists. each contributing their unique skills to These developments will mirror the broadened managing care and improving outcomes. range of clinicians in general medical practice. Primary care dentistry is provided, in the Within general practice there will be a main, by independent practices or the public significant shift in roles in the future. Firstly, dental service, and accounts for over 4 million there must be increasing emphasis on courses of treatment per annum and provides prevention, self-management and individual most of the dental care for the population. responsibility. The aim of primary care The capacity of the service has increased must be to support people to maintain the substantially over the last decade and now maximum level of health they can achieve, but there is an average of 90% of children and in a way that encourages independence and over 80% of adults registered with a dentist. self-management and reduces dependency There is a reduction in registration as the on the healthcare system. This will require patient ages and this highlights a significant the provision of information and training to issue in years to come with an increasingly people so that they can manage their own ageing, frail, dentate population. There health problems – often with motivational have never been so many older people interview techniques. The general practice of who have retained their own teeth and the the future will have stronger links with social demand on the service is expected to rise care support – via local government and the steadily. The skills required to treat this often third sector – directing people to services and vulnerable group vary from those required to community assets that can improve health, provide routine preventive care to complex increase resilience, and add purpose to lives. restorative or surgical procedures. There is For many, self-management is a difficult an opportunity for dental care professionals challenge if their lives are ruled by more (therapists, hygienists, dental nurses and
46 clinical dental technicians) to contribute to ‘Everyone is able to live longer healthier the oral health of this population and at the lives at home or in a homely setting. other end of the clinical spectrum enhanced We will have a healthcare system where skills will be required of the dentists. The we have integrated health and social service which was developed in the early care, a focus on prevention, anticipation days of the NHS had a history of supporting and supported self-management.’ restorative care (fillings etc.) and now there is a need to focus more on the preventive All members of the wider primary element in conjunction with the older and community care team must have person’s carers. Similarly younger adults are a focus on a philosophy that, as well expected to need a preventive approach to as providing conventional evidence- maintaining oral health and for both groups based healthcare, aims to8: the system will have to adapt. A revision of • Change the balance of power: Co-produce the system for the remuneration of general health and wellbeing in partnership with dental practitioners will take place, with a individuals, families, and communities. view to developing a contract that rewards a more preventive approach to treatment • Customise to the individual: Contextualize care to an individual’s needs, values, and While the basis of primary care will continue preferences, guided by an understanding to be universal registration with general of what matters to the person in medical practices, there is a need for very addition to “What’s the matter?” significant change in order to ensure that • Promote wellbeing: Focus on outcomes that there is effective integrated working across matter the most to people, appreciating health, social care, third sector organisations that their health and happiness may and communities to improve health, not require healthcare or medication. healthcare and wellbeing. The challenge for primary care will be to integrate the wider health and social workforce into small, relatively autonomous, multidisciplinary teams that are able to flexibly deliver a broad range of personalised services – ensuring that health and social care needs are addressed in a personalised way to support the ambitions laid out clearly in the 2020 vision:
8 Based on IHI’s Rules for Radical Redesign of Healthservices: Institute for Healthcare Improvement 2105.
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• Make it easy: Continually reduce waste • Collaborate and cooperate: Recognize and all non-value-added requirements that the health and social care system and activities for individuals, families, and is embedded in a network that extends clinicians. This requires an appreciation of beyond traditional boundaries. Eliminate the “treatment burden” that some people siloes and dismantle self-protective may experience for example in terms of institutional or professional boundaries complex medication regimes, and frequent that impede flow and responsiveness. and multidisciplinary review appointments, • Support Self-Management: Using the as well as a need to reduce bureaucracy benefits of longer-term relationships with for clinicians as much as possible. It also people, encourage patients to move from requires improved access for patients to being dependent recipients of healthcare, a much wider range of appropriate health to informed individuals, better able to and social care professionals, across the understand and manage their conditions. statutory and third sectors – possibly This will include a greater use of social by further developing doctor telephone support approaches and greater use of triage systems or even electronic access evidence-based psychological therapies. to information, advice and, where The drive to support self-management appropriate, online consultations. will understand the patient’s personal • Assume abundance: Use all the assets that needs, wishes, values and capacity for can help to optimize the social, economic, change – aiming to promote systematic and physical environment, especially standardised treatment, but avoiding those brought by individuals, families, and undue burdens or unrealistic expectations communities. This helps move away from for patients and their carers. a strictly medical model of health and • Anticipate: Work to develop more wellbeing, and recognises the importance of comprehensive anticipatory care plans optimising life circumstances. This is not the with higher risk patients, to understand sole responsibility of health services – their preferences and to plan for challenges and requires primary care services to work that might otherwise result in undesired in an imaginative way to use community and avoidable hospital admissions. supports to optimise wellbeing. This links to the point above, and enables • Use technology to the full: While there is and supports self-management. currently insufficient evidence to support the widespread use of telemonitoring people’s health, there is evidence that simple telecare can support patients to manage and remain at home, and appropriate use of technology can help overcome social isolation in house bound patients.
48 The Health Foundation, among many Some studies included in the review argue others, argues the case for that supporting self-management reduces self-management. This approach is the use and costs of health services. It supported by their review of 550 pieces has been suggested that self-management of high-quality research, which evidence support programmes may reduce visits to the effectiveness of self-management. health services by up to 80%.
The authors of this review state: Other findings suggest it is more likely ‘Hundreds of systematic reviews, that patterns of service use change, randomised controlled trials and large rather than reduce overall. For example, observational studies have examined the people may engage more frequently with impact of supporting self-management for a practice nurse, telephone coach or with people with long-term conditions. Whilst peers, but less with hospital services. The the findings of individual studies are aim is not to reduce contact overall, but mixed, the totality of evidence suggests rather to support a different pattern of that supporting self-management can contact which may lead to fewer crises have benefits for people’s attitudes and inpatient admissions. and behaviours, quality of life, clinical de Silva, D. Helping people help themselves: A review symptoms and use of healthcare resources.’ of the evidence considering whether it is worthwhile to support self-management; 2011
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The proposal that GPs become more for GPs. A re-defining of the role must develop involved in complex care and system- for GPs so that they can use their skills to wide quality improvement activities will the maximum. It is proposed that there will require a refocusing of GP activity. It is be a revised role for the GP from 2017, with expected that GPs will be less involved the GP as the senior clinical decision maker in the more routine tasks and provide an in the community, who will focus on: opportunity for other health professions • complex care in the community in the practice and the wider community team to work to the “top of their licence” • undifferentiated presentations (i.e. i.e. taking on roles that their professional first presentations of illness), and training has prepared them for. To achieve • whole system quality improvement this, the training needs of GPs, members and clinical leadership. of the wider practice healthcare team, and the other professionals working across The new GP contract will not include the primary care, will need to be considered, current Quality & Outcomes Framework (QoF) and where necessary developed and met. which the Cabinet Secretary has confirmed will be phased out from April 2016. This will There will be challenges in managing the move practice funding from a significant successful transition of care from provision Payment for Performance scheme which by an individual GP or a small team, to care relied on incentivising increased activity in that is delivered by a much broader team. The practices. It is anticipated that the negotiation aim will be to provide people with appropriate of the new GMS contract for Scotland will clinicians to support their needs, but to ensure see the development of recognition of, and that complexity is minimised, duplication payment for, “values based quality”. This avoided, and professional boundaries blurred. approach recognises that the contribution This will require considerable leadership of general practice to individuals and – which may not always come from the communities is more than the sum of bio- GP – but must aim to provide continuity medical management of illness, and relates and holistic care to all patients without also to issues such as access, continuity, providing an episodic, impersonalised task- relationship forming over many years, and a focused service. It has been shown that holistic approach to all issues impacting on experienced nurses, often with years of physical, mental and social health. A similar clinical experience in hospital settings, can be revision of the remuneration of general dental trained readily to take on substantial roles practitioners will take place, with a review within practices. There will likely be a need of the payment scheme and the possible to look at the capacity for nurse training. replacement with a contract that rewards a There is a current opportunity to reshape more conservative approach to treatment. roles with the negotiation of a new contract
50 Although co-location per se will not Use of technology and IT will underpin these necessarily lead to the required increase in changes. Electronic information sharing joint working, it is nonetheless recognised will facilitate collaborative working across that it can significantly support it. For integrated health and social care teams to best that reason it should be an objective to support people’s needs. People and their GPs increasingly arrange for co-location of primary will have access to electronic patient records and community care services, in a way and patient held information from medical that enables them to work as manageably devices and other consumer products to help sized, close-knit teams with excellent inter- them manage the individual’s health and professional communication, and “one-stop” social care needs and agree outcomes which access for people. This will probably only are then recorded in electronic anticipatory be achievable over time due to the obvious care plans. NHS approved web-based tailored constraints of premises development – but information and telehealth/telecare will help the benefit of co-location and team building in people and their carers to self-manage at taking joint responsibility for patient care must home. Clinical decision support and evidence- not be overlooked. Some practice premises based knowledge hubs are being developed are currently used in the evenings and at to support clinicians to have access to have weekends by community groups – this should the most up to date information when they be encouraged so that these valuable assets need it about clinical risks and best practice. can maximally contribute to communities. Visual tools are being considered to combine this with people’s own data and information The contribution of pharmacists can be to allow informed decisions to be taken. considerably enhanced, with their expertise Enhanced GP digital services will make it more ensuring that people with complex medication efficient for people to book appointments and regimes have their care optimised, and order repeat prescriptions and over time will the potential for side effects or harmful provide greater choice for people who might interactions reduced. It is likely that they prefer digital interaction and consultation would have particular benefit in care home with their primary care team, where that is settings where polypharmacy is a significant appropriate. Virtual electronic medication problem, as well as reconciling people’s records will ensure reconciliation of medicines medications on discharge from hospital. between a hospital and primary care setting and will be accessible to community pharmacists to ensure safe medicine use.
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The distribution of general practices across Primary Care Out of Hours Services Scotland is determined largely by historical patterns of care and populations, and there A review of GP out of hours services, led is evidence that the allocation of resources by Sir Lewis Ritchie, has recently been does not always match need, particularly completed and a report published. The report deprivation. In general there is evidence of describes a need to have a broadened multi- fewer doctors working in smaller practices in professional team, working from a number the most deprived areas of Scotland. A recent of emergency hubs. There are suggestions survey by the Deep End GPs (a group of GPs to increase the input of GPs to the service, who work in the 100 most deprived practices and development of a more integrated and in Scotland) has shown that deprived areas responsive service capable of supporting generally have fewer doctors, and that the alternative professionals. It will be essential doctors there are more likely to be older and to ensure that the service retains high in single-handed or smaller practices. There effectiveness and has skills to effectively was an ambition to address this inequitable assess risk, and avoid admission to hospital distribution in the 2004 GMS contract and as a “default” action where there is diagnostic there is potential through the new 2017 or prognostic uncertainty. An over-reliance GMS contract, and resource allocation by on admission to hospital has the potential Integration Joint Boards to further address to seriously strain hospital capacity in a this issue either by redistributing existing way that may not always bring benefit to resources, or ensuring that any additional the patient or carer. Reducing avoidable resources improve the match with need. admissions is an important system wide objective that can improve overall care for the population. A national implementation plan, including an outline of investment to support delivery, will follow in spring 2016.
52 Community services One of the assets of high functioning teams (such as GP practices or clusters) is the Community services will significantly ability to work to a degree of autonomy, change over the next few years as a result and develop a flexible range of solutions to of integration between health and social meet people’s needs. They are driven by care. This offers significant opportunities professional standards and often work best to support people better at home, using with small teams able to manage their own integrated and co-ordinated services. workload, and to have minimal bureaucracy. This has been the philosophy behind the The experience of Torbay is relevant here. Buurtzorg nursing teams in the Netherlands.
Torbay was an early example of integration of health and social care services (in 2004) and the progress made was written up in a report in 20119. Integration there led to significant system wide change, leading to the development of a wider range of intermediate care services, working closely with general practice to provide care to older people in need, supporting them to live independently in the community. Importantly the support included the development of care planning for the most vulnerable, and the provision of rapidly responsive services for crisis management of problems which was overseen by health and social care co- ordinators. The culture developed across the integrated organisation was based on a common understanding of the need to develop responsive services for a fictitious elderly “Mrs Smith”, and strong leadership. The results were a reduction in the use of hospital beds, low rates of admission for people over 65, minimal delayed discharges, reduced use of residential and nursing homes (balanced by an increase in home care services).
9
9 Integrating health and social care in Torbay: Improving care for Mrs Smith; The King’s Fund
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In 2006, community nurses started a new client, solving problems and rebuilding concept in the Netherlands: Buurtzorg, their self-confidence as part of recovery. which in English means “neighbourhood The organisation has shown that a single, care”. It is a not-for-profit provider of care unhurried visit by a highly-trained district through care homes and in community nurse is more effective than several settings. The experience of Buurtzorg visits by specialised care workers, each shows how understanding demand in performing their allotted tasks. human terms and supporting self-help are fundamental prudent improvement This way of working has increased principles. the unit cost of interventions but this is compensated for by a 50% Most traditional home care in the reduction in total demand. Nurses serve Netherlands has been based on an neighbourhoods of 10,000 people in approach similar to that in the UK. This self-managing teams of ten. Working with model views home care as a product that GPs, they see themselves as community can be delivered most efficiently when builders, developing neighbourhood-level divided up into separate component support for their clients from friends, processes. These processes can then families and volunteers and they even be delivered by different individual have a weekly slot on local radio they specialists, for example, those who can use to advertise events and services, administer pills and injections, those provide advice and put people in touch who dress wounds and others with more with one another. specialist skills who, for example can connect morphine drips. Preliminary findings show that Buurtzorg’s patients use 40% of the care they are The Dutch organisation found any savings entitled to. Half of people receiving care made in cost per hour from specialisation do so for less than three months and were lost when the cost of managing a patient satisfaction scores are now 30% complex and fragmented process was higher than the national average. With also factored in. A better system, one no managers, communication lines are that put people’s needs at the centre of short and employees report greater care, was needed. Buurtzorg decided work satisfaction. In 2011, Buurtzorg was to revitalise the district nurse role. The chosen as the Dutch employer of the year. care provided by its generalist district nurses is to build a relationship with the
54 The learning from this powerful example is information sharing to support secure that post-integration structures must not be rapid exchange of up to date information afraid to experiment with quite devolved between services, and mobile access to structures for professional teams, with a information to support community working. minimum of bureaucracy, but based upon clinically relevant shared objectives. Above all Reduction of Avoidable Admission their success relates to taking ownership of people’s problems and feeling empowered to It will be an essential objective for Integration address the problems using locally available Joint Boards to support people to manage resources with flexibility. Technology also at home, through a range of local initiatives. played a key role in supporting the devolved The ability of innovations to reduce avoidable structure by providing electronic access unscheduled admissions to acute care is to client information at the point of care. variable. The King’s Fund review of factors There is potential here for reductions in which reduce avoidable admissions to management spend, as well as better overall hospital concluded that there was evidence outcomes. There is already considerable to believe that the following reduce interest in the Buurtzog model and avoidable unscheduled care admissions. how it could be tested in Scotland. However, further evaluation is required.
From April 2016, the Integration Joint Approaches that reduce avoidable admissions: Boards will be responsible for planning • Continuity of care from being able local services including those that are at the to see the same family GP interface between primary and secondary care. There should be a continued emphasis • Integration of primary and secondary care on identifying those people most at risk of • Self-management in patients avoidable admission, providing adequate with COPD and asthma support for them. The aim should be for joint development of anticipatory care plans for • Tele-monitoring in heart-failure crisis points, provision of rapidly responsive • Assertive case management in mental health services that can provide an alternative to • Senior clinician review in A&E hospital admission, and support for rapid discharge, with continuation of rehabilitation • Multidisciplinary interventions in the community if required. All of this must • Comprehensive geriatric review. be supported by robust IT services to ensure that data can be captured and analysed in real time to support service planning, home monitoring technology to support people who are at risk, digitised case notes and electronic
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Approaches that reduce avoidable re-admissions: • Structured discharge planning • Personalised healthcare programmes.
There is also modest evidence that a proactive approach to anticipatory care and case management can reduce avoidable admissions. Primary care and community teams should combine to identify those at greatest risk of avoidable admission to hospital, and ensure that a proactive approach is adopted to reduce the risks of exacerbations of illness, and to prepare effective support should deterioration develop.
Anticipatory Care Planning (Anticipatory Care Planning and Integration: A study was undertaken in 2010 to evaluate a primary care pilot study aimed at reducing the impact of introducing Anticipatory Care unplanned hospitalisation: British Journal of Plans (ACP) for a cohort of people from a General Practice, February 2012) general practice in Nairn, Scotland, that were considered to be at high risk of experiencing A similar study of Anticipatory Care Plans a hospital admission (identified using the was undertaken in a care home in NHS Scottish Patients at Risk of Readmission and Lanarkshire in 2009. Evaluation of the Admission tool). A group of individuals with study found that when comparing the a similar SPARRA score were also identified six month periods prior to and following but ACPs not introduced to compare the implementation of the ACPs, there was a two sets of results. When comparing the 12 34% reduction in the number of inpatient months preceding the introduction of ACPs admissions and over 50% reduction in the to the 12 months following (for those that number of hospital bed days were still alive in the second 12 months), (NHS Lanarkshire, Long-term Conditions the group of individuals for which ACPs Team, Anticipatory Care Plans in Lanarkshire were introduced saw a 52% reduction in the Evaluation, April 2010). number of days spent in hospital. The study also found that for those who died during the second 12 month period, individuals with an ACP were more likely to be able to die at home.
56 Future development of electronic patient contribute to the burden of these diseases. information summaries (building on the For this reason Scotland has improved current Key Information Summary) should access to clinical health psychologists, be based on Anticipatory Care Plans to as recommended in SIGN guidelines on enable a coordinated, person-centred cardiovascular disease, diabetes and stroke. approach across the health service. Rates of dementia and cognitive impairment Mental health increase with age. Scotland has a good record in initiatives to identify and support patients Mental illness is one of the top public health and families to manage this illness. However challenges in Europe. It has a significant in the elderly, depression is considerably more impact on the overall health of the population, common, and is particularly associated with and on health inequalities. Overall, mental social isolation and loss of independence. illness is the most prevalent of the longer Depression may be harder to recognise in the term conditions as measured by burden of elderly and medication tends to cause more disease and disability. Estimates vary, but side effects, including falls and confusion. there is evidence that mental illness affects up to one third of the population every It is important to recognise the significant year10. Psychotic illnesses affect around changes that have occurred in mental health 1-2% of the adult population, with substance services over the last 15 years – changes abuse including alcohol excess impacting which have considerable relevance to on 5% of men and over 1% of women. the changing shape of services in other Mental illness has a significant correlation specialties. Specialist mental health services with deprivation, and around 40% of those have moved from being primarily a hospital adults in receipt of welfare benefits and based service to being a more community- disability payments suffer from mental ill based service, centred on multidisciplinary health. Patients with persisting mental health community mental health teams that work problems have increased rates of long- closely with practices and with local social term conditions, particularly cardiovascular work services. They have developed increased disease, cancer and diabetes, and have a life interaction with voluntary and third sectors to expectancy that is typically 10 years less support their patients, and have increasingly than the least deprived and healthiest in recognised the importance of non-medication our communities. Long-term conditions also approaches to treatment, with particular bring challenges to mental wellbeing, and as emphasis on “the talking therapies” and the a result, high rates of depression are found potential benefit of exercise. All general in association with long-term conditions, and practices across Scotland now have access to counselling services for their patients,
10 Mental Health Strategy for Scotland 2012-15 and waiting times for psychology services
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continue to fall, allowing more rapid access Mental health services have worked on to alternatives to medication, and support developing outcome measures which are that can impact on patients motivation and holistic and take account of patients’ social management of other long-term conditions. and physical wellbeing, as well as more readily measured clinical parameters. The description Mental health services have moved to of the transformation of mental health encompass a paradigm that has a strong focus services that has occurred in the last 15 years on reablement and recovery, with anticipation is important. In many ways, the development and prevention of crises a strong feature. of services mirrors some of the developments Supported self-management is the aim, with that are proposed in other areas, namely: increased input from voluntary and third • Supported self-management from sector organisations to support patients to multidisciplinary teams, accessed have a better experience of illness than would where possible in communities be achieved by a purely health-focussed approach, and to help reintegrate patients • Reduced reliance on hospital admission, into employment, where possible, and into helped by community mental health communities. Principles of risk assessment and social work teams working locally, and management, in a way that is least and supported by consultant specialists restrictive to the patient, and proportionate who have a more focussed role to their needs, are well developed. managing the most complex patients • An approach that is anticipatory, plans An enhanced approach to the management for crises, and uses voluntary and third of behavioural issues in childhood and sector input to develop the support and adolescence, and increased input from social integration that helps improve the multidisciplinary Child and Adolescent experience of illness, and improve outcomes Mental Health Services, results in a reduction in longer-term behavioural • Greater understanding and and personality issues, helping prevent measurement of outcomes that are life-long problems from developing. more holistic in their approach, to drive improvements that matter most to There is scope to further develop use of IT patients, associated with reduced use to deliver mental health. Health Boards and of medications where appropriate NHS 24 have developed computer based • Exploration of the role of IT in helping Cognitive Behavioural Therapy packages patients manage their own conditions for patients as well as telephone supported guidance. Patients are able to access a range of online and written support for mild to moderate mental health issues, and can be signposted to local community resources.
58 • Greater liaison between acute Increased investment in primary care will hospital services and mental health ensure the sustainability of secondary care services, with stronger appreciation services by allowing an increasingly elderly of the interplay between physical, population with multi-morbidity to be treated mental and social wellbeing. more appropriately in primary care. GPs will have a leadership role, and will focus their Summary skills on more complex cases making best use of their experience. Focused attention on the In summary, the integration of health and most complex cases, including those at highest socialcare for adults in April 2016, and risk of avoidable admission should enable the development of a new GP contract by patients to safely and appropriately be cared 2017 offer an opportunity to modernise for more at home, or in a homely setting. Pro- primary care. Primary care will continue active planning for crisis will clarify responses to be based on general practices with required in advance, based on people’s universal registration of the population. The expressed preferences. More input to care and traditional primary care team will expand nursing homes will support them to respond with greater roles being played by many to people’s acute healthcare needs without other professionals working in autonomous the need to default to hospital admission. GPs teams. Continuity, and the building of will have protected time for roles that require therapeutic relationships will continue to be leadership, teaching, training and redesign preserved in primary care. Expanded teams of services to support improved outcomes. will need to ensure that the services they Balancing medical and social care will be deliver are person, and not task, orientated. important: patients with multiple long- term conditions and resultant loss of Supported self-management and motivational independence may benefit from increased encouragement will continue to develop social care, rather than more than medical significantly, especially for those with long- intervention. The balance of care that term conditions. This will match an increased is required is often best ascertained by emphasis on recovery and reablement, comprehensive geriatric assessment carried supported both by community rehabilitation out by community facing geriatricians. teams, and the use of third sector and voluntary organisations. Increasingly services will be co-located, supporting better joint working and enabling people to access a wider range of services across health and social care settings. Health centres may become health and care centres, and premises may be used for wider community benefit outside normal working hours.
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Local development of intermediate care Rural practices will need particular support. services to support care at home will be This may be from expanded multidisciplinary developed. They must be properly evaluated roles, but will also require better phone so that evidence of what works most coverage, and internet connectivity, along effectively can be determined and shared. with decision support from remote clinicians The role of community hospitals in the with greater expertise. Recruitment to rural local delivery of intermediate care needs practices will in the future be improved if to be considered, ensuring that they can be more support is given to training doctors in supported to provide cost-effective and high rural settings, and encouraging schools to quality care. It may be more appropriate prepare children for entry to medical schools. to temporarily use care home and nursing Strategic development of mental health home resources for some patients. services will be set out in the new Mental Health Strategy to be published in 2016, but Expanding the range of online services and much of the transformational change in mental information for patients will encourage self- health services, moving from an institution management and co-production as well as based service, to a multidisciplinary, integrated more efficiently direct people to the right community-based service, with strong primary care professional, relieving pressure emphasis on supported self-management using on GPs. The way in which primary care will voluntary and third sector resources, provides be delivered for certain types of patients an example of successful, patient-focused, will be transformed through increasing use service evolution that outlines principles of online consultations, remote monitoring that could be considered more widely. and non-medicine prescribing. IT will be a crucial enabler for new models of coordinated, person-centred care delivered by community care teams and will increasingly support decision making and service delivery across primary and community care.
60 4. SECONDARY AND TERTIARY CARE
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4. SECONDARY AND TERTIARY CARE
Secondary and tertiary care services have shown that in order to achieve improvements seen a very marked change over the last 10 in the quality and sustainability of care, years. There have been increases in both changes in the provision of medical care are elective and un-scheduled admissions to required. If change had not been progressed secondary care, a significant increase in previously we would still have a health service the care provided as a day-case, steady that provided general practitioner emergency rises in out-patient referrals, increased surgery in small community hospitals – a accident and emergency attendances and service that no-one would advocate now. the development of an enhanced range of services, both secondary and tertiary. At This section outlines significant proposals the same time, considerable work has been for change, and describes the evidence done through the Scottish Patient Safety and that we must make rapid progress on these Healthcare Acquired Infection Programmes changes if we are to maintain high quality to ensure that our hospitals are amongst services for the population of Scotland. the world leaders in improving safety for patients and protecting them from harm. It is important to remember the challenges that are prompting change Scotland has had success in managing in acute hospital services: increased demand, improving quality and • the potential to significantly safety, reducing wasteful variation and improve outcomes producing good clinical outcomes. However in order to respond to, and effectively • new technology dictating the need to have manage, increasing demand for secondary centres of excellence for more complex and tertiary care and ensure sustainability interventions (eg. robotic assisted surgery) of provision, NHSScotland will need to • Increasing volumes of elective procedures make radical changes. There is evidence to such as cataracts and joint replacements suggest that a radical approach is required to plan services differently11 in order to • pressures in recruiting highly skilled staff be able to continue to improve the quality • increasing demand, and and outcomes from hospital services. • financial considerations, and the need to invest substantially more in a locally There are always pressures to cling to the delivered primary and community status quo believing, against the evidence, health service in response to the ageing that current service configuration offers population and the prevalence of long- the best possible service provision. term conditions. The evidence shows However, history has clearly that a strong primary/community service achieves improved outcomes and 11 Imison, C., Sonola, L, Honeyman, M., Ross, S. The reconfiguration of clinical services, what is the evidence? helps to address health inequalities The King’s Fund, November 2014
62 In this context there are two very significant by pre-operative management, modern change programmes that need to occur within anaesthetics ensuring effective post-op pain secondary care in order to maintain the control and early mobilisation. The impact quality of service that the people of Scotland has been that the average length of stay has expect. These programmes relate firstly to reduced from ten days to less than three days: changes in process within acute hospital care, patients mobilise more quickly, with less side- and secondly to the structure of acute care. effects and with better longer-term outcomes. This work is now being extended to a number Changes in process of other operations, and it is likely that effective management of such standardised We have to ensure that hospitals deliver the procedures will continue to provide benefits best possible value to patients. This is not for both patients and costs. In order to value in narrow financial terms, but is the improve efficiency and effectiveness, we benefit that is delivered in terms of outcomes, will need to have a concerted programme and how these are delivered efficiently for of change across all hospitals. patients: producing outcomes that matter to them, in a way that is as safe as is possible, A considerable amount of this is already and minimises the disruption to their lives. happening, supported by improvement teams from Healthcare Improvement Delivery of care through reliable, safe services Scotland, and Scottish Government. We must has been shown to promote both quality, continue to examine processes in hospitals, and cost-effectiveness. It can be a way of and work effectively to implement change driving out waste and variation in services, where evidence of benefit exists. There producing better services at lower cost. are already some excellent examples of hospitals taking forward initiatives including: There is a need for continued work on Outpatients: many reviews of outpatients can process within acute care, aiming to improve be dealt with by letter, email or telephone quality for patients, reduce bed usage instead of clinic appointments. Where there where possible by finding alternatives to is a need for patient-clinician interaction admission, and by aiding early discharge we should consider, especially for rural – to make sure care is more effective for patients, the use of tele-consultations patients and is delivered efficiently. using effective video-linking. Patient surveys show that changes of this kind This has been shown for example in the are acceptable to the majority, and may recent work on “ERAS” – enhanced recovery significantly reduce both the burden on the after surgery. By adopting a comprehensive patient and the work needed in hospital. approach to hip replacement for example, it has been possible to produce better outcomes
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Delayed Discharge: It is recognised that can improve safety, reduce wasted patient tackling delayed discharge is a priority and clinician time, reduce the costs of medical for NHSScotland. Although the situation is records departments, and, with appropriate improving, there were over 48,000 occupied safeguards in place, allow for treatment bed days used in September 2015 by patients across hospitals, professions and regions. who were clinically ready for discharge (a For patients, online access to electronic reduction of 4,482 on September 2014 ). data and services such as appointment Achieving significant reductions will take a booking would allow joint decision determined whole-systems approach and will making and improve their satisfaction. significantly improve the ability of hospitals to cope with winter surges of activity and Reducing bed usage, where clinically year round optimum patient flow and care. appropriate: Multiple studies have shown This is a priority for the NHS, local authorities that a proportion of patients remain as and Integration Joint Boards to ensure the inpatients on days when no treatment or best outcomes for people – remembering that investigation is being provided, representing 75% of the patients delayed in their discharge considerable waste. Processes that cause are over 75, and in older patients, prolonged delay, such as waits for scans or OT stays in hospital increase the potential for assessment must be investigated, and loss of mobility and independence. The demand and capacity balanced so that delay Scottish Government is providing a range is significantly reduced. This should of course of practical support, guidance and toolkits be preceded by assessment of need so that to help local partnerships reduce the level excessive variation in requests is reduced. of patients delayed in their hospitals.
Many areas are making great progress. NHS Greater Glasgow & Clyde, for example, are implementing a policy of discharge to assess, and have invested heavily in step-down intermediate care beds. This has seen a reduction in the number of over 75 patients delayed over three days, and associated bed days, of over 70% since November last year.
Developing IT further: There are huge advantages that can be obtained by having electronic clinical notes, electronic clinical decision support, and electronic prescribing and administration systems. Such systems
64 Key messages on reducing bed use in the Interventions that improve frail elderly frail elderly patient outcomes and might have an impact on bed use: Interventions which improve frail elderly • Interventions to prevent delirium patient outcomes and reduce bed use: • Medication review • Reorganisation within hospitals to provide care in special units (eg. geriatric • Treatment for malnutrition assessment units, acute care of elderly • Exercise interventions. units, orthogeriatric units) • Multidisciplinary early discharge planning Changes which introduce interventions need to consider local context and needs. • Clinical pathways for the most common Staff should be involved in planning and presentations implementing the changes. Data needs to • Comprehensive geriatric assessment be collected at baseline and measured going • Senior review early on in admission forward to see that changes introduced are having the desired effect. • Ambulatory care (Investigating, treating and following-up patients, but avoiding (Based on a Literature Review commissioned by Scottish their admission). Association of Medical Directors 2015)
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Acute and tertiary care services need to The same appears to also hold true for continue the extensive work that has been hospitals – indicating that the contribution to undertaken in improving processes in the best possible outcomes comes partially healthcare. We should standardise process from the wider team as well as the surgeon. where it is appropriate to standardise12, and redesign flexible processes where required. Over the past 10 years there has been some While there is a financial benefit from concentration of services on a small number improving process, it should be recognised of hospital sites, allowing specialised services that in all of the examples given above, there to produce the predicted higher quality is direct patient benefit, and indirect patient outcomes. This has allowed the evidence base benefit (in that more patients can potentially for improved clinical outcomes of specialist benefit from the fixed resource available). units to develop. For example in England, there is evidence that the centralisation Successful change in processes often requires of vascular services is resulting in better understanding and use of improvement clinical outcomes13. The UK wide mortality methodology. The work on training staff rates following abdominal aortic aneurysm and building improvement capacity must surgery fell from 7% in 2008 to 2.4% in continue. The other requirement for 201214. A report from the Vascular Society progressing effective change is identified published in November 2015 shows that this clinical leadership, and the NHS requires to has continued to fall, and is around 1.5%. This invest time in building clinical leadership is significantly, but not wholly, related to across all disciplines to drive forward concentrating vascular services on fewer sites. significant change in process to make care ultimately more patient centred, as well as The early evidence on the relationship making better use of existing resources. between increased volume and improved outcome tended to consider only post- Structural change in hospital services operative mortality. More recently however there has been accumulating evidence Evidence shows that specialised procedures, that outcomes that are less dramatic – but concentrated on a small number of high extremely important to patient wellbeing volume sites, will improve outcomes. This – are positively impacted upon by care conclusion is prompted by evidence that – provision in specialist units. For example a especially for complex procedures – there specialised urology unit in Germany had a is a relationship between the volume of five year prostate cancer survival rate which procedures carried out by a surgeon and was only slightly higher than less specialised the likelihood of improved outcomes. units treating lower volumes of patients.
13 Earnshaw et al: 2012 12 IHI: Rules for Radical Redesign of Healthcare 14 Royal College of Surgeons: 2013
66 However the specialised centre had a rate of that level. In Scotland we provided about permanent severe incontinence of 8% that 7,600 hip replacements and 7,170 knee was a quarter of the rate of the other units, replacements in 2013/1417. There were also and a rate of impotence that was around one 950 hip arthroplasty revisions, and 460 third of the other units. These are serious knee arthroplasty revisions. Hip and knee quality of life issues that will have an obvious arthroplasty revisions are recognised to be impact on patients. Another review showed more complex and challenging procedures, that centralisation of care resulted in an and there is a greater risk of adverse outcome improvement in five-year survival from 58.6% for the patient. The arthroplasty project to 68.6% for all gynaecological cancers that report results show that 40% of hip revision could be staged and graded. These changes operations were carried out by surgeons who have been most marked with endometrial and do less than ten such operations per year, ovarian cancers15. A further report considered and just under one third of the knee revision the impact of a reconfigured regional upper operations were carried out by surgeons who gastro-intestinal cancer service: “The curative do less than five procedures per year. Some to palliative treatment ratio increased by of the revisions will have been non-elective, 71%, operative morbidity fell 50%, lengths of but a significant proportion were not. Whilst hospital stay reduced on average by 3 days, the surgeons may have produced acceptable median survival improved by 20% and overall results in the patients, it seems to be the case 1 year survival improved by nearly 20%”16. that such arrangements increase the risk of adverse outcomes – a point acknowledged There are known examples of where we by the Arthroplasty Project Report. accept a structure that is unlikely to produce the best possible outcomes. For example, This section presents only a fraction of the evidence from the US suggests that a available evidence that better outcomes surgeon doing hip replacement operations are obtained by organising and delivering should do at least 35 operations per year. some procedures in larger, more specialised At that level of activity the occurrence of and better resourced centres. In order to complications falls to around the minimum ensure that a surgeon, or a surgical team, level – although a small further improvement deliver enough clinical procedures to obtain is seen with increased activity beyond the best outcomes, that surgeon or team must provide services to a large enough 15 Crawford R, Greenberg D, 2012. Improvements in survival population to ensure that they will retain of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of their skills and maintain sustainable services multidisciplinary management?. BJOG: An International through an adequate volume of activity. It Journal of Obstetrics & Gynaecology 119(2):160-5. 16 Chan DS, Reid TD, Whit C et al, 2013. Influence of a regional is important to understand that a specialty centralised upper gastrointestinal cancer service model on patient safety & quality of care 17 Scottish Arthroplasty Project: Biennial Report 2014: ISD published August 2014
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delivers a range of services – some of which Health Boards has allowed specialisation of can be safely delivered locally by skilled services, with improvements in outcomes for staff, while others need to be delivered in a patients. Planning across larger populations larger unit. The conclusion from this is that has made high quality specialist services we need to plan individual specialties on available to more patients, even though the basis of populations – ensuring that we some patients have to travel further. are planning for a large enough population to preserve high standards of specialist The management of acute heart attacks skills, as well as ensuring that there is an changed some years ago. Instead of treatment adequate range of local services which can being provided at all local hospitals, most be accessed. This would include out-patient patients are transferred as an emergency to services, diagnostics and day-case surgery. a small number of centres across Scotland where there are teams of specialist staff If we are to ensure that the population are who can urgently provide specialist services able to benefit from the better outcomes that designed to unblock the occluded artery are provided by larger volume centres, then that has caused the heart attack. This has we need to move from planning at a Health led to a higher quality clinical intervention Board level to planning at a population level. being reliably available to patients, and This is not new. Work on the Scottish Vascular has contributed to improved outcomes. Services Framework18 indicated that it was not appropriate to plan to deliver a vascular For some specialties therefore, it is only service for a population of less than 800,000. by planning services across a larger This population would provide a level of need population that it is possible to provide the that would allow a vascular surgery service range of services that might be required, to deliver enough interventions to maintain including an effective arrangement to skill levels amongst the clinicians involved. deliver urgent services over 24/7 time It also made effective use of resources – in periods, effective maintenance of skills by order to provide 24/7 availability of the the surgeons and other skilled clinicians, service, it needs to be of a sufficient size to cost-effective provision of the complex have rotas that will allow a realistic prospect technology that may be required (such of recruitment of highly skilled surgeons. as hybrid theatres) and a service that is able to deliver world-class outcomes. The changes suggested have also been seen in cancer services. The planning of cancer services on either a national basis, or through the three regional planning groups of
18 Quality Framework for Vascular Services in Scotland, Scottish Government,2011
68 It is not appropriate for all services to be greater adoption of telemedicine so virtual planned on the basis of large populations. The consultations can take place electronically. volume of unscheduled medical admissions This allows specialist input to be delivered means that we will continue to require to remote and rural locations, and has been inpatient beds in local hospitals as at present. shown across the world to provide a very Therefore, for example, there would not be satisfactory and clinically safe service. a need to plan care of the elderly services on a large-population basis. It is likely that The outcome from these changes would most hospitals would require a minimum be that increasingly certain services are of an accident and emergency service, an planned across large populations, regionally acute medical admission unit and supporting or nationally as appropriate, resulting in: inpatient wards, including care of the elderly, • optimal clinical outcomes from AHP services (such as physiotherapy/speech fewer, specialised hospitals and language therapists, dieticians etc), outpatients, laboratories and diagnostics, • effective use of highly skilled staff critical care and day-case theatres. • more standardised care, through agreed clinical pathways, and optimal This strategy proposes that for many use of high technology equipment specialties, services should be planned for a population, and delivered across a network of • services that are much less dependent hospitals. Within that network, one or more on a small number of individuals, and hospitals would provide inpatient care, and • excellent centres for teaching, access to specialised or complex treatment. research and development. Other hospitals in that network would not provide inpatient services, but in order Within Scotland, it is possible to see how to provide local access to services, would networks of specialty services could be provide out-patient clinics, diagnostics and arranged within a grouping of say five to day-case surgery. The network of hospitals six hospitals. Consider the possibilities for would be helped to work effectively by urology for example (currently supplied on established clinical pathways, by electronic 21 sites across Scotland). In a regional model, availability of clinical records, (including a concentration of all inpatient beds and radiology and other test results) and by major surgery in one hospital would meet promoting strong connections between all the requirements of a more specialised unit clinicians involved in the network. In some (with some patients being referred for more cases – and particularly to support smaller and complex procedures such as robotic radical more rural hospitals – clinicians would work prostatectomy to a small number of nationally across more than one hospital to assist service designated sites). If a network of sites were delivery. Over time this will be replaced by developed it would be possible to arrange
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that out-patient, diagnostic work, and minor units in London is hard to ignore, and procedures like day-case cystoscopy to be should prompt consideration of how many provided across all hospitals in the network. hospitals should deliver hyper-acute stroke This would require the appropriate IT and services, particularly across the central belt. communication systems to be in place to The Royal College of Radiologists has ensure information is available in a timely produced a report on the future of radiology and efficient manner across locations. This proposing that there should be regional achieves a more specialist service with planning of services. They are clear that image improved outcomes, local access to the bulk capture should take place in all hospitals, of other clinical services, and more efficient and all hospitals should employ radiologists, use of the skilled staff and other specialist but by using the varied clinical expertise resources in the service. All inpatient care across a network and making use of the PACS would be centred on one site. The reduction system which allows remote access to digital in the number of out of hours rotas would scan and x-ray images, it becomes possible considerably reduce workforce pressures. to deliver increased specialisation. This proposal would also help make the services In higher volume specialties, such as more resilient by ensuring that should there orthopaedics there would be a need for a be capacity problems in one hospital with larger number of beds to deal with the volume regard to interpretation of results, there of inpatient work. It would be appropriate would be protocols across the network to therefore to have orthopaedic services on provide remote assistance. It would also several of the sites within the cohort of enable much better peer-to-peer consultation, hospitals. This could be in the form of the a key component of clinical decision support. traditional orthopaedic departments, or A key component to developing this model there could be separation of elective and is further work on the radiology information unscheduled care. In any event, the formation systems to ensure excellent connectivity of a network could be used to address the across Health Board boundaries. need for a degree of specialisation, as well as mitigate the constraints provided by the limited workforce. Services like vascular surgery and interventional radiology have already, to a degree, been concentrated on fewer sites to make best use of limited skilled staff, and specialist equipment. The principle of fewer sites for some surgical specialties would apply to some medical specialties as well. The evidence of improvement in stroke outcomes from having fewer stroke
70 Rural general hospitals rounds with the local clinicians in order to provide expert input. The specialist visits the It is important in the context of this strategy islands regularly to maintain good relationships to recognise the significant contribution with clinicians he is working with, and to of rural general hospitals to the provision support teaching and protocol development. of healthcare in our more remote areas. This approach can be much more widely Despite small volumes of activity, they used if there is a firm commitment to have to be capable of providing primary regional planning of services from all emergency care for the complete spectrum concerned, ensuring that we significantly of emergencies, and appropriate onward reduce inequity of access to expert care. referral when required. It is essential that these hospitals are supported to maintain A review of available literature on emergency and elective services: this requires reconfiguring clinical services was undertaken Boards to collaborate to ensure that these as part of this strategy development. Whilst hospitals are supported – the success of the detail may require further expert this has been described earlier, describing advice, analysis suggested that, for the the networking of clinicians in the north of services considered, there are advantages Scotland to ensure that, as far as possible, as described in adopting a national, specialist services can safely and effectively regional or local approach to planning of be provided in the rural hospitals, often by services for relevant populations. It must visiting specialists. Further developments be emphasised that regional planning of will be enhanced by increasing use of IT. a service does not mean that there would only be a regional delivery of that service. In rural and island settings it is more difficult to maintain high quality clinical services across a wide range of specialties. In many cases there is not the activity to justify the employment of specialists. Specialists may not wish to work in more remote areas where their valuable acquired skills may decrease through lack of use. However there are examples of where a regional approach to the planning of services for more remote hospitals has improved services significantly. For example, stroke services in the Western Isles are shared between local clinicians and a stroke specialist in another health board. The stroke specialist does regular “virtual” ward
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Specialty Proposal Cancer (less common Low volume and specialist nature makes the case for planning for cancers and related less common cancers on a national basis, though actual delivery of oncology) services might be on more than one site. Neurosurgery Low volume, high complexity, need to support major trauma centres – all suggests a national, clinically integrated planning approach. Burns care Decreasing numbers of severe burns, and increasing success of specialised units suggests that national planning would be appropriate. Cancer (higher volume) Services planned across regions as now, with more specialist services available in cancer centres. Orthopaedics Planned regionally to provide for emergency trauma work and expanding volume of elective work for an ageing population. Radiology Planned across regions – regional planning approach may support change as described above, assuming technology issues addressed. Could help standardise use of radiology. Links to interventional radiology need to be considered. Paediatrics Planned regionally, ensuring good local access to day-case and diagnostics, community support, but regional planning of specialist inpatient services. Urology Regional planning with reduction of inpatient sites, but retained local access to out-patient, diagnostic and day-case surgery. Emergency pathways must be established (though low volume). Stroke Evidence from London shows regional planning of stroke services and reduction in number of sites resulted in improved survival. Needs further evaluation in Scottish context, and in view of emerging possibilities of thrombectomy for stroke. This will require a regional approach. Cardiology Already has strong regional component – requires to be planned across regional network of services.
72 Ophthalmology Mostly local Board level planning at present – this requires review. Some high volume services such as cataract surgery may be dealt with by elective centres, though there will be a need to plan remaining services across populations. Some care (eg. stable glaucoma), could be transferred to high street optometrists. Oral and maxillofacial Includes high volume of day-case work, and small volumes of highly surgery complex work – so suitable for a regional planning approach. Could have highly specialised out-reach staff delivering services across multiple hospitals. Neonatal Being reviewed currently by maternity and neonatal review. Maternity Being reviewed currently by maternity and neonatal review. General surgery Potential for joint local/regional approach to planning. Should review pathways for emergency out of hours surgery – may benefit from more specialist centres – but workload considerations. E.N.T Includes high volume of day-case work, and small volumes of highly complex work – so suitable for a regional planning approach. Gynaecology Includes high volume of day-case work, and small volumes of highly complex work (cancers, endometriosis) – so suitable for a regional planning approach. Intensive care Should relate to trauma centres19, and elective surgery requirements. Mental Health Services planned across regions, delivered locally: Some tertiary level services planned nationally (eg high secure, specialist in-patients, CAMHs)
19
19 A review of the potential to develop a network of Major Trauma Centres across Scotland is currently under way, and will provide recommendations, based on national planning, for the pathways and sites of such centres. The requirement to have co-located services (eg critical care, neurosurgery, cardio-thoracic surgery) will be a major determinant of the structure of some services
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This is not, of course, an exhaustive list of in a significant reduction in mortality from specialties concerned. Where specialties have heart attack. Emergency stroke pathways not been listed, it is because of a relative lack have been developed to ensure rapid of evidence on reconfiguration. This must not scanning, and administration of appropriate be confused with evidence of a lack of benefit medication to relieve symptoms caused by – it is likely that the same basic principles occlusion of carotid arteries. These examples apply, especially where there are low volumes indicate that, for a proportion of patients, and of cases, or complex interventions involved. particularly for those who are most unwell, transfer to the most local A&E department It seems appropriate to conclude that some may not be the best possible option. Instead, core services which do not involve highly we need to focus on the development specialised interventions, and have moderate of emergency care pathways that are to high levels of demand, should continue to responsive to different local and clinical be planned for at a local level. This would contexts to achieve best possible outcomes. include a number of specialties such as care of the elderly and palliative care. It is appropriate for A&E services to be available at hospitals locally – but it is vital It is vitally important to the public that that Scottish Ambulance Service staff have services required in an emergency are of the capability and are supported to respond high quality and structured so as to deliver promptly in making an early diagnosis the best possible outcomes. Responses to and streaming the patient to the most emergencies have been improved with better appropriate emergency pathway to ensure response times from the Scottish Ambulance rapid access to high quality definitive care. Service, and the continuing evolution of the highly trained paramedic role. The current work on the evolution of major trauma pathways for critically injured patients will improve outcomes, and projections suggest this will save an additional 40-50 lives per year. The emergency pathway that has been in place for some years in relation to the management of myocardial infarction (heart attacks) has shown that directing the patient with a myocardial infarction beyond the most local Accident and Emergency Department to a specialised centre with 24 hour a day capability to perform coronary artery interventions immediately has resulted
74 Separation of elective and unscheduled care: best practice in the clinical delivery of services Diagnostic and Elective Treatment centres with the latest technology and enhanced recovery techniques. The new centres will We know that speedy access is important to significantly reduce the chances of cancellation patients. Prompt treatment reduces anxiety, and the use of the private sector. We will leads to better outcomes and avoids further also wish to ensure that this investment in clinical deterioration. Scotland stands among elective care leverages in benefits for the the best in the world in delivering prompt wider community with greater operational and effective heath care. For example the efficiency and with the promotion of smooth conversion of the Golden Jubilee hospital to a flow through the entire healthcare system. high volume, specialist centre for a relatively narrow set of surgical conditions has helped Summary reduce the need for buying over flow capacity from the private sector. It also has driven The concluding principles from this section are: increasingly high quality care, with lower rates of complications for procedures than those Most care will be provided locally with the that are carried out in lower volume hospitals. expansion of primary care avoiding many Given that there will be an increasing having to access secondary care at all. need for a range of age-related surgical interventions as the population changes Most local hospitals will be able, as now, (e.g. hip replacement, knee replacements, to provide emergency services, including cataract surgery) there is a need for planning accident and emergency services, for increased diagnostic and treatment out-patient, diagnostic and day-case capacity. This has been recognised by Scottish services across a range of specialties. Government who have recently pledged a total of £200 million over the next five Using a network of hospital sites, some years to expand capacity across a number of specialties will provide inpatient services hospitals. The expansion capacity that will be in a smaller number of hospitals. This provided should be considered when regional will allow hospitals to develop a degree planning processes are developing options of specialisation in some specialties for the consolidation of some services into to ensure high quality outcomes. fewer centres of excellence. The geographical spread of the proposed developments offers The evidence suggests that secondary and significant potential across most of Scotland acute care services should be planned on and particularly in Health Boards where the a population basis – which could be either forecasted population changes will be largest. regionally or nationally. Further work needs to be undertaken to establish which These new facilities will be designed to adopt services might better be planned regionally
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or nationally for local delivery across a These changes will be complex and must be relevant hospital network. It should be accompanied by the improvements in process noted that planning a service regionally that have been described earlier. It may mean or nationally also supports and underpins that clinicians have to change their ways of local delivery of services in that specialty. working. It will require improvements in the electronic transfer of patient information. The proposal is not that large hospitals But experience elsewhere has shown it is would harbour all of the specialist inpatient possible, and it does result in improvements units. This would be a wasteful use of our to patient outcomes, and it will make current hospitals. But it will be possible for services more sustainable. It is imperative services to be planned regionally in a way that progress is made on these changes as that sees the advantages of specialisation, soon as possible if we are to maintain a high and identify hospitals which will become more quality service to all patients that will be specialist centres of care. This will improve sustainable in the challenging times ahead. patient outcomes, will ensure that there is an equitable standardisation of services, will make best possible use of skilled staff, and may result in reduced costs that will help sustain services. The reduction in the number of inpatient units will reduce the requirement for the employment of locum staff, preserving a significant resource for more effective delivery of value to patients. The changes proposed will support the delivery of 24/7 emergency care in more specialist services.
76 5. THE NEED FOR “REALISTIC” MEDICINE
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5. THE NEED FOR “REALISTIC” MEDICINE
There is a need to improve the basis of clinical year by up to 6%. This has been driven by decision making to ensure that there is a disease-specific guidelines – some of which clearer focus on the provision of healthcare are based on evidence from clinical trials, of greatest value to the individual in a way and some of which are based on expert that has the least potential to harm, and opinion. There is also concern that there is an is most in line with the patient’s wishes. excessive emphasis on a bio-medical model in developing guidelines – in other words There is evidence of a growing cultural concerns when treatment is aimed at, and shift among clinicians, many of whom feel measured by, physiological or biochemical uneasy at times regarding the level of tests, targets, which may or may not have direct interventions and medications that are relevance to outcomes that people value. provided for patients. While a considerable amount of modern medicine is based on The increased use of medicines has also been evidence from clinical trials and research, this driven by a shift to treating risk, as opposed evidence is often subject to amendment in to treating illness. It can be seen that this the light of further research, or the evidence has advantages for the manufacturers of may be relied on beyond the context of the medicines as a far greater proportion of the evidence. For example many medications population will potentially be at risk from an prescribed for elderly patients with multiple illness than actually suffering from it. The illnesses are often prescribed on the basis treatment of risk is strongly promoted by of trials in much younger patients with medicine manufacturers, by expert opinion single illnesses. The benefits may exist and evidence-based guidelines. The strength for older patients, but there are increased of the rationale for treating a particular risk risks to them from drug-drug interactions with a particular treatment can be assessed and increased likelihood of side-effects. by measuring the “NNT” – the “number needed to treat”. This measure indicates The potential over-use of medicines is a how many patients will need to be treated cause of concern. Figures recently released for one year to prevent a certain outcome. by Healthcare Improvement Scotland suggest In many cases this may be hundreds of that around 20% of the population is taking patients: unfortunately this means that five or more prescribed medicines on a hundreds of people may take a medicine regular basis. Many elderly patients may be and derive no benefit – and indeed may taking considerably more than that, and it is experience side-effects from the medication. not uncommon for patients being admitted to hospital to be on over ten different medications. The volume of medications prescribed has been increasing steadily every
78 There is sometimes poor information provided about the financial consequences of wide- on the benefits of medicines. For example a spread medication use – it is concern about medicine may be described as reducing the the adverse impacts of medication use. risk of a specified event by 25%. This is often Estimates vary widely, but studies suggest understood to be suggesting that one in four that between 5% and 16% of admissions to patients will avoid the specified event. But hospital are related to medication use. if the absolute risk of the specified event is only one in 25 without treatment, then the It is recognised that many of the long-term absolute reduction in risk is only from 5% conditions are related to life style factors to 4% – a 1% reduction in absolute risk. Poor such as obesity, lack of exercise, smoking, communication of risk and benefits may result excessive alcohol intake and poor diet. Recent in doctors and patients using medicines that evidence suggests that clinicians may be too they might otherwise have chosen not to use. ready to move to medication rather than helping individuals make serious progress in Many doctors confirm that they are prompted lifestyle change. Promoting lifestyle change to provide more treatment rather than less is difficult, and all too often unsuccessful, by a range of pressures including clinical but studies in type 2 diabetes have shown guidelines, fear of litigation, peer pressure and that significant changes in diet and exercise, patient expectation. The Quality and Outcomes leading to weight loss can return the Framework of the GP contract (being removed underlying biochemistry to near normal – in in April 2016) acted as a strong prompt effect delaying the onset of diabetes and for doctors to provide treatment based on its associated morbidity by some years. evidence and guidelines arguably without always the same degree of consideration to The Royal College of Surgeons have patient context. For example whilst there may recently urged surgeons to promote have frequently been evidence of possible increased exercise in patients prior to benefit, that evidence was often based on any elective surgery. Not only does this the evidence from single disease trials and reduce mortality associated with surgery, therefore not as readily applicable to patients it also reduces overall recovery time after with multi-morbidity (most patients with Long- surgery, and may, on occasions obviate the term Conditions have at least one condition). need for surgery – such as hip replacement or pelvic floor repair – completely. We must ensure that non-medical interventions are tried first (or concurrently) We need to develop a medical culture that much more frequently in a wide range of seeks to use the least invasive or the least conditions – there is significant evidence interventional approach as a first step. that shows benefit to overall wellbeing This may reduce the potential for harm to from this approach. This concern is not patients, and may also bring significant other
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benefits, including mental health benefits. These concerns, and others, have led to a It is difficult, and clinicians will describe number of initiatives. The British Medical their frustration at not seeing more patients Journal has for the last two years produced succeed in lifestyle changes. However there a series of articles on “Too Much Medicine” is a risk that if we discount less interventional a campaign aiming to “Highlight the threat approaches (such as physiotherapy, diet and to human health from over-diagnosis and the lifestyle modification) as being unlikely to be waste of resources on un-necessary care”. The of benefit, then we recommend them less Journal of the American Medical Association routinely to patients, and thus potentially has run, over a similar period, a series of deprive them of effective and safe solutions. articles under the heading of “Less is More”, arguing that in numerous situations, less More subtly, by advocating for a more intervention or prescribing can result in better interventional approach clinicians may be outcomes. Last year the Welsh Government removing from the individual responsibility launched the concept of “Prudent Healthcare” for managing their own health. By favouring aiming to make better use of resources and intervention, the impact of patient resilience get better outcomes by providing “Healthcare is undermined and, at a transactional level, that fits the needs and circumstances of the responsibility for improvement is handed over patient, and avoids wasteful or harmful care”. to the clinician from the patient. A longer-term The Prudent Healthcare movement in Wales is approach which encourages self-management driven not by a desire to save on resources, where possible, and the building of resilience but driven by a desire to engage in co- and capability within patients, may have production (mutually agreeing treatment plans less potential to cause harm, and may have and objectives) with patients, ensuring that wider benefits to their health and wellbeing. they are fully informed on the benefits and dis-benefits of any treatment or intervention, This is not to argue that doctors should and supporting them to make choices not provide interventions and treatment – according to their individual preferences. All of there are many instances where treatment the evidence shows that this results in greater produces dramatic, life-altering results – satisfaction with outcomes – and that as a but we require to ensure that the balance consequence of the approach, patients usually between active involvement of patients in prefer less treatment rather than more. their own recovery, and the provision of clinician directed care is carefully calibrated.
80 In November 2014 the Academy of Royal showed that the rates of prescribing testing Colleges published “Protecting Resources, and surgical interventions were significantly Promoting Value: a doctor’s guide to cutting affected by “Supply led demand”. The waste in clinical care”. It reminds doctors of paper made a number of observations: their obligation to use resources effectively, • Patients make different decisions and indicates that significant waste is when well informed. caused by poor quality or unwanted care resulting in high cost and poor outcomes. • People often lack full understanding of Subsequently, the Academy has launched this the prognosis of their illness (or the risk year its “Choosing wisely” campaign, following of developing a specified harmful event). similar initiatives in the United States. In the They may make different decisions if they briefing regarding the initiative, it is noted: are fully informed about their condition, and the treatment options available. Often “The Academy believes: they will choose less treatment rather than more. While this is seen most markedly • There is evidence of a considerable volume when discussing treatment options for of inappropriate clinical interventions cancers, or advanced stages of long-term • The reasons for this are complex conditions, it is also seen before elective and various but form part of a surgery or starting long-term medication. culture of over-medicalisation • It is of concern that generally doctors • The result is sub-optimal care for chose less treatment for themselves than patients which, at best, adds little or no they recommend for their patients. value and, at worst, may cause harm • There are significant variations in care • This is, therefore an issue for across geographic regions, which are not clinicians about the quality and explained by patient needs or preferences. appropriateness of care” • Evidence across all countries shows that there are significant variations in the use An output from the Choosing Wisely of diagnostic tests, the rate of operations, campaign is a list of tests or procedures, the rate of initiation of medications etc. The from each speciality, that should not be variation is considerably in excess of the carried out on the grounds of minimal natural variation that would be expected in benefit or potential for harm. patient’s choices, and in excess of variation in measureable patient need. Evidence In 2012, the King’s Fund published a paper suggests that the variation is invariably called “Patients’ Preferences Matter” in which clinician driven, suggesting that there is both they demonstrated a wealth of evidence wasteful over-use of some interventions that doctors misjudged what a patient but also some possible underuse of would most want if fully informed, and also potentially beneficial interventions.
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• Variation that is unwarranted is potentially Considerable work has been done to improve harmful (because the patient may not end of life care. Doctors may feel difficulty need it and will not benefit from it), and in communicating poor prognoses, and may wasteful. We must improve data collection feel emotionally pressurised into providing so that variation can be measured treatments that may not significantly prolong accurately, and embrace a new culture life. Often treatment at this stage is intensive, where individual clinicians can expect to carries significant side-effects, and may, at be asked to justify their clinical behaviour worse, result in a death that is preceded in the event of significant variation. This by a prolonged period of discomfort or approach has been helpful in addressing distress due to the treatment. While it may some of the variation seen between be appropriate for a patient to prefer such practices in referral and admission rates. treatment in the hope of extending life, it is It should be recognised that there will not always the case, and professionals have always be some variation, and change is to spend time in giving honest assessments slow, but can significantly improve overall of prognosis and potential benefit. Many quality (and may identify un-met need). patients will choose to forego the discomfort of treatment now for potential limited benefit Benefits of co-production (equal participation in the future. Time taken to communicate in deciding on treatment options between effectively and honestly, with outlines clinician and patient) can include meeting of prognosis including descriptions of patient preferences, improvement of patient uncertainty, can ensure that people are able specific outcomes, personalised treatment, to make informed and supported choices overall quality improvement, more effective that match their individual values. This must patient pathways, reduced pressure on care become the default position for engaged services and better value for money. The person-centred care. While many clinicians ability for clinicians and patients to make appreciate the need to have emotionally informed decisions together is however challenging conversations regarding patient greatly influenced by the availability aspirations and what matters to them, this of information, and so decision aids for is not universal. This may be a consequence patients should be further developed – of consultation slots that are too short, and an essential part of the current “Patient care must be taken to support clinicians Centred Care” approach seen above. who need to discuss very difficult options.
82 The NHS collects a huge array of information Over-treatment, wasteful treatment and this valuable resource can be put to and variation is a broad subject, and an use by creating the concept of a learning important one. It is important that it is care system in which decision making is addressed in Scotland so that we can be supported by outcomes of previous decisions more confident that the use of resources as well as research and analysis. We are is targeted to producing outcomes that already developing a national roadmap matter to patients. It is proposed that a for Clinical Decision Support and NHS significant resource should be put towards Information Strategy, the implementation a national collaborative movement, similar of which will be crucial for ensuring clinical to the Prudent Healthcare programme in care decisions are optimised. As part of the Wales, set up to understand the scope of move towards more extensive co-production the issues, and to influence both clinician and patient empowerment, there will be an and patient behaviour so that wasteful and increasing need to integrate professional care ineffective care is significantly reduced. information with data recorded by the patient. The long-term vision is for an electronic patient record which can be viewed and added to by both the health and care services and the patient, allowing a joined up approach to self-management and professional care. The content requirements could usefully include patient reported outcomes and selected self-monitoring data in addition to the professional data requirements.
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Summary The importance and potential of self- management needs to be better understood. We have had successful initiatives in It is more than simple disease management; Scotland that have developed improvement it is the motivation of patients to change in safety and person centred care. We lifestyles, preserve responsibility for, and need to invest more time in promoting control of, their illness, and move from clinical effectiveness – understanding that being a dependent recipient of medical this effectiveness must be measured in care to a more independent and selective relation to individuals and their contexts. consumer of healthcare, utilising, where possible, their own resources. This is The issues described above highlight the particularly true with long-term illnesses. need to have a national movement that Failure to address these important issues seeks to understand these complex issues, poses a potential risk of avoidable harm to to build clinical consensus, to provide tools individuals and wasteful use of resources. for leading change (such as information sources and risk communication resources) so that we can ensure that care is an appropriate personalised synthesis between clinical advice and patient choice.
Where a lesser intervention is possible, this should be selected first in most cases. It may be provided more appropriately outside traditional health delivery models – for example in Edinburgh the development of a COPD Choir allows patients to have an enjoyable activity that provides pulmonary rehabilitation and social integration – as well as community benefit.
84 6. CONCLUSION
85 A NATIONAL CLINICAL STRATEGY FOR SCOTLAND
6. CONCLUSION
This strategy sets out the need for These changes are complex, and require significant change in order to adapt consideration of workforce resources, to changing circumstances. potential outcomes, inter-relationships between specialties, and finance. It will require In primary care we need to build capacity careful yet thorough conversations with the and provide a more broadly based mix of public and their representatives. However, professionals based around practices – which failure to change will limit the potential to should increasingly be working collaboratively build on world-class standards of care. in clusters. We need to increase the shift of work from acute hospitals services to primary Lastly this strategy calls strongly for a new care, and we need to ensure that we benefit clinical paradigm. This would be one that: from integration of health and social care, • adopts least invasive or disruptive with particular emphasis on an anticipatory processes as a first step. This will often approach to those at risk of avoidable hospital more appropriately include lifestyle admission, the development of flexible interventions before drugs and operations. alternatives to hospital admission to reduce This helps patients remain in control of, those avoidable admissions, and the prompt and responsible for, their own illnesses discharge of patients from hospital care. • avoids unwarranted variation in standards In secondary and tertiary care the case for of care or activity redesign of services is clear and compelling. • avoids wasteful investigations and Clinical teams who provide complex and treatments that do not add value high-tech services more often get better for patients outcomes for their patients. This extra benefit is not marginal, and so we must • recognises that patients can only be true review services, specialty by specialty, partners in care if they are provided considering the potential for developing with comprehensive information fewer inpatient sites that will provide more about their illness, the prognosis, and highly specialised services, linked into local possible treatment options, and hospitals which will provide a comprehensive • understands patient preferences and range of outpatients, diagnostics and day adapts treatment to their preferences. case surgery. In addition, local hospitals will need to provide suitable primary emergency Adoption of a changed clinical paradigm treatment for all conditions, with some will reduce the harm and cost that can patients referred, as now, via clinically agreed be associated with modern medical care, pathways, to larger centres for specialist care. and by ensuring that treatment is tailored to patient preferences, will deliver care that is of greater value to patients.
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www.gov.scot Chief Medical Officer’s Annual Report 2014-15
REALISTIC MEDICINE Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
Letter to doctors from the Chief Medical Officer for Scotland
I realise that many of you will have insufficient time to read yet another document which lands in your inbox or on your desk. I ask you to dip in to this report and read the chapters that interest you, contact me to agree or disagree with the content, use the data and graphs as evidence to celebrate the successes we have achieved in the NHS in Scotland or as levers to drive improvement where this is possible. Data too has influence, especially when combined with the narrative of your everyday experience.
I want to engage in a conversation with clinicians on Dear Colleagues, the following questions:
I am pleased to present my first annual report, n How can we further reduce the burden and harm which arrives nine months after starting my post as that patients experience from over-investigation Scotland’s Chief Medical Officer; perhaps fitting for an and overtreatment? obstetrician and gynaecologist, who continues to work n How can we reduce unwarranted variation in clinical in clinical practice. My report is written in two parts as practice to achieve optimal outcomes for patients? I seek to engage with the medical profession across n How can we ensure value for public money and Scotland. In the first part I explore and ask for answers prevent waste? to important aspects of how medicine is practiced in n How can people (as patients) and professionals this changing world and part 2 describes the health of combine their expertise to share clinical decisions our nation. that focus on outcomes that matter to individuals? n How can we work to improve further the patient- We are working in times of challenge in our NHS and doctor relationship? I recognise how this impacts on your professional and n How can we better identify and manage clinical risk? personal lives. In this report I want to lay out some of n How can all doctors release their creativity and these issues and begin a discussion on some of the become innovators improving outcomes for people fundamental principles of how we practise medicine they provide care for? today; how we, as doctors, can be hugely influential in improving care, reducing these pressures and ultimately being true to the values and ambitions we held when we were competing for those highly desired and limited places at medical school. The role of medical trainees and junior doctors is vital to sustaining the Dr Catherine Calderwood, MA Cantab FRCOG FRCP Edin NHS in Scotland and building a profession to meet the Chief Medical Officer for Scotland challenges of the future. Medicine remains a highly respected profession, and though many regard their chosen vocation as an extremely fulfilling career, some I’d really welcome your opinion. If you have doctors are disillusioned, unhappy and feel undervalued feedback I can be reached at: in their work. Email: [email protected] Phone: 0131 244 2379 I believe that the profession, with doctors as collaborative leaders, as in so much of our history, You can also interact with me on can influence and be a driver for change. The clinical twitter.com/CathCalderwood1 voice of the highly trained experts in all specialties and via my blog blogs.scotland.gov.uk/cmo/ and across all aspects of medical care is extremely and via at www.linkedin.com/in/catherine- important in our National Health Service in Scotland. calderwood-691979108 or complete my survey www.surveymonkey.co.uk/r/LMDCMWM
1 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
Page Part 1: Realistic Medicine Introduction 3 Acknowledgements 4 Executive Summary 5 1. The Added Value of Doctors in a Complex System 8 2. Realism in Healthcare 11 3. Sharing Decision-making and Informing Consent: People and Professionals Combining their Expertise 16 4. Doctors and the Management of Clinical Risk 22 5. Changing our Practice to Support Improvement 26 6. Translation of Medical Research into Routine Clinical Practice 30 Conclusion 35
Part 2: The Health of the Nation – Executive Summary
Health Improvement:
Premature mortality 37 Multimorbidity 37 Obesity 38 Poor diet 39 Physical activity 39 Alcohol 40 Smoking 40 Cancer 41 Mental health 41 Suicide 42
Communicable Diseases:
Vaccination 42 Healthcare associated infections 43 Antimicrobial resistance 43 Blood-borne viruses 43 Travel and surveillance of imported infections 44
References 45
2 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
Introduction
It is a huge privilege as Chief Medical Officer to: The Audit Scotland report NHS in Scotland 2015 (http://www.audit-scotland.gov.uk/report/nhs-in- n provide a clinical voice – shaping the direction of scotland-2015) published in October presents us Scotland’s future health policies and its approach to with a clear challenge to change the way services are healthcare and public health; delivered in order to continue to provide high-quality care. n lead medical and public health professionals in driving forward improvements to ensure a health To put that challenge in context, the NHS is the largest service fit to meet the challenges of the future; employer in Europe. In Scotland the NHS serves n inspire young people to enter the medical 5.2 million people. In terms of the medical profession, and public health sphere; it employs 4,918 GPs across 987 GP practices; 4,902 consultants and 5,656 medical trainees. There are also n provide trusted clinical advice on professional 43,237 nurses and midwives and a total NHSScotland standards and guidelines on behalf of the workforce of 165,000. Scottish Government; and n provide independent advice to Scottish This report is divided into two sections. The first Ministers. section addresses the issue of “Realistic Medicine” and explores the challenges that face us as doctors today. The Scottish Government has laid out its vision for I hope this will encourage more conversations with and 2020 so that everyone is able to live longer healthier between doctors about the way we practice. lives at home, or in a homely setting. We strive to deliver safe, effective, person-centred care and all The second section is our report card which presents clinicians should be empowered to lead changes in the the surveillance data on the health of our nation. way we design and deliver care with the people who This report contains a summary of the data and use our services. you can find the full document at www.gov.scot/ cmoannualreport201415part2. We can interpret these trends to inform how we continuously improve our management of health and disease.
3 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
Acknowledgements
I would like to thank my colleagues for their input into this report.
Project Manager and Editor
Dr Christine Gregson, Scottish Clinical Leadership Fellow with the Chief Medical Officer and Healthcare Improvement Scotland. Specialist Trainee in Infectious Diseases and General Medicine.
Authors
Dr Tom Barlow, Senior Research Dr John Mitchell, Principal Medical Officer Manager, Chief Scientist Office, Scottish and Psychiatric Adviser to the Mental Government. Health and Protection of Rights Division of Scottish Government.
Dr Angus Cameron, Medical Director, NHS Dr Gregor Smith, Deputy Chief Medical Dumfries and Galloway. Seconded part- Officer for Scotland. time to work on the development of a National Clinical Strategy within Scottish Government. Dr Graham Kramer, National Clinical Lead Professor Craig White, Divisional Clinical for Self Management and Health Literacy, Lead Healthcare Quality and Strategy Scottish Government. GP at Annat Bank Directorate, Scottish Government. Practice, in Montrose, Tayside.
Dr Padmini (Mini) Mishra. Senior Medical Officer, Directorate for Chief Medical Officer, Scottish Government.
Chief Medical Officer’s Business Unit
Diane Dempster, Business and Policy Richard Lyall, Senior Business and Policy Support Officer. Support Officer.
Mark Johnstone, Head of Business Unit.
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Executive Summary
Through “Realistic Medicine” can we …? Sharing Decision-making and Informing Consent: People and Professionals Combining their n Build a personalised approach to care Expertise n Change our style to shared decision-making n Reduce unnecessary variation in practice and outcomes “The single biggest problem with communication is the n Reduce harm and waste illusion that it has taken place.” n Manage risk better George Bernard Shaw n Become improvers and innovators We need to change the outdated “doctor knows best” The Added Value of Doctors in a Complex System culture to one where both parties can combine their expertise and be more comfortable in sharing the Current models of healthcare services are stretched power and responsibility of decision-making. It requires and do not always suit patients, their carers or the system and organisational change to promote the aspirations of the workforce. High profile failures in required attitudes, roles and skills. care have emphasised the importance of good clinical leadership which is clearly linked to good patient care. Such system change is articulated in models such Strong clinical leadership is arguably the single most as the House of Care, which provides a useful effective means of preventing similar failings occurring representation of the components, all of which are in the future. required, to place collaborative, relational decision- making and planning at the heart of our system. Realism in Healthcare Organisational Doctors generally choose less treatment for Processes & themselves than they provide for their patients. Arrangements! !
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Scotland’s House of Care Evidence-based guidelines developed for people with single diseases should not necessarily be extrapolated Shared decision-making is not a one-way transmission to the management of patients with multiple of information about options and risks from the conditions, given the possibility that this may result in professional to their patient. It is a two-way relational over-treatment and over-complex medication regimes. process of helping people to reflect on, and express, their preferences based on their unique circumstances, We as clinicians have a duty to ensure that we are expectations, beliefs and values. Simple approaches able to acknowledge our powerlessness at times, can readily be implemented within consultations and ensure that a difficulty on our part in accepting to improve communication by avoiding jargon, and the inevitable does not adversely affect the patient’s checking understanding, using techniques such as experience of death. Teach Back.
5 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE REALISTIC MEDICINE We should be focusing completely and relentlessly on Doctors and the Management of Clinical Risk what matters most to the people who look to us for CAN WE: care, support and treatment. Managing risk in healthcare is a universal challenge for doctors and other professionals. Doctors tread a Translation of Medical Research into Routine difficult path, with the expectation that they will make BUILD A PERSONALISED Clinical Practice robust decisions balanced against criticisms of being overly paternalistic. APPROACH TO CARE? The translation of research findings into clinical practice has transformed healthcare. It is a cornerstone There is risk associated with every clinical decision, of modern evidence-based medicine and of an whether it is to do something, or do nothing. Beyond advanced healthcare system. However, the route to risk factors identified by statistical analysis there is no translation can be challenging: high costs, scarce funds, substitute for clinical experience. An early sign in burn shortages in key research infrastructure, capacity or out of doctors is their reduced ability to tolerate the capabilities, slow and incomplete recruitment to trials anxiety of making risky decisions. are amongst the potential barriers to the progress of translational research studies. Medical research and Good risk management is also dependent on development can follow ill-defined and circuitous paths CHANGE OUR STYLE TO communication of risk with other services. before being taken up into improved patient care. SHARED DECISION-MAKING? Changing our Practice to Support Improvement
Scotland’s medical staff, working with all our colleagues in health and social care, continue to be at the forefront of the wide range of improvements in the safety, effectiveness and quality of care and treatment within our National Health Service. Improvements in the quality of care are often REDUCE UNNECESSARY dependent upon having the right conditions in place – positive relationships with colleagues, a learning REDUCE HARM VARIATION IN PRACTICE culture and an understanding of tried and tested ways of implementing change in complex systems. AND WASTE? AND OUTCOMES? MANAGE RISK BETTER?
BECOME IMPROVERS AND INNOVATORS?
From Lucas, B & Nacer, H. (2015). The habits of an improver. Thinking about learning for improvement in healthcare. London: The Health Foundation. P.8.
6 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE REALISTIC MEDICINE CAN WE: BUILD A PERSONALISED APPROACH TO CARE?
CHANGE OUR STYLE TO SHARED DECISION-MAKING?
REDUCE UNNECESSARY REDUCE HARM VARIATION IN PRACTICE AND WASTE? AND OUTCOMES? MANAGE RISK BETTER?
BECOME IMPROVERS AND INNOVATORS?
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CHAPTER 1
The Added Value of Doctors in a Complex System
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Doctors work in a complex system which, in these demanding times, is under pressure to change. Scotland has an increasingly aging population and a growing number of people who live with multiple and complex conditions. The subsequent increase in demand for services in an age of austerity requires us to achieve more through better use of resources.
Audit Scotland has called for a fundamental change The training of doctors has been mainly in a traditional in the way NHSScotland delivers services to cope model of care with patients reliant on healthcare with these increasing demands and has challenged professionals for information, diagnosis and referral, us to increase the pace of change. Drivers for change and with interventions decided mainly by healthcare will be and should be the needs and expectations of professionals. people who use our services. Services must adapt to the way in which people with multiple, complex and The future model of care is one with an empowered frequently changing conditions require to access care patient in a shared decision-making partnership with and support. the clinician. There needs to be co-creation of care packages that include prevention and rapid access to Current models of healthcare services are stretched services when required. The growth of supported self- and do not always suit the patients, their carers or management is a key priority, as this allows patients the aspirations of the workforce. Delivering person to regain control of their own health. Healthcare now centred and integrated healthcare with other agencies, needs to extend far beyond the classical settings of statutory and non-statutory, is a challenge in the hospitals, GP practices, and hospices and reach more current configuration of our health and social care effectively into a person’s own home and community. services. However, the expectation in the minds of many of our population remains that care should be hospital based, In addition, our health services have tended to focus when the evidence tells us that this is not always the on urgent care rather than the early detection and optimal location. even prevention of illness. Erasmus observed in the 1500s that “prevention is better than cure”.
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Professor Sir Lewis Ritchie, in his independent review and to outcomes The lack of this leadership from of the Primary Care Out of Hours Service in Scotland, clinicians, managers and within governance systems has begun to lay the foundations for an approach that was arguably the single biggest contributor to poor will provide consistent urgent and emergency care that outcomes and experiences. is sustainable throughout Scotland. The demand for urgent care is increasing, and many of the approaches Doctors continue to have an integral role in leading recommended in his review are equally applicable when and facilitating the multi-disciplinary team. However, providing care during daytime, so that increasingly care we need better distributed leadership in teams will be given by well led multi-disciplinary and multi- where different individual team members may take sectorial teams in community settings. As we move on leadership roles, depending on the task being to reform the approach to delivering primary care and tackled and their individual expertise and experience. orientate towards a community-led health service, We need collaborative leadership, working across the these new models of care will be further developed traditional role and organisational boundaries, for the in test sites across the country, and in both rural and best interests of patients rather than the promotion or urban environments. furthering of single aims or areas, and to promote the development of other professions to ensure a holistic The morale of some doctors is low and there is approach. Well trained health and social care workers, reported erosion of professional status. Although nurses, allied healthcare professionals, physician’s we must adapt to the needs of a changing system assistants, pharmacists, community members and it is important for us as a profession to recognise patients themselves have clear roles in providing and build on our added value throughout healthcare. services. Doctors have seen some of the work The practice of medicine is not a pure science. It is a traditionally undertaken by the medical profession discipline with the concerns of people at its heart and very successfully delivered by other trained healthcare therefore requires integrity, ethics and knowledge. professionals. This up skilling of others requires us to further adapt and redefine our role, so that we Medicine is a vocation. Communication and compassion continue to provide our care where it will have greatest are at the core of doctors’ work. Developing these impact. professional skills is an essential part of the development of an individual clinician, which adds to the ethical value of his/her work. “There is no better person to improve the role of doctors than doctors themselves. This is why High profile failures in care have emphasised the I want to start a conversation among doctors importance of good clinical leadership which is about changing healthcare.” clearly linked to good patient care. Strong leadership would have made significant differences to care Dr Catherine Calderwood
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CHAPTER 2
Realism in Healthcare
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This chapter outlines the various concerns that have arisen with regard to modern medicine over the last five to 10 years and how clinicians might address these issues. At its heart, the concern has been that in striving to provide relief from disability, illness and death, modern medicine may have overreached itself and is now causing hidden harm – or at best providing some care that is of lesser value. But the problem has gone beyond that into what may not really be considered illness, to the medicalisation of common life experiences.
Jacob Bigelow, Professor of Surgery in Harvard until his necessarily be extrapolated to the management of death in 1890, was famous for a number of reasons. patients with multiple conditions, given the possibility He wrote and disseminated information about the that this may result in over-treatment and over- first uses of inhalational anaesthesia in the United complex medication regimes. This is a common problem States, encouraging its spread. Less famously, he also for patients as our population becomes increasingly wrote “the amount of death and disease suffered by elderly and accumulates ever more long-term chronic mankind would have been less if all disease were left conditions. This is not to suggest that guidelines for to itself”. For much of history, his view was largely single conditions should not be used, because currently accurate: for centuries doctors had treated seriously we have little evidence for what should replace them. ill people with purges, with bleeding, with leeches and There is, however, a need to balance this with the risks with poultices of doubtful sterility. Despite the direct inherent in the resulting complex treatment regimens experience suggesting that the treatments offered where less appropriate polypharmacy itself may cause no value, society had sought out treatment and advice harm and hospital admission. from doctors driven more by hope than experience and struggling to accept the inevitable limitations of our short lives. However, doctors need support in choosing, with their patients, not to apply evidence From around the beginning of the twentieth century, based guidelines: the strength of guidelines science gradually and incrementally discovered more of can make doctors feel unable to deviate from the biochemical and physiological aspects of disease them, driven by feelings of peer pressure, and treatment, gradually more and more treatments assumed patient demand, concern about were developed. In the United Kingdom a very litigation and an understandable, emotional significant advance was made by Dr Austin Belford- need to “do something” in the face of long- Hill, who pioneered the use of Randomised Controlled term conditions. Trials (RCTs) in his work on streptomycin in the treatment of tuberculosis. This was the first example of applying rigorous and repeatable experimentation Since 2004 the GP contract has introduced a Quality to establish the effectiveness of treatment. It was and Outcomes Framework, incentivised by performance followed by an increase in proliferation of RCTs which related pay, encouraging doctors to use evidence based helped establish the effectiveness of many treatments guidelines, mostly developed for people with single in use today, as well as dismissing a great number to diseases to treat patients who very often have multiple history. The dawning of the age of evidence based conditions. This has coincided with an aging population medicine followed with considerable energy devoted and older patients who have accumulated multiple, to standardising healthcare based on evidence long term conditions. The widespread use of guidelines derived from these trials. It is easy to understand has contributed to the massively increasing volume this progress and to assume that all treatment now of medication taken by the population each year. offered is likely to be effective and unlikely to cause Twenty per cent of the adult population in Scotland is much harm. Unfortunately, this is not universally the taking more than five medications every day. With the case. This chapter will lay out the reasons why we increasing complexity of multiple drug regimes come should continue to remain curious about the overall the inevitable loss of uptake, increased potential for effectiveness of modern medicine and why we should interactions and side effects, and a significant increase re-calibrate our approach to medicine in many settings. in the risk of unintended harm, such as falls, confusion It has been argued that evidence-based guidelines and hospital admission. developed for people with single diseases should not
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doesn’t provide value for them). This can be seen in the use of heroic, complex and uncomfortable treatments as a patient approaches the end of life. It also appears to be demonstrable in many more settings.
2. Patients tend to choose less treatment when they are provided with greater detail of the impact, potential benefits and harms of a proposed intervention.
3. Doctors generally choose less treatment for themselves than they provide for their patients.
4. Despite our beliefs that treatment is based on evidence, the complexity of presentations possible means that 30-45% of care is not based on available evidence – partially a reflection of gaps in available evidence, and partially a reflection of the There is evidence that doctors tend to underestimate impossibility for clinicians in keeping up with the the frequency and impact of side effects from increasing volumes of guidance. treatment and fail to understand the total “treatment burden” that may be forced upon patients. This may These conclusions are followed by discussion of involve complex medication regimes, multiple side variation in treatment and investigation rates: it is effects (for which other medications may be required) well known there is considerable variation between and specialist and generalist follow-up appointments. geographical areas that is not related to measurable It is argued that it will be in the better interests patient need – and the strong suggestion from of patients for intelligent, patient-centred use of the paper is that the supply of treatments is evidence-based guidelines, a reduction of over-literal determined by variation in doctors views far more interpretation of evidence, and support for doctors than any differences in disease prevalence, or patient who provide a skilled and generalist view using their preferences in different populations. This observation clinical judgement to advise patients and then make – mirrored in the “NHS Atlas of Healthcare” produced shared decisions on realistic goals and treatment by the NHS in England – suggests that a proportion options. of medical care may be prompted by “supplier induced demand”; healthcare that is provided in excess of While evidence-based guidelines will continue to patient/population potential to benefit, that is driven inform the management of people with complex, by a range of factors including legitimately held interrelated conditions, we must acknowledge that a medical views, pressures from the manufacturers of focus on biochemical and physiological outcomes alone medicines or equipment, perceived risk of litigation, and may frequently fail to support people to achieve their patient expectation in populations where treatment own realistic and holistic goals; asking “What matters levels are high. to you?” becomes one of the fundamental questions underpinning the discussion with patients. There has been an increasing trend to treat or intervene to address risk (rather than symptomatic In 2012, the King’s Fund produced a challenging paper illness). This can greatly improve outcomes – as seen entitled “Patient’s Preferences Matter”. This collated in careful management of diabetes in pregnancy – but a great number of studies that showed across a wide it can also result in large numbers of the population range of specialties and settings that: taking medicines, or undergoing screening, when they would never themselves have developed the condition 1. Doctors often fail to take into consideration patient in question. Increased use of medical approaches preferences in suggesting and providing treatment. to reduce risk may result in less implementation of Treatment that does not coincide with the patient’s strategies for lifestyle changes, or treatment being preferences may ultimately be wasteful (in that it provided to older patients who will not live long enough
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to derive the potential benefits, and, of course, will cause direct harm in a small number of cases – as well as producing the psychological adjustments that occur when a patient is labelled as having a disease. While the reduction in heart disease rates can be attributed to the use of primary prevention with statins, and better control of hypertension and diabetes, trends show that the fall in heart disease rates pre-dated widespread use of these treatments, and has continued at the same rate as before. One explanation may be that the majority of the decrease has come about from the improvement of lifestyles and environment.
In an era when we have constrained resources, this overuse of medical interventions is of serious concern: It is certain that it co-exists with undertreatment of patients who might benefit, and the intensity with which modern medicine can consume resources, Figure 1: From Early Palliative Care for Patients with may mean that society is less able to progress Metastatic Non-Small Cell Lung Cancer. New England improvements in poverty, education, housing and Journal of Medicine. environmental factors that may more simply (and with less side effects) produce significant benefits in both Atul Gawande spoke passionately of this issue in the life experience and the incidence of diseases. 2015 Reith Lectures, and in his book “Being Mortal”: He describes a study in patients with stage 4 lung Possibly of greater concern is the issue of “heroic” cancer: half were given conventional chemotherapy, medicine when we are faced with the likelihood of and comparable patients were assigned to a hospice death. A study in the United States asked relatives to at home programme, which focus strongly on symptom assess the quality of death that had been experienced control, and achieving patient-focused goals that by their relatives. Using matched data it was possible related to social interactions and enjoyment of life. to calculate the cost of treatment in the last six Survival in the group treated with hospice at home care months of that patient’s life. The results showed that was better than those given conventional treatment there was an inverse correlation between the quality – and it is certain that their experience of the last few experience of death and the resources used. What months of life was more rewarding, and, more under does this suggest? Overall there is a thread that the their control. Atul Gawande powerfully speaks of the intensity of treatment did not result in better importance of asking the simple – but emotionally outcomes, and reduced the quality of some lives of the difficult – questions of “What do you understand patients who were dying. about your illness at the moment?”, “What matters most to you thinking about the future?” and “What This should not prompt a trend towards therapeutic would good look like?”. He shows that an integrity and nihilism – but suggests that much greater honesty in initiating these conversations, and ensuring consideration needs to be given to recognising the that the patient has both the time and confidence progression of disease to a point where death is to make their own fully informed decisions, results in inevitable, and greater care taken to communicate a better experience of the remaining time, and less effectively to patients and their relatives in order to regret for patients and their relatives. It doesn’t mean help them make appropriate choices. While it is easy that no patients choose aggressive treatment – but to assume that patients and relatives will cling to it does allow patients to feel in control, and to allow treatments that may prolong life, and easier still to an honesty of communication that acknowledges the avoid the emotionally challenging acknowledgement approach of death, and the emergence of the priorities of the ultimate futility of treatment in the face that mean most to the patient. Many doctors are adept of advanced disease, we owe it to our patients to at pursuing this approach, but many are not: we as give honest assessments of prognosis, and clearer clinicians have a duty to ensure that we are able to descriptions of the likelihood of benefit from acknowledge our powerlessness at times, and ensure treatments that will often be invasive, unpleasant, that a difficulty on our part in accepting the inevitable toxic and occasionally cause death. does not reduce the patient’s experience of death.
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REALISTIC MEDICINE CAN WE:
This section has highlighted some of the important Healthier Scotland” national conversation started in BUILD A PERSONALISED emerging challenges to modern medicine. What August 2015 and will be continuing this year. This APPROACH TO CARE? action, if any, should we as clinicians take? Perhaps we engagement with the people of Scotland over the should follow the example of the “Prudent Healthcare” future of our health and social care services will be movement in Wales – an initiative to ensure that instrumental in shaping care. healthcare that focuses on true value to the patient is delivered. Waste in healthcare should be assessed This is a difficult subject. We have moved far from not in terms of what might be thrown away, but Bigelow’s assertion that overall clinicians would be in interventionsREALISTIC that don’t add value for patients. betterMEDICINE not to have intervened, but we must remain Ultimately, this is a topic for a widespread debate CANalert WE: to the possibility that we may be over-treating amongst clinicians and the population which we serve, patientsCHANGE to their detriment. OUR Experience STYLE shows thatTO but the outcomes might be: thisSHARED may be best achievedDECISION-MAKING? by honest, open and full discussionBUILD with A patients. PERSONALISED n More research to establish the additional benefits of medicines in the older patient, especially those APPROACH TO CARE? who are already on multiple medications. n Increased attempts to support individual and population lifestyle changes, avoiding a rush to intervene where a lesser intervention might suffice. n Understanding that treatment of risk must be carefully thought through. Aiming to treat with a probability of benefit should be more prevalent than REDUCE UNNECESSARY treating with a possibility of benefit. VARIATION IN PRACTICE n StandardisingCHANGE process OUR where appropriate STYLE to get TO the REDUCE HARM best results, but allowing variation where this is a resultSHARED of patients DECISION-MAKING?expressing their preferences. AND WASTE? AND OUTCOMES? n Clinicians should expect to be questioned if their practice varies from others, and be prepared to offer justification for the variation. MANAGE RISK BETTER? n Above all, we must continue to involve patients more and more in their treatment, understanding that they must be fully informed on their illness and prognosis, and the risks and benefits of their possible managements. REDUCE UNNECESSARY The National Clinical Strategy will be published BECOME IMPROVERS later this yearREDUCE and will provide a guide HARM to further VARIATION IN PRACTICE address theseAND complex issues. WASTE? The “Creating a AND OUTCOMES? AND INNOVATORS?
MANAGE RISK BETTER? 15
BECOME IMPROVERS AND INNOVATORS? Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
CHAPTER 3
Sharing Decision-making and Informing Consent: People and Professionals Combining their Expertise
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This chapter examines the future challenge in healthcare of helping people and professionals to be more involved in developing shared or partnership decisions. It explains the need to leave behind the outdated “doctor knows best” culture to one where both parties can combine their expertise and be more comfortable in sharing the power and responsibility of decision-making. It requires system and organisational change to promote the required attitudes, roles and skills. We highlight examples of policy and practice in Scotland that are supporting this change.
Time for Change? to the perpetuation of health inequalities. Empowering these patients may be our greatest challenge, as they On 1 October 1999 in Bellshill Hospital, Lanarkshire, have traditionally often not engaged with the care Nadine Montgomery gave birth to a baby boy who service until further on in their illness journey. They subsequently developed severe disabilities. This was can often be less confident and articulate when it does due to a traumatic vaginal delivery as a result of come to expressing their needs. shoulder dystocia. In March of this year, the Supreme Court, in a landmark ruling, awarded substantial This contrasts with patients who are prepared to damages to Mrs Montgomery and her son. The case engage early with care services in order to ensure was unique in that the medical decision-making and that their health needs are met. On occasion this management of her obstetrician was not inappropriate can generate what is effectively more demand than or negligent. The basis of the claim was that Mrs need and further contribute to health inequalities. Montgomery had not been fully informed and involved The “worried well” consuming resources while the in that decision-making. Had she been so, she argued, “unworried unwell” do not come forward. she would have stated a strong preference to have her baby delivered by caesarean section. The Montgomery case took place 16 years ago and we could argue that the system has moved on. With the volume and complexity of information we are However, there are numerous examples of referrals increasingly asked to consider, shared decision-making to the Scottish Public Services Ombudsman (SPSO) represents huge challenges for all of us. When we and medico-legal process when individuals have account for the time constraints that professionals had insufficient information, communication or and their patients have together, it is no surprise we understanding. have evolved a system and culture which favours “doctor knows best” or medical paternalism. Here Studies have also indicated a significant proportion the balance of decision-making power within the of people wish to be more involved in decisions about professional patient relationship is shifted more heavily their care than they are currently allowed to be. These onto the clinician to decide in the best interest of show that when people are more involved in decisions, the individual. Meanwhile people often happily cede they are more likely to adhere to treatment, less likely control and entrust themselves into the hands of their to suffer the consequences of over-investigation professionals. and over-treatment and be more satisfied with their outcomes and relationship with their professionals. However, the Montgomery ruling now sets a legal Doctors often recommend end of life treatments and precedent that this “parental” approach is insufficient interventions that they would reject for themselves. and there is an imperative for a system and values This implies a lot of decision-making is based on change that rebalances decision-making power, where unclarified assumptions and expectations. the expertise of professionals is valued equally to the expertise that people have about themselves. This shift can be challenging for both people and their Informed Consent professionals. The goal of shared decision-making is to reach an agreed decision or state of mutual consent. A literal This imbalance in the relationship can be seen most definition of consent, “feeling with”, is derived from the markedly in the parts of our society where need is Latin Con – with and Sensere –to feel. It is where each often greatest, particularly patients living with the party feels the others’ acceptance and agreement to highest degrees of socio-economic deprivation, leading
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participate. The Consent Form represents a legally relational process of helping people to reflect on, signed record of that agreement and is required for and express, their preferences based on their unique most interventions and procedures. circumstances, expectations, beliefs and values. This can be a challenging communication process and Obtaining consent before a procedure is commonly a individuals will equally need reassurance that their professional-centred process done by practitioners professional has understood them. Finally, and crucially, to patients. In the time limited setting of busy people need help to evaluate the medical options in clinical practice it can be a rushed responsibility the light of their preferences in order for both parties of the most junior staff member, just before the to agree on the best course of action. procedure, when the individual is not at their most empowered. Obtaining a signature of informed consent There is a caveat in that people vary to the extent they is insufficient as it is not an endorsement that an wish to be involved in making decisions. Certainly it can individual may have received enough information or only really take place when people have full decision- that it has been heard and understood. It provides making capacity which might not apply for people with no clarification that true shared decision-making has cognitive, learning or severe mental health difficulties. been achieved. Indeed evidence suggests that oral Similarly in emergency situations, where fear, pain and and printed communication is often of a complexity distress exist, professionals need to reach an agreement that exceeds people’s reading skills (functional literacy) as to the extent their individual patient is willing and and ability to make sense of it (health literacy). People able to collaborate in decision-making. Many may be often hide their lack of understanding and clinicians put off by low health literacy (poor understanding, frequently overestimate people’s abilities. As George confidence, knowledge and skills) which should be Bernard-Shaw famously stated: addressed by offering more time and support.
“The single biggest problem with communication Because of the limitations of traditional informed is the illusion that it has taken place.” consent procedures, some have advocated moving to a more person centred process of “request for treatment”. This requires the person to record, Furthermore, shared decision-making is not a one-way in their own words, why they want a particular transmission of information about options and risks treatment, what they expect it to achieve and what from the professional to their patient. It is a two-way their understanding is of the risks and limitations. It
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promotes the notion that decisions should be informed ensure people get the most out of their healthcare and considered before people request treatment. It appointments. highlights any lack of decision-making competency, unrealistic expectations or misunderstanding that There are rising expectations and perhaps, to a degree, needs to be addressed. The practitioner can then health consumerism. Faced with increased access be sufficiently reassured before they agree to that to almost every other aspect of life it might not be request. Recommendations to replace informed unreasonable for patients to expect the same ease of consent with request for treatment features in the access to healthcare professionals, both electronically recent Scottish Cosmetic Interventions Expert Group and face-to-face. This expectation may be in addition Report. to the existing access arrangements – NHS 24, A&E, NHS Inform, out of hours GP services.
Policy Landscape There are 4.1 million outpatient appointments in Scotland per year, of which 2.7 million are follow Things were perhaps different in 1999, cultural up appointments. Might it be appropriate in some attitudes have evolved, along with policies, guidelines specialties for outpatient appointments to be tailored and professional codes. Patients and carers are to more immediate access when the person has increasingly knowledgeable, confident and expect to symptoms/needs to be seen rather than “routine share decisions. The role of community and third sector follow up” arrangements? The Scottish Government organisations and charities, for example the ALLIANCE Delivering Outpatient Integration Together (DOIT) (which is the national third sector intermediary for a team is working to streamline outpatient visits and is range of health and social care organisations) have keen to have input from interested clinicians. been instrumental in championing policies, meaningful information, advice, advocacy and support for people Shared decision-making is core to the safety, to be in the driving seat of their care. Modern media effectiveness and person-centredness of care and and the internet have made medical knowledge therefore resonates with Scotland’s Healthcare Quality accessible and have provided opportunities for hosting ambition. The person centred portfolio in Scottish online communities for peer support. Government is driving and supporting policies and quality improvements that help reshape health and In 2012 Scottish Government published The Charter care through the lens of people using services. For of Patient Rights and Responsibilities a key thread of example, people with low health literacy face many which is around Communication and Participation: the barriers to shared decision-making. Low health literacy right to be informed and involved in decisions about is a key determinant of poor health outcomes and a healthcare and services. It chimes with 2008 GMC significant cause of health inequality. In response to Guidance on consent: www.gmc-uk.org/guidance/ this, Scottish Government produced “Making it Easy” ethical_guidance/consent_guidance_index.asp. which set out key actions to help NHSScotland rise to the challenge of responding to people’s health literacy “Fundamental to the doctor and patient needs. relationship is the requirement that a patient with capacity to decide should be informed about the treatment options open to him or Changing Practice her; the risks and benefits of each option; and Despite favourable policies, implementing shared be supported to make their choice about which decision-making in practice is problematic given treatment best meets their needs.” the constraints of delivering healthcare. This may be particularly difficult in hospital settings where Many professional bodies such as Royal Colleges have professionals and people may have little previous produced updated guidance on consent and shared knowledge of each other. In part it needs to be decision-making. addressed by pragmatic solutions that can dovetail into existing practice, but it also needs considerable Public information sources such as NHS Inform organisational and whole systems change to support are encouraging people to play an active role in what is a fundamental shift in the relationship decision-making by making them aware of their rights between people and professionals. At its core, it regarding consent and promoting “It’s OK to Ask” to involves making those short and precious interactions
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that professionals and people have together, as A pragmatic example of how practice can be re- productive as possible. This involves thinking outside configured to enhance shared decision-making is of the consultation to prepare both parties beforehand illustrated by the Navigator Project (see below). and augmenting the process afterwards.
Simple approaches can readily be implemented within The Navigator Project at the Western General consultations to improve communication by avoiding Hospital in Edinburgh set out to improve shared jargon, and checking understanding, using techniques decision-making about treatment options for men such as Teach Back. Teach Back involves a person diagnosed with early prostate cancer. They met paraphrasing, in their own language, what they have with a “navigator” who helped explore what was understood. It is a simple, yet powerful, method important for them in terms of quality of life, life to screen for misunderstanding. NHS Tayside, are expectancy, acceptability of side effects etc. They exploring how Teach Back can be routinely applied to then shared meaningful and tailored information. informed consent procedures. When they met with the specialist, both were able to have a more productive conversation about There is a great opportunity to build on existing the choices they faced. They were then given an tools and develop new innovations to support shared audio recording of that consultation so that they decision-making out with the consultation. Important could replay it at home, perhaps with their family. approaches include: Interestingly the study showed that those people who took part in Navigation opted for less invasive n Personalised information sharing so that a treatment and, at follow up, had less regret about person can have in advance, and reflect on, the the decisions they had made compared with those same information that their professional has about who received usual care. There are plans to develop them. The challenge is to provide this information an online tool to augment the navigation process. in formats that are meaningful. IT developments such as shared medical records and patient portals (e.g. My Diabetes, My Way and Renal Patient View) Catering for this new type of relationship that our can aid this process. It should also be helpful for empowered “Google generation” has with those people to provide personal information about that deliver health and care, is one of our biggest themselves that they wish to share with their challenges. We will need to create system and professional in advance. organisational change to embrace and promote it, mindful that those who are the least empowered will n Shared decision aids are widely available for need the greatest help to flourish. many conditions to help people explore their preferences with their professionals and find Such system change is articulated in models such as options that best match those preferences. the House of Care (see Figure 2), which provides a However, they can be difficult for some and people useful representation of the components, all of which may need help to use them. are required, to place collaborative, relational decision- n Information tailored to need: Written making and planning at the heart of our system . information has often proved disappointing, either Integrating these components into practice will take because there is too much or challenges those time but early progress is being made in Scotland with poorer reading skills. We need to look beyond with those adopting this approach with people living relying exclusively on patient information leaflets. with long term conditions. A key initial phase of this Digital technology now makes it feasible to is in developing the skills and values that healthcare provide information in more engaging, multimedia professionals require for shared decision-making. formats to enhance people’s confidence and skills in sharing decisions. n Written summary or audio recording: People can find it difficult to remember or interpret what has been discussed and it is helpful to leave with a record of their encounter. Professionals may find it challenging to have their consultations recorded but can take comfort that it can be highly valued by their patients.
20 Chief Medical Officer’s Annual Report 2014-15 REALISTICREALISTIC MEDICINE MEDICINE CAN WE:
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REALISTICo MEDICINE c CAN WE:SHARED DECISION-MAKING? INFORMAL AND‘M FOREM TAHL ASNO UMRECDEICSI NOEF’ S! UPPORT AND Informal and formal soCuArRceEs ! of support and care ! sSuussttaaiinneedd bbyy tthhee rreessppoonnssiivvee allllocattiion off rresourrces !! BUILD A PERSONALISED Figure 2: Scotland’s House of Care APPROACH TO CARE? Finally, different groups whether they are nurses, pharmacists, allied health professionals, doctors, or in social, community or voluntary care have different skills, approaches and resources that can help and REDUCE UNNECESSARY empower people to be fully involved in decisions. There VARIATION IN PRACTICE are great opportunities to integrate this skill mix and REDUCE HARM share learning to enhance shared decision-making. AND WASTE? AND OUTCOMES? CHANGE OUR STYLE TO ConclusionSHARED DECISION-MAKING? MANAGE RISK BETTER? The traditional “doctor knows best” approach to decision-making has proved inadequate and there is now a cultural and legal expectation on both professionals and people to collaborate in partnership decisions. This sets all of us a challenge as to how we design and develop health and care services so that it brings out the best of the expertise of people and their professionals. There is a great potential to BECOME IMPROVERS harness the support of friends and families, as well REDUCE UNNECESSARY as the resources in local and online communities to AND INNOVATORS? help inform REDUCE decisions. It will also require HARM us to make VARIATION IN PRACTICE healthcare simpler and more engaging so that it is responsive, ANDparticularly to thoseWASTE? with the greatest AND OUTCOMES? health literacy needs and those with the least support. Professionals will need to develop the personal capabilities,MANAGE within an organisational RISK system,BETTER? that helps them to communicate with and support people to make the decisions that are right for them. Decisions that help them live well, and indeed die well, on their own terms.
BECOME IMPROVERS
AND INNOVATORS? 21 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINE
CHAPTER 4
Doctors and the Management of Clinical Risk
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This section looks at doctors’ management of clinical risk, its challenges and ways we can improve.
What is Clinical Risk? acceptance that it is not possible to mitigate against all bad outcomes but instead to apportion blame. A clinical risk is the chance of an adverse outcome Mistakes and incompetence, of course, do occur and resulting from clinical investigation, treatment or these do need systems to mitigate them. At the point patient care. (National Patient Safety Agency: May of decision, a patient has to trust the doctor to be 2007 report www.npsa.nhs.uk) working to their benefit and have confidence in their ability, knowledge and experience. Weighing Up Risk in Decision-making Standards of behaviour and sanctions for breaching Managing risk in healthcare is a universal challenge these exist, whether they are through the professional for doctors and other professionals. This is because regulation of doctors by the General Medical Council or it is inherent in every clinical decision and because no other bodies such as the Colleges. (GMC: Good Medical risk assessment tool or process can ever be 100% Practice 2013 – Duties of a doctor) accurate. Expectations can be very high, believing that if a perfect outcome is not achieved then blame should Managing risk is an inherent part of a doctor’s role. be apportioned. Doctors tread a difficult path, with the The breadth of their training and knowledge allows expectation that they will make decisions balanced the management of complexity required to best plot against criticisms of being overly paternalistic. the course of a patient’s care and treatment through assessment, investigation and treatment. This can be In the stressful environment of illness and suffering rewarding when things go well for the patient but can it can be comforting to project an omnipotent and also be stressful when the doctor realises that they benevolent identity on a doctor who can then be are often making “judgement calls” where a decision is counted upon “to make it alright”. However, regardless based not just on following an algorithm with a clear of the skills, wisdom and abilities of any doctor there evidence base but also on “gut feeling” resulting from are situations where the outcome is bad. This could be the application of wisdom rather than knowledge. An side effects or failure of a procedure or treatment or early sign in burn out of doctors is their reduced ability advancement of disease. The effect of this is seldom to tolerate the anxiety of making risky decisions.
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society. Older people experience functional decline as The Importance of Positive Risk Taking early as 72 hours after admission and are more likely to Everyone understands that everyday life contains risk have an episode of delirium or infection. and we all make positive decisions to expose ourselves to it. Our recreational lives are full of this. We choose There is also a wider service and societal impact from to pursue certain sports with a degree of danger like using resources inappropriately, preventing their use skiing. We choose to travel on holiday to exotic and by others when they need it or driving an inappropriate potentially risky destinations where gastrointestinal increase in acute capacity at the expense of chronic upsets, insect bites or other more serious risks care and support. await. The reason we take these risks is because the potential benefits of the choice outweigh, in our There is risk associated with every clinical decision minds, the potential adverse consequences. Just as whether it is to do something, or do nothing. Apparent in healthcare decisions, our risk assessment is based therapeutic inaction may be frustrating or confusing on a combination of factual knowledge, experience for patients unless clear explanation is given. It and expectation. Avoidance raises anxiety rather than can be tempting as a doctor to manage a patient’s reduces it and it is psychologically healthy to stimulate expectations and anxieties by prescribing or ordering and empower ourselves by taking some risks. an investigation when a better course of action is to do nothing beyond simple support and waiting. There are situations in healthcare where risk taking can be positive too. The decision to not admit to hospital Public concern about the steady risk in antidepressant or to a care home may be perceived as a risk, especially use (www.nhs.uk/news/2013/07July/Pages/Prozac- when there is a different expectation or pressure from nation-claim-as-antidepressant-use-soars.aspx) is patients and their carers. However, if we are to support based on the theory that these medications are being more people to remain independent for longer at home unsuitably prescribed rather than there being a true or in the community we have to admit to hospital only increase in depression presentations and prevalence. those for whom there will be benefit and where there The reality is that antidepressants are an effective is no appropriate community alternative. treatment for depression and some other conditions. The increase is prescribing mirrors increased Similarly, the decision to discharge carries a degree awareness and treatment. However, people presenting of risk and again may be resisted by some patients acutely unhappy to doctors are not best helped by and their carers. However, the advantages of keeping antidepressants. Their prescription may make the a patient in an inpatient bed have to be weighed up patient feel that their suffering has been validated and against the risks to that patient. The risks associated may fulfil their expectations that the reason for their with being in hospital need to be recognised. Some unhappiness is disease based and therefore treatable. are obvious and measurable like hospital acquired However an inappropriate prescription can cause infections. Some are less obvious like increasing problematic side effects and imply a diagnosis that is dependency or dislocation from home, family and not accurate. The antidepressant “treatment” may then
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prevent the patient seeking more effective solutions as well as people. In Scotland, Healthcare Improvement to their mood state such as exercise or socialisation. Scotland is taking forward work to translate the This also does disservice to the effective use of understanding of these organisational factors into antidepressants which for some people are lifesaving. the “Reducing suicide risk – discussion framework” document for teams to use.
How Can Risk Best be Managed? Beyond risk factors identified by statistical analysis Effective clinical risk management requires first and there is no substitute for clinical experience. This is foremost an understanding by public, providers and best gained by direct exposure to decision-making, policy makers that good outcomes are not guaranteed initially supported and supervised. Good medical despite the best efforts of people and systems. trainingREALISTIC requires this. Some decision-making that MEDICINE This does not mean that all bad outcomes should doctors traditionally did, is now being done by other be accepted. Avoidable risks should be identified disciplines. It is important that doctors are not de- CAN WE: and when bad outcomes occur in relation to these skilled in this remodelling of service provision. It is investigations, learning and action should occur to also important that the other disciplines doing risk reduce the probability of such an outcome occurring assessment and making decisions on the basis of it are BUILD A PERSONALISED again. Healthcare providers use clinical governance appropriately supervised and supported. machinery to manage avoidable risk and Healthcare APPROACH TO CARE? Good risk management is also dependent on Improvement Scotland have an important national role communication of risk with other services. Lessons in improving service quality and patient safety. The learned from mental health significant incident/ Scottish Patient Safety Programmes have delivered adverse event reviews commonly find failings in the significant improvements in safety across a range communication of risk between organisations. Issues of specialities through a collaborative approach to of patient confidentiality are often cited as being the identifying and actioning opportunities for service obstruction to communication, however, this should improvement. not be the case. Guidance is given by the GMC. Risk assessment is a challenging skill. Across www.gmc-uk.org/15___Risk_Management_CHANGE OUR STYLE TO medicine, efforts have been made to apply a scientific Framework.pdf_56300660.pdfSHARED DECISION-MAKING?. approach to what is often an intuitive process, with Doctors should always remain open to seeking the varying degrees of success. The Prevention of Falls opinion of others in clinical risk assessment. Second Programme identified significant risk factors that help opinions can be invaluable, as can discussion with predict which falls require additional, more specialist peers. Other disciplines can bring an important interventions to avoid future poor outcomes like alternative view on a situation and decision-making fractures. The simple recognition that identifying and is often best shared through discussion. This is targeting people with poor bone health and cognitive particularly relevant in the delivery of integrated impairment could mitigate future fracture risk is a good services where social workers have an important example of using scientific evidence base to modify insight, especially in relation to vulnerable adult and REDUCE UNNECESSARY risk assessment. child protection REDUCE issues, not to mention HARM housing and VARIATION IN PRACTICE More contentious has been the management of risk employment. in psychiatry. Creation of psychiatric risk assessment AND WASTE? AND OUTCOMES? tools for general use has been criticised by clinicians. Significant incident/adverse event reviews have consistently shown that these risk assessments MANAGE RISK BETTER? only work when they are translated into dynamic risk management plans effectively communicated between people and agencies. As simple lists of tick boxes they are ineffective. Research by the National Confidential Inquiry into Homicides and Suicides in people with mental illness has identified organisational factors that significantly affect suicide risk. This is an important illustration that the factors affecting risk are often BECOME IMPROVERS beyond the direct patient – clinician relationship and that consequent outcomes are dependent on systems AND INNOVATORS?
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CHAPTER 5
Changing Our Practice to Support Improvement
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Scotland’s medical staff, working with colleagues in health and social care, continue to be at the forefront of the wide range of improvements in the safety, effectiveness and quality of care and treatment that are being made within our National Health Service. Hundreds of doctors across the country have fulfilled a range of vital roles in making the changes and testing ideas on how to ensure that everyone in Scotland receives the highest quality of care possible – leading teams, encouraging junior medical staff to test their improvement ideas and emphasising the importance of time for learning and reflection amidst the demands of clinical practice.
Improvements in the quality of care are often consideration of how team-working can support dependent upon having the right conditions in place improvements in the safety and quality of care. – positive relationships with colleagues, a learning culture and an understanding of tried and tested ways The importance of taking time to talk with other of implementing change in complex systems. members of the team about the quality, safety and flow of people through healthcare systems has been For several years, doctors have been the driving force reflected in the safety huddles that are now taking behind quality monitoring work such as the Scottish place – as well as through the advice given to directors Intensive Care Society Audit Group system – a system and senior managers by medical staff as part of the that is now being used to inform and design ways leadership walkrounds. that routine data like these can be used to design routine quality monitoring and improvement systems Doctors who are supported to engage with broader across the country. Data are very powerful and organisational perspectives and have opportunities important influencers. Surgeons and other clinicians to discuss issues and problems within their work have participated in the thousands of surgical safety are likely to find it easier to identify and implement “pauses” that take place across the country every quality improvements. A team culture focused on week – collectively contributing to reductions in valuing doctors and providing support is essential surgical mortality. and something that every member of the medical profession has a responsibility to nurture. Through the Scottish Patient Safety Programme doctors of all grades and a wide range of specialties The literature that shows a relationship between have changed the way they think about practice in organisational performance and the quality of clinical respect of sepsis – more people than ever before are leadership emphasises the importance of ensuring receiving timely antibiotics when sepsis is suspected, that the work of doctors is aligned to strategic undoubtedly contributing to the 20% reductions in priorities and organisational goals. This is just as mortality from sepsis that have been observed. These much the responsibility of doctors as their colleagues improvements have been made possible through the working in management. This will in turn influence and engagement and enthusiasm of clinicians who have shape organisational culture and build positive working been willing to review the harms occurring within their relationships with the wider team. teams and systems, consider learning from colleagues and then test ways of implementing this within their Doctors working on improvements need to be clear teams for every person that receives care from them in what the aim of the work is and be clear that they the future. It is this complete focus on design and the have the knowledge and skills to deliver this. reliable delivery of care processes that has been at the Medical staff meeting with patients and families heart of the significant improvements in quality and where they have concerns or have been dissatisfied safety across the country. with the quality of care is an essential component of a The emphasis on using data to support discussions learning culture – and must continue to be a prominent and learning in clinical teams, already an established element of our approach to feedback and complaints. approach within general medical practice, has been Clinicians can significantly influence the approach seen most strongly this past year through the work taken within teams – building on relationships with on measuring the safety culture of almost 950 patients, their families and carers and taking early general practices. Data that can be used for GPs and action when it is becoming clear that someone has their practice colleagues for reflection, learning and cause for concern or complaint.
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A recent article in the Harvard Business Review We must all demonstrate through our actions that by Giona and Staats, focused on the reasons that we are committed to ensuring that everyone has organisations don’t learn, has some useful insights the opportunity to grow through challenge and that can be applied to the way we approach quality opportunity for continuous learning. Clinical leaders and systems improvement. They suggest that deeply need to challenge their own thinking and ask ingrained human tendencies can interfere with themselves whether they have a growth mindset. This strategic aspirations to become a learning organisation. will mean an enhanced awareness of opportunity for self improvement, more engagement with complexity There is greater recognition that medical staff are and a greater persistence in the face of obstacles. not immune from the human factors that impinge upon performance, but there can still sometimes be a Time for reflection and personal commitment to tendency to forget that doctors have the same fears “pause before action” can be very difficult for clinicians. as everyone else and that sometimes behaviours However, reactive modes with no time for reflection need to be more supportive of learning, reflection are energy depleting and ultimately ineffective. and change. A growth mindset has been shown to be Although it can be counter-intuitive to think that important – emphasising a recognition of the potential taking more breaks increases productivity, there is that exists for continuous learning and improvement, compelling evidence that achieving a balance of more not taking the view that the capacity for change and frequent breaks and restoration leads to greater learning is fixed by some genetic predetermination. productivity. These are important areas that can
Figure 3: From Lucas, B & Nacer, H. (2015). The habits of an improver. Thinking about learning for improvement in healthcare. London: The Health Foundation. P.8.
28 Chief Medical Officer’s Annual Report 2014-15 REALISTIC MEDICINEREALISTIC MEDICINE contribute to feelings of personal control and mastery CAN WE:Conclusion in the workplace – both of which can protect against burnout. Scotland’s medical staff have been at the forefront of identifying,BUILD testing A PERSONALISED and implementing changes that Junior medical staff have reported that they often have seen world-leading changes in the safety of care have ideas on how improvements might be made, andAPPROACH treatment within NHSScotland. TO Quality CARE? monitoring though have little opportunity to implement them. systems have demonstrated the ways in which data This is changing as NHS Boards have enhanced their collected at the point of care can be used to identify understanding and capacity of how to support a more test of change, to make connections and prompt widespread emphasis on quality improvement capacity questions in support of improvement. Resilience in the and capability. It is increasingly being recognised that face of rising demand, critical thinking and challenge the development of a range of improvement science of the status quo have been valued across multi- skills, although necessary is unlikely to be sufficient to disciplinary teams. Medical staff lead and participate in create the sort of widespread learning culture we want hundreds of empathetic and facilitative conversations to seeCHANGE in Scotland. OUR STYLE TO with patients, families and colleagues. The habits of SHARED DECISION-MAKING? improvement are in action across hospitals, clinics and The Health Foundation recognise the importance of care settings every day. The medical profession in reflection, communication and collaboration as the Scotland is in a strong position to lead and contribute basis for the development of “habits” that will help to the challenges of delivering safe, effective and shape future activity. Their recent paper on this issue person-centred care in the future. There is still much states that “The science of improvement and the to do though – not everyone has developed the habits art, craft and practices of improving quality require of improvement; and some may have habits that don’t us all to change our habits.” It has been suggested positively contribute to the learning and improvement that these habits should be the primary outcomes of culture that is vital to an engaged workforce and all learning activities, and that conversations about continuous improvements in quality. learning for improvement capability can be helpfully REDUCE UNNECESSARY framed through the lens of five desirable improvement WhatVARIATION habits would you like IN to cultivatePRACTICE to develop, habits – learning,REDUCE influencing, resilience, HARM creativity and sustain and spread a learning and improvement systems thinking. Each of these have “sub-habits” culture across the country? defined andAND outlined. They WASTE? are habits that we could AND OUTCOMES? all benefit from reviewing – identifying the ones we have already acquired, considering how they might be bestMANAGE applied within our RISK work and decidingBETTER? how we might begin to develop new habits to support our collective work on quality and systems improvement. Communication is central to all improvement habits and sub-habits. (see Figure 3.) BECOME IMPROVERS AND INNOVATORS?
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CHAPTER 6
Translation of Medical Research into Routine Clinical Practice
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The translation of research findings into clinical practice has transformed healthcare. It is a cornerstone of modern evidence-based medicine and of an advanced healthcare system. However, the route to translation can be challenging; high costs, scarce funds, shortages in key research infrastructure, capacity or capabilities, slow and incomplete recruitment to trials are amongst the potential barriers to the progress of translational research studies. Medical research and development can follow ill-defined and circuitous paths before being taken up into improved patient care.
Over the last decade or so considerable attention Translational Lags and the Return on Investment has been given to understanding the process better, in Medical Research recognising it is often slow and the advantages of rapid translation of research are considerable. Economic analyses of UK medical research have found Hence, there is widespread interest in identifying returns from investment in different disease areas to opportunities to shorten translational pathways for be substantial in terms of health gain and economic . the earlier realisation of research benefits to patients, benefit. In the area of cardiovascular disease (CVD), for the health service and wider society. Reaping the example, it was estimated that UK public and charitable benefits of advancements in biomedical science investments in research may produce an annual rate of including the development of precision medicine, return of around 39% (about 9% in health gain from and the care needs of an increasingly multi-morbid new interventions and about 30% direct returns to the population are likely to drive changes to shorten UK economy) or expressed differently: for every £1 translational pathways. of investment in CVD research, benefits equivalent to earning 39p per year in perpetuity may be produced. However, these analyses revealed such estimates were Translational Lag Time very sensitive to the lag between the time of research investment and when the eventual health benefits from Estimates, based on analyses of the later impact of research are accrued. The CVD estimate above was medical research conducted during the 1970s to 1990s, based on a lag of 17 years but when this was extended suggest the average time for medical research to to 25 years the annual rate of return in terms of health become embedded into clinical practice may have been gain, for example, dropped to 5.6% and conversely when around two decades. The considerable duration of this the lag was shortened to 10 years it rose to 13.4%. lag is not due only to the time to devise, undertake and report research studies or the nature of research, which often produces outcomes needing further investigation Translational Pathways to be understood more fully. It can take time for a body of research evidence to accrue that is considered to be Understanding translational pathways to identifying sufficiently well‑developed to be applied into clinical potential opportunities to reduce avoidable time lags practice. Rarely, for example, are conclusions about has become a major pre-occupation of health research the safety and clinical and cost effectiveness of an funders, regulators, the life sciences industry and the intervention based on a single study. There can also be research community in general. other factors at play in the journey from invention to application.
Figure 4: A critical path for translation of medical research into clinical practice. Taken from Cooksey (2006) A review of UK health research funding.
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In the UK, the process of translation of medical and potential for toxicity. In the human research and research and associated lags were considered in review track, the safety and efficacy of the best detail in 2006 in the influential Cooksey review. candidate identified from the pre-clinical programme This investigated how the potential of UK health is assessed in a series of clinical trials which when the research to benefit patients, the NHS and the wider data are combined and synthesised provide robust healthcare economy could be optimised. The review evidence of safety and efficacy. In the non-research defined a critical path for the process of translating tracks, the synthesised evidence supports the market medical research into healthcare improvement with authorisation for use in patients by a medicine a number of discrete stages. Beginning with basic regulator and, together with economic evidence, a research, through pre-clinical development and then positive recommendation by guideline developers clinical testing into health technology assessment, for adoption in the health service for the indicated demonstration and finally implementation of research group of patients. The drug is then supplied and used findings into practice (see Figure 4). routinely in the health service.
Cooksey also identified two “translational gaps” – However, progress along these tracks is often points of failure along the critical path where moving incremental and iterative. For example, in case promising research further forward into application studies of the route to translation along these tracks can be impeded. The first gap related to a failure in of the antihypertensive drug, amlodipine, and the the development of ideas from basic or early stage antipsychotic drug, olanzapine, the translational research that could be applied into clinical practice. timelines from discovery research to routine UK use The second gap related to a failure to implement of these drugs was judged to be 23 and 20 years into clinical practice new healthcare approaches or duration, respectively. Inspection of the timelines, interventions developed from those ideas. These revealed potential avoidable lags of years between gaps were considered to be the result of cultural, different clinical trial phases, between the completion institutional and financial barriers that could be of clinical trials and syntheses of the findings, and addressed in part by: greater prioritisation of health between regulatory approval of the drugs and policy research funding (particularly to support medicines statements on their use in the NHS and then their and therapies for unmet health needs); greater actual use in routine clinical practice. Thus, these coordination between research funders with funding timelines in these cases might have been appreciably directed to supporting promising leads across the shortened. translational gaps (for example to support health technology assessment); and a culture in the NHS more supportive of clinical research.
Research funders responded to address these gaps. In Scotland for example, the Chief Scientist Office (CSO) focused its research grants towards the “Cooksey gaps” and created NHS Research Scotland – a partnership between CSO and the Health Boards – to agree and implement national clinical research policies and provide a supportive and efficient environment in Scotland for clinical research in the NHS. Nevertheless, translation remains challenging and continues to receive considerable attention. More recent analysis has represented it as a series of key milestones along a number of different research-based and non‑research‑based tracks (see Figure 5). In an idealised drug development scenario, this pathway begins in the discovery track with a biological target and series of compounds that can act on that target identified, that are taken through a programme of pre-clinical testing to establish the mechanism of action with the most promising candidate(s) tested in animal models to examine the effect on disease
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Figure 5: Research and non-research based tracks of development of a medical intervention with key milestones. The blue arrow represents the direction of the innovation process and the green arrow represents time. Based on Hanney et al.
• Discovery research track – basic and pre-clinical development of intervention • Human research and research review tracks – intervention testing and synthesis of evidence
o First in human/safety study (phase I)
o Dosage/design (phase II)
o Efficacy (phase III)
o Effectiveness/post launch research
o Research review and synthesis on effectiveness and safety • Non-research health service/policy development tracks – evaluation of evidence and decisions on application into clinical practice
o Regulatory approval/first non-research use in patients and monitoring § National policy announcement/guidelines/advice • Reimbursement/financial support • Clinical practice track – adoption of the intervention into standard health service practice
Improving Translation base can be established thereby enhancing evidence assessment and synthesis and reducing Refinements to current process around the discovery unnecessary replication of research. research, human research and research review tracks to 5. Better reporting of research study methods generate greater efficiencies in translation have been and findings in order that the findings can be suggested recently with five key areas where there is understood and used by others with confidence in scope for improvement identified: an accurate and meaningful way. 1. Better prioritisation of research by defining research questions of relevance and importance While much of the responsibility for improvement in to users of research and for which there is an these areas lies with the research community and established need based on systematic reviews of health research funders and regulators, the wider the existing evidence. clinical and patient communities can play important and active roles. Patients, carers and clinicians can 2. Improved design, conduct and analysis of research become actively involved in research prioritisation. studies so that they produce high quality, Through initiatives such as the James Lind Alliance reproducible research results with a low likelihood these groups can systematically identify and prioritise of bias. important uncertainties about treatments, that could 3. Research appraisal, regulation and management be answered by research. In this way, the research processes that support efficient and robust agenda cannot be pushed forward by the research approval process to ensure high quality relevant community and research funders but also pulled research is funded with minimal delays in approval through by users who may be the eventual potential and administration times. beneficiaries of research. Greater patient (and user) involvement in research design and conduct has been 4. Better provision of information about studies advocated and patient and public involvement in underway and on all studies that have been research funding decisions is now widespread. completed, including those that produced negative results, so the complete existing evidence
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Reducing avoidable lags in the later non-research studies. With generic study issues now being tracks is also currently under much scrutiny, notably considered once for the whole country, as opposed through the UK Government Accelerated Access to being revisited at every site as was previously the Review. This aims to speed up patient access to case, there has been a significant reduction in the time innovative drugs, devices and diagnostics by looking at taken to approve studies. The introduction of a single how processes may be accelerated in three key areas: cost and contract negotiation for the whole country assessment of safety and efficacy; health economic has further increased efficiency and made Scotland a assessment and re-imbursement; and uptake by the popular destination for commercial trials. NHS. The review is part-way through but an interim report published recently has set out a number of But addressing this part of the process in isolation will guiding principles for development including: greater not deliver the improvements required for an efficient patient involvement, early identification of emerging 21st century health service. For that reason CSO has products offering the most patient benefit, and been working with our Scottish universities with a supporting innovation along the translational pathway view to joining up early stage innovative research with and in the NHS. later stage clinical testing. Taking a holistic view of the product development pathway is essential if time wasting delays are to be avoided, and patients are to Responding to These Challenges have earlier access to novel treatments. The conventional translational model with average A good example is the development of a Scottish lags of two decades is unsustainable and the demand precision medicine ecosystem, pulling together the for new translational models favouring more rapid academic excellence of our universities with the clinical realisation of patient and health service benefits expertise of NRS, creating a joined up portal through and economic returns is growing. With advances in which a single contract – spanning early development genomics and informatics driving better understanding work through to clinical evaluation – can be made. of the molecular basis of diseases, the research opportunities to develop new therapeutics (or This model developed for research has the scope repurpose existing ones) and diagnostics to stratify for wider application. As reported above, the Interim patients to guide treatment (precision medicine) will Report of the Accelerated Access Review (AAR) increase. Combined with innovative clinical trial designs also outlines the need for a coherent and joined- that allow more flexible methods to accumulate safety up innovation infrastructure from research to and efficacy data, the challenge, as predicted by the procurement. The Innovation Cluster approach being Accelerated Access Review, will be systems that can adopted in Scotland aims to facilitate this move evaluate, select and adopt effective and cost effective towards a simpler and clearer pathway through the innovations more quickly. innovation landscape. Initiatives such as the Cluster’s work on Open Innovation and a Small Business Scotland has made great strides in addressing this Research initiative (SBRI) call in diabetes (co-funded by challenge. In terms of study start-up, NHS Research Scottish Government and Scottish Enterprise) are good Scotland (NRS) has significantly removed the examples of work in this area. bureaucracy associated with commencing multi‑centre
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Conclusion
I am glad to have had this opportunity to use my I hope that you will engage with me on the issues first report to address the challenges of “Realistic raised in this report and use the infographic as an aid Medicine.” I believe that the profession, with doctors as for discussion. collaborative leaders, as in so much of our history, can influence and be a driver for change. REALISTIC MEDICINE CAN WE: BUILD A PERSONALISED APPROACH TO CARE?
CHANGE OUR STYLE TO SHARED DECISION-MAKING?
REDUCE UNNECESSARY REDUCE HARM VARIATION IN PRACTICE AND WASTE? AND OUTCOMES? MANAGE RISK BETTER?
BECOME IMPROVERS AND INNOVATORS?
I’d really welcome your opinion. If you have feedback I can be reached at: Email: [email protected] Phone: 0131 244 2379
You can also interact with me on twitter.com/CathCalderwood1 and via my blog blogs.scotland.gov.uk/cmo/ and via at www.linkedin.com/in/catherine-calderwood-691979108 or complete my survey www.surveymonkey.co.uk/r/LMDCMWM
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The Health of the Nation – Executive Summary
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This is an Executive Summary containing highlights of the Health of the Nation report. The data and graphs are evidence of both the successes we have already achieved in Scotland and the areas where we need to drive further improvement. The full report can be found at www.gov.scot/cmoannualreport201415part2.
Health Improvement: Premature mortality has reduced substantially in recent years, down 38% since 1994.
Death rates (<75y) per 100,000 population by selected causes, Scotland 1994-2014
Multimorbidity. The Scottish Health Survey shows that 46% of adults (aged 16 and over) have at least one long-term condition. There are more people in Scotland with multimorbidity below 65 years than above.
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Obesity. The Scottish Health Survey (SHeS) 2014 found that almost two-thirds of adults (65%) in Scotland were overweight or obese (Body Mass Index (BMI) > or = 25), with 28% classified as obese (BMI > or = 30). In addition, around one in six (17%) of children were at risk of obesity, with a further 14% at risk of overweight. There has been a significant increase in the proportion of adults aged 16 to 64 categorised as obese, from 17% in 1995 to 27% in 2014, although the level has remained fairly constant since 2008. Women have higher rates of obesity than men (29% compared to 26% in 2014) with obesity rates highest in areas of greater deprivation. This pattern is particularly marked among women with women in the most deprived quintile in 2014 having obesity rates 16 percentage points higher than women in the least deprived quintile.
Obesity rates (adults) by gender and deprivation, Scotland 2003-2014
Children from the most deprived areas are more likely to be overweight or obese than to those from the least deprived areas.
The Projected Prevalence of Obesity in Primary 1 Children in Scotland for Scottish Index of Multiple Deprivation Quintiles 1 & 5 compared to Scotland as a whole: school years 2001/02 to 2019/20
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Poor diet continues to be a major driver of the obesity epidemic. The Supporting Healthy Choices (SHC) framework outlines the Scottish Government and the Food Standards Scotland ambition to work collaboratively with partners to improve Scotland’s diet and tackle health inequalities.
Four core principles of SHC: • Put children’s health first in food-related decisions • Rebalance promotional activities to significantly shift the balance towards healthier choices • Support consumers and communities with education and information • Formulate healthier products and menus across retail and out of home catering
Physical activity. There is strong scientific evidence that sufficient, regular physical activity is beneficial for the health of body and mind. This infographic was developed from the UK Chief Medical Officers’ 2011 Physical Activity Guidelines. It is designed for use by healthcare professionals but has been well received by many others and shared widely using social media. In 2014, 63% of adults in Scotland met the guidelines on moderate or vigorous physical activity (MVPA) of at least 150 minutes of moderate, or 75 minutes’ vigorous activity, or an equivalent combination of the two, per week. This figure has not changed significantly in the 2012-2014 period. Men are more likely to meet the physical activity guidelines than women (68% v 59% in 2014). Activity levels are significantly associated with age, with adherence in 2014 highest among adults aged 25-34 (79%), and steadily declining with increasing age, with the lowest proportion found among adults aged 75 and over (26%).
PHYSICAL ACTIVITY INFOGRAPHIC COLOUR_AW_HR.pdf 1 21/08/2015 14:58 Physical activity benefits for adults and older adults
BENEFITS HEALTH
IMPROVES SLEEP
MAINTAINS HEALTHY WEIGHT
MANAGES STRESS
IMPROVES
QUALITY OF LIFE REDUCES YOUR CHANCE OF Cancers (Colon and Breast) What should you do?
UK Chief Medical Officers’ Guidelines 2011 Start Active, Stay Active:
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Alcohol continues to cause significant harm in Scotland. The scale of the problem is clear but the most recent data paints a mixed picture: consumption relatively stable, alcohol-related deaths up for the second year running and hospital admissions continuing to fall. There are clear links between alcohol and social deprivation. The UK CMOs’ new consultation on guidelines for lower risk alcohol consumption were launched in January 2016.
The main recommendations are that men and women are advised not to regularly drink more than 14 units a week; to spread drinking over three or more days if drinking as much as 14 units a week; and there is no safe amount of alcohol that can be drunk during pregnancy.
https://consultations.dh.gov.uk/alcohol/uk-cmo-guidelines-review
Alcohol-related deaths by deprivation decile, Scotland 2014
Smoking is the leading preventable cause of ill-health and premature death in Scotland, with half of all regular cigarette smokers estimated to die prematurely as a result of smoking. Smoking is associated with around a fifth of all deaths, and around 128,000 hospital admissions, per year in Scotland.
The decline in 2014 brings smoking prevalence in line with our projections towards the 2034 policy target (smoking prevalence of 5% or less by 2034). However, as with many other lifestyle factors significant inequalities remain: in the 20% most deprived areas 34% of adults smoke, compared to 9% in the least deprived areas.
Smoking prevalence: 1999-2014 and Projected smoking prevalence towards 2034 target1
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Cancer. Age-standardised cancer mortality rates have decreased by 20% since 1989, with a greater fall in males than in females (24% and 13% decrease, respectively). Cancers of the lung (4,117), colorectum (1,525), breast (976), prostate (906) and oesophagus (850) were responsible for more than half of the deaths from cancer in Scotland in 2014.
Cancer mortality rates, Scotland 1989-2014 (excluding non-melanoma skin cancer) European Age Standardised Rate (EASR) per 100,000 population
Mental health is one of the top public health challenges as measured by prevalence, burden of disease and disability, with around one in three people estimated to be affected by mental illness in any one year. In 2012-13, 26% of adults in the most deprived areas had a below average Warwick-Edinburgh Mental Wellbeing Scale score, compared to 6% of adults in the least deprived areas. The inequality gap has widened in recent years.
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Suicide. There has been a 17.8% reduction in the suicide rate in Scotland over the period 2000-04 to 2010- 2014, with the number of deaths by suicide in Scotland in 2014 the lowest in a single year since 1977.
Suicide rates, Scotland 1994-2014, European Age Standardised Rate (EASR) per 100,000 population
Communicable Diseases: Vaccination
Since the beginning of 2014, immunisation programme developments include: • Offering seasonal flu vaccine to all children from age two years to the end of primary school; • Introducing vaccination against Meningococcal B disease for infants; • Expanding protection against meningococcal disease for adolescents with introduction of ACWY vaccine for those aged 14-18 years and new university entrants; • Continuing with the phased catch-up programme for herpes zoster (shingles) vaccine for those aged 70-79 years.
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Healthcare associated infections continue to represent a threat to safe care.
Types of HAI outbreaks and incidents (n=69) reported to HPS, January 2014 to September 2015.
Norovirus outbreaks continue to be the most common cause of ward closures within NHS Boards.
Antimicrobial resistance. There is growing concern about antimicrobial resistance. Multidrug resistance among Gram-negative organisms continues to be a major threat to public health and patient safety. Established in 2015, the Control of Antimicrobial Resistance in Scotland team in HPS is leading Scotland’s strategic response to control of antimicrobial resistance.
Blood-borne viruses. In the first quarter of 2015, over 400 individuals commenced treatment for chronic Hepatitis C virus infection, almost three-quarters of whom were being treated with a sofosbuvir-containing regimen.
5,000 people are estimated to be diagnosed and living with HIV in Scotland. An estimated further 1,600, however, remain undiagnosed. The first licensed HIV self-testing kits, based on a finger prick blood sample, went on sale at the end of April 2015.
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Travel and surveillance of imported infections. In 2014 the Travel and International Health team (TIHT) of HPS continued to carry out surveillance of travel-related infectious disease imported in Scotland, surveillance of outbreaks and incidents abroad, in particular by supporting the risk assessment for the 2014 Commonwealth Games, and also playing a central role the Scottish public health response to the Ebola outbreak in West Africa.
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www.gov.scot 2015 Review of Public Health in Scotland
Strengthening the Function and Re-Focussing Action for a Healthier Scotland
February 2016
2015 REVIEW OF PUBLIC HEALTH IN SCOTLAND: STRENGTHENING THE FUNCTION AND RE-FOCUSSING ACTION FOR A HEALTHIER SCOTLAND
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TABLE OF CONTENTS
Page
1. Ministerial Foreword 3
2. Executive Summary 4
3. Part 1. Background, Context and Resources 8
4. Part 2. Findings, Conclusions and Recommendations 31
5. Annex A. Terms of Reference for the Public Health Review Group 55
6. Annex B. Membership of the Public Health Review Group 56
7. Annex C. Methodology for the Public Health Review 57
8. Annex D. Public Health Policy: Recent History 58
9. Annex E. The Structural and Organisational Landscape 61
10. Annex F. Public Health Contribution to Community Planning and Health and Social Care Partnerships 67
11. Annex G. Glossary of Terms 72
12. Annex H. Abbreviations 75
13. Annex I. References 77
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Ministerial Foreword It is my pleasure to provide a foreword to this important and timely report which emphasises the need for collective action focused on improving health and wellbeing for all of Scotland’s people. I am grateful to the Public Health Review Group, and Dr Hamish Wilson as Chair, for the work undertaken in the preparation of this report, as well as to everyone that has supported and engaged in the review process that informed this report. This Public Health Review Report provides a comprehensive picture of the current public health endeavour in Scotland - the strengths and successes, and the challenges and areas for improvement. The report reiterates the breadth of public health activity, covering both physical and mental wellbeing, undertaken by a range of professionals across the NHS, Local Authorities, the third sector, and through communities and by individuals. All of this activity goes towards creating a healthier population, addressing health inequalities and reducing the potential for ill-health. The National Conversation on Creating a Healthier Scotland has been finding out what really matters to people and their families in terms of improving health and living healthier lives, as well as the future of health and social care services. The Conversation will take account of the engagement and findings of this review of public health. We have had a number of successes in Scotland, and on some issues we are recognised as leading the way. But there is clearly more that needs to be done as the issues we face are complex, combining an ageing population; enduring inequalities; and changes in the pattern of disease requiring action to address the determinants of population health, as well as particular health priorities. We need to be ready to respond effectively to all these challenges. The Review Group’s recommendations provide a clear basis for further work to strengthen and re-focus the vital public health function in Scotland for the future. Thinking about our structures and public health leadership will be an important activity for Government in the coming months. I welcome and support the proposal for a single Public Health Strategy for Scotland, setting out the wider population health priorities and the contribution that many partners can make to tackle these challenges. Such a document would be a significant parallel strategic statement to the National Clinical Strategy. Supporting and developing our multi-disciplinary public health workforce, which is recognised as extending beyond the NHS, and ensuring effective partnership working across the public and third sectors on population health are also vitally important. The recommendations within this report provide clarity on the steps we need to take in Scotland and the next phase is to work with stakeholders to take forward implementation. We can achieve the best use of our resources and our collective endeavour in Scotland so that we have a positive and lasting impact on creating a healthier Scotland.
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Executive Summary
Conclusions and Recommendations 1. This Review of Public Health in Scotland has identified the need for the function to be clearer about its priorities and delivered in a more coherent manner. The changing organisational context (including the clear emphasis on partnership and integration and the importance of community empowerment and engagement) has implications for how public health is organised and operates. Major public health challenges such as obesity, mental health problems and inactivity, together with the persistence of health inequalities, require a concerted population health response, achieved through the organised efforts of society. They cannot be addressed solely through treatment. The evidence received by the review group emphasised the cost- effectiveness of preventive approaches and a wide appetite for a more active public health effort in Scotland. The Review Group’s recommendations seek to support that through:
a. Further work to review and rationalise organisational arrangements for public health in Scotland. This should explore greater use of national arrangements including for health protection. b. The development of a national public health strategy and clear priorities; c. Clarification and strengthening of the role of the Directors of Public Health(DsPH), individually and collectively; d. Supporting more coherent action and a stronger public health voice in Scotland; e. Achieving greater coordination of academic public health, prioritising the application of evidence to policy and practice, and responding to technological developments; f. An enhanced role for public health specialists within Community Planning Partnerships (CPPs) and Integrated Joint Boards (IJBs); and g. Planned development of the public health workforce and a structured approach to utilising the wider workforce.
2. The Executive Summary outlines the review process and key themes which inform these recommendations. These are expanded on in the full report.
Public Health Review 3. The Public Health Review has been given a specific remit to examine public health systems and functions and their contribution to improving population health and reducing (health) inequalities. Ministers have asked for recommendations to seek to strengthen the contribution; maximise the effectiveness and efficiency; and ensure the responsiveness and resilience of the public health function in Scotland for the future.
4. The material described in the first part of this summary, and in Part 1 of the report, reflects the population health and policy analysis undertaken to ensure recommendations are made on the basis of a good understanding of public health. The second part of the summary, and Part 2 of the report, describe the key themes emerging from the engagement processes undertaken by the review (full report published separately at www.gov.scot/publichealthreview-analysisofresponses- engagementpaper), and the additional research evidence commissioned around the
Page | 4 specific areas of public health leadership, partnership and workforce (summary report published separately at www.gov.scot/publichealthreviewresearchreport- keyfindings). Collectively this work reflects the review process and has been undertaken on behalf of the Review Group. The Group’s recommendations take account of all these strands of the review.
Population Health in Scotland 5. Good health is beneficial for individuals and families, and also strengthens capacity for participation in learning, employment, caring, and many other activities. In short, good health is a resource for society.
6. The population health challenge remains complex and persistent and current measures are not seen to be sufficiently accelerating improvement in the country’s public health:
• Life expectancy is increasing, but is not improving equally or improving to the levels seen in other Western European countries. Scotland continues to experience ‘excess’ mortality, even when deprivation is accounted for. There is no single explanation.
• The overall challenge is to increase the years of life that people in Scotland live in good health. Behaviours detrimental to health remain prevalent and the burden of disease is now with longer-term conditions and associated with lifestyle and economic and social circumstances. An increasing proportion of people live with multiple conditions including, in particular, concurrent physical and mental health conditions.
• The impact of the public health challenge is greater in the more deprived sections of the population than the more affluent. The importance of tackling poverty and inequalities is reiterated in this report given the clear links between social deprivation and poorer health outcomes. Greater equality in society is associated with better population outcomes on a range of domains. Scotland, like many countries, continues to see a stark difference in the life circumstances, experiences and outcomes of people in different groups. These differences are perpetuated across generations. The challenge of impacting on these inequalities has been identified as one of the top priorities for Local Government and Scottish Government.
7. Specific population health priorities in Scotland now encompass health inequalities with their social determinants, inactivity, nutrition, obesity, and poor mental wellbeing, concurrent with the demography of an ageing population. Solutions go beyond the direct control of public health and require work across complex systems, far beyond NHS and health boundaries, to influence wider agendas, policies and programmes, and these require new ways of working.
8. Addressing these challenges matters for individuals and communities as there is a significant burden of disease and suffering that is avoidable, especially among the less affluent, and having caring responsibilities can preclude carers from working or living full and meaningful lives. It matters for health and social care services and wider public services as the sustainability of services depends on improving
Page | 5 population health. It matters for a flourishing and successful Scotland as a healthy working population contributes to sustainable economic growth. 9. In a number of areas of public health, both within the health sector and beyond, Scotland is recognised as being at the leading edge. In each case there has been bold, committed, leadership with local and national political support; effective partnership working; an applied evidence-base; clear accountability and monitoring processes; a critical mass of effort and investment; and action at national, regional and local levels. Creating the conditions for similar success across the breadth of population health in Scotland is now the immediate task to enable effective responses to ongoing and emerging local, national and international challenges for the benefit of current and future generations.
10. At the centre of the public health endeavour is the core public health workforce, largely employed in the NHS in Territorial Health Boards and National Boards, but also within Local Authorities and Academia. Responsibility for public health action also rests with the wider NHS, with national and local governments, the pivotal role of CPPs and IJBs. The third sector, other public services, communities and the private sector make a major contribution, as does the wider workforce across the public sector and voluntary and community sectors. These are considerable organisational and people resources, but not all of the potential is currently being realised.
11. Public health supports the shift to prevention and to tackling the inequalities in our society with a wide-range of preventative approaches shown to be cost-effective. Given the significant and rising costs associated with ill-health, there is both an economic and health benefit from taking a public health approach.
12. The landscape of public sector reform provides new opportunities for Public Health to respond to both the persistent and the emerging challenges facing Scotland’s health. Responses to the engagement processes undertaken as part of this review indicate that the public health community in Scotland wants to be supported to capitalise on these opportunities.
Public Health Review – Key Themes 13. Some clear themes emerged from across the various sources - the material generated during the review from the engagement process supported by the research analysis and the population health and policy analysis. There were strong messages about the importance of both national and local perspectives and the need for greater coordination between these. The process highlighted the need for greater visibility and a clearer identity for the public health function. The challenges and opportunities for public health featured the need to respond more effectively to large-scale strategic challenges (such as the desired shift to prevention) and to focus more clearly on identified priorities. The desire for strengthened leadership from individuals and organisations was a reoccurring theme, including to increase impact in partnership areas including IJBs and CPPs. There was also clear support for the fundamental importance of effective partnership working as a prerequisite for better population health. The value of the existing workforce came through strongly, but the process also noted the changing nature of the workforce and the challenges of supporting and strengthening multi-disciplinary public health.
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14. Many of the themes and issues are in fact interconnected. The main report presents these findings in more detail, with specific discussion on the key themes. 1. Organisation – the perception of there being a cluttered public health landscape; the need for greater efficiencies; more clarity on organisational roles; better links with Local Authorities and Community Planning; and taking forward those actions which could be categorised as ‘once for Scotland’ nationally. 2. Strategy – the need for a single, over-arching public health strategy for Scotland and clear priorities. 3. Leadership – the need for strengthened local and national leadership across the breadth of public health endeavour, including the role of Directors of Public Health (DsPH). 4. Evidence – the importance of data, information, intelligence, research and evidence as a basis for public health decision-making and action. 5. Partnership and collective responsibility – the need for responsibility for public health to be shared widely across different organisations, sectors, communities and individuals to ensure we are able to address the determinants of population health, as well as particular health priorities. This includes Local Authorities and the third and voluntary sectors. 6. Workforce – the need to respond to the challenges associated with a dispersed workforce involving varied skills and professions to ensure a robust, resilient and competent workforce of the future, and that new talent can be attracted to the field of public health.
Implementation 15. Implementation of the recommendations in the report, and outlined at the start of this summary, will require an overarching implementation plan to ensure that all elements are taken forward as a subsequent phase of the public health review. Delivery of a future public health strategy will require the contribution and collaboration of many partners, recognising that responsibilities for addressing public health issues sit not only within the health sector but also with national and local governments; public, private and third sectors; and communities and individuals.
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PART 1. BACKGROUND, CONTEXT AND RESOURCES
Introduction
1. Scottish Ministers announced in November 2014 that they had asked for a review of Public Health in Scotland and had established a Review Group to take this forward and report back in 2015. The purpose of the review was to consider the role of the public health function in the context of the emerging policy landscape and current and future public health challenges, and to recommend how the function could be strengthened to respond more effectively to the opportunities and challenges.
2. There were a number of areas specifically identified for inclusion within the review and these formed part of the terms of reference agreed between Ministers and the group (Annex A). The group was asked to examine public health leadership and influence, both within the health sector and more widely, and to recommend how these could be developed further to deliver maximum impact. A second consideration concerned how public health featured in community planning and health and social care integration, and how the potential of partnership opportunities could be used to maximise the successful implementation of public health measures. The third area was workforce – workforce planning and development, succession planning and resourcing.
3. In establishing the review, Ministers sought recommendations that would strengthen the contribution of Public Health in Scotland; maximise the effectiveness and efficiency of the public health resource; achieve consistency where this would enhance quality and impact; and ensure the responsiveness and resilience of the public health function for the future.
4. The Review Group was convened in December 2014, under the chairmanship of Dr Hamish Wilson, with membership as listed in Annex B, and supported by a secretariat from within the Scottish Government. The review process (see Annex C) incorporated: analysis of population health in Scotland; stakeholder engagement through written responses and workshops; research analysis; and meetings with specific stakeholders.
5. The material described in Part 1 of this report reflects the population health and policy analysis undertaken to inform the recommendations and ensure these are made on the basis of a good understanding of public health. Part 2 of the report describes the key themes emerging from the engagement processes undertaken by the review, and the additional research evidence commissioned around the specific areas of public health leadership, partnership and workforce. The Review Group’s recommendations take account of material described in both Part 1 and Part 2.
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Public Health
6. Public health is the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society. Some key features help to distinguish a public health approach from other approaches to improving health and wellbeing, such as those delivered through personalised health and care. Based on the definitions used by the Faculty of Public Health, we can describe public health as:
a. Being population based – concerned with the factors that make populations (e.g. communities, cities, regions, countries) healthier or unhealthier; b. Emphasising collective responsibility for health, its protection and disease prevention – through the organised efforts of society; c. Recognising the role of the state, and of the underlying socio-economic and wider determinants of health and disease, including the distribution of power, resources and opportunities within and across populations; and d. Involving partnership with those who contribute to the health of current and future populations.
7. Professionals from medical, dental and other non-medical backgrounds train to become specialists in public health. This training involves competence in nine key areas (Table 1) relating to the three domains of public health practice – namely health protection, health improvement, and improving health services. Public health data analysis and intelligence provide a foundation for these three domains of practice.
Table 1 Core and Defined Competency Areas of Public Health Practice1:
Competency Area 1 Surveillance and assessment of the population’s health and wellbeing. 2 Assessing the evidence of effectiveness of interventions, programmes and services intended to improve the health or wellbeing of individuals or populations. 3 Policy and strategy development, and implementation. 4 Strategic leadership and collaborative working for health. 5 Health improvement. 6 Health protection. 7 Health and social service quality. 8 Public health intelligence. 9 Academic public health.
8. Health protection involves: immunisation programme effectiveness; ensuring the safety and quality of food, water, air and the general environment; preventing the transmission of communicable diseases; and managing outbreaks and the other incidents which threaten the public’s health.
9. Health improvement incorporates a broad set of activities to create the circumstances for better health and reduced health inequalities within
1 As set by the Faculty of Public Health as the standard-setting body for public health practice in the UK. Page | 9
populations. It includes attention to: prevailing cultures and values; the health impact of policies and programmes across the wider determinants of health (housing, employment, transport, poverty, etc.); behaviour-change interventions; and support for community-led action to improve health.
10. Improving health services supports the planning and development of services to ensure that they meet the needs of the populations they serve. Activities include needs assessment; support for inequalities-sensitive services; clinical governance; audit; and effectiveness. Screening services – such as those to detect changes indicative of specific health problems including cervical cancer, breast cancer and bowel cancer – are also part of the public health contribution to health services.
11. Public health intelligence underpins all of the above three domains of public health practice. It includes the surveillance and monitoring of population health and the determinants of health and wellbeing; support for evidence-based practice; and assessment of the effectiveness of policies, programmes and services.
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Population Health in Scotland
12. The nature and scale of the population health challenge changes over time, and each iteration takes longer to pass for the more deprived sections of the population than it does for the more affluent. During the 20th century life expectancy increased, communicable diseases became less common and better controlled, non-communicable disease became more prevalent, and an increasing proportion of people developed and lived with multiple morbidities. The burden of disease now lies with longer-term conditions and is associated with lifestyle, and the nature of wider social, economic and environmental factors in society. Scotland’s health is also characterised by the years of life lost on account of deaths from ‘external causes’ such as suicide, violence, alcohol and drug-related mortality among young adults.
13. Some features of our population health in Scotland are particularly worthy of note:
i. We have lower life expectancy than our European counterparts, and there is no single explanation for this. On average people in Scotland die younger than in any other country in Western Europe, Scotland’s life expectancy having increased more slowly than other European countries since the 1950s. Mortality rates in Scotland are higher than would be expected on the basis of population characteristics and levels of socio- economic deprivation. This phenomenon of ’excess mortality’ is evident for Scotland as a whole, but is particularly concentrated in West Central Scotland.
ii. There are high levels of preventable mortality and morbidity in Scotland’s ageing population. According to the UK Global Burden of Disease Study (Murray, 2010) the leading risk factors for disease are: tobacco and second hand smoke, high blood pressure, high body mass index, physical inactivity and low physical activity, alcohol use and poor diet. Underpinning these risk factors is a complex picture of economic, social, biological and environmental factors which influence behaviours and outcomes.
iii. Continued increases in the levels of overweight and obesity in the population have the potential to overturn the life expectancy gains achieved through behavioural and health service responses to heart disease and diabetes in recent decades. At present over 64% of the adult population in Scotland is overweight or obese (27% obese). In comparison with other Organisation for Economic Co-operation and Development (OECD) member states (Scotland, UK and 15 other nations) Scotland ranks fifth highest for overweight (including obesity) and sixth highest for obesity alone. At school entry just under 23% of children are at risk of overweight and obesity (with 10% at risk of obesity). Prevalence increases with age up to age 75. On the surface the rate of increase in obesity is slowing, however this masks the now-evident socio-economic inequalities, particularly marked for children.
Page | 11 iv. Health inequalities persist across a range of outcomes, including the marked difference in the number of years people live in good health between our most and least deprived citizens. There is a clear relationship between deprivation (however measured) and population health. Our more deprived citizens live shorter lives and more years in poor health. Moreover, the greatest health benefits from services, programmes and opportunities often fall to the more affluent. Tackling health inequalities is a matter of social justice, and involves actions that operate across the whole social gradient, as well as those tailored to the needs of the most vulnerable and ‘at risk’ groups (Marmot, 2010).
v. We have high levels of multi-morbidity – in particular concurrent physical and mental health conditions. A striking (and increasing) number of people are living with multiple conditions impacting on their health, wellbeing and ability to function. Mental illness is associated with a 15 year reduced life expectancy compared to the general population, mainly due to cardiovascular disease. Multi-morbidity is also associated with multiple medication and dependence on a range of health and social care services, including unpaid and informal caring. The ageing population contributes to this trend, yet many younger people are also living with multiple conditions, signalling a future challenge. The onset of multi-morbidity occurs 10–15 years earlier in people living in the most deprived compared with the most affluent areas of the country, and deprivation is particularly associated with multi-morbidity that includes mental health conditions. There are concerns too for the mental wellbeing of Scotland’s unpaid carers. Mental wellbeing decreases as the number of hours spent caring increases. The number of hours spent caring is highest in deprived areas.
vi. Despite improvements in a number of dimensions of mental health, considerable challenges remain. Mental health problems are common and greatly affect life chances. Social inequalities in mental health are enduring and persistent. The UK Mental Health Foundation estimates that 1 in 4 people will experience a diagnosable mental health problem each year: source Office for National Statistics Psychiatric Morbidity Report (Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2001). The World Health Organisation (WHO) estimates 40% of the European disability burden is due to chronic mental ill health (World Health Organisation, 2001). Despite the ongoing reduction in suicide rates (overall and in terms of inequality), suicide is the leading cause of death in Scotland among people aged 15-34 years and is strongly related to deprivation. There is concern about the increasing prevalence of suicide among middle aged men (suicides in Scotland is most common among men aged 35 to 55). The incidence of dementia is also rising, reflecting efforts to increase awareness and improve diagnosis, and also associated with population ageing. vii. Despite considerable improvements in dental health, marked inequalities still exist. Dental decay is the single most common cause for children being admitted to hospital for a general anaesthetic in Scotland and presents a particular burden for the most deprived groups. As a result of
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major effort there is no gradient in dental registration between the most and least deprived areas.
14. In summary, specific population health priorities in Scotland encompass health inequalities and their societal determinants, inactivity, nutrition, obesity, and poor mental wellbeing, concurrent with the demography of an ageing population. There are therefore pressing public health challenges at every level: ongoing challenges to support the shift towards prevention; to protect the health of the population and address risk factors; complex social, economic and cultural challenges; and new threats to health and wellbeing. The difficulty for public health is to combine focussed action on clear current priorities alongside wider system influence and ‘holism’ (it all matters). The overall challenge is to increase the years of life that people in Scotland live in good health - Healthy Life Expectancy (HLE) - and to reduce the inequalities in health that exist in Scotland.
15. Public Health has recognised that new population-based approaches are now needed, giving rise to the concept of a fifth wave of public health (Hanlon, Carlisle, Hannah, Reilly, & Lyon, 2011). Looking historically (Table 2) (Hanlon, Carlisle, Hannah, Reilly, & Lyon, 2011) and (Davies et al, 2014) the first wave of public health was associated with great structural work such as the provision of clean water to urban areas. The second wave saw the emergence of medicine as science. The third wave was characterised by the redesign of social institutions (including the establishment of the NHS and the welfare state) and the role of everyday life and lifestyles on our health was explored. The fourth wave has been dominated by recognition of the influence of social determinants. The best of what these previous four waves can achieve needs to be preserved. However, it is argued that a different approach – a fifth wave of public health – is needed in the 21st Century (Hanlon, Carlisle, Hannah, Reilly, & Lyon, 2011) (Davies et al, 2014) to address modern phenomena and epidemics. This approach would differ radically from its forerunners. It is likely to be characterised by enabling government, greater interdependence and co- operation across sectors and geographies, and involvement of the public more individually and personally in improving and maintaining their own health. Davies argues that a fifth wave which is ‘cultural’ in character is inevitable – essentially a society where healthy behaviours are the norm, supported by the physical, social and economic environment.
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Table 2 Making the case for a 'fifth wave' in public health (Davies et al, 2014)
Policy context
16. In considering the future arrangements for Public Health in Scotland, the Review Group recognised the need for the public health function to align with and support the wider policy landscape and to be effective in helping to address current and future resource, sustainability, service and demographic challenges. There is an opportunity for the core public health workforce to be more directly influential, as well as being instrumental in advocacy and support for others in delivering public health outcomes.
17. The influential work of the Christie Commission on the Future Delivery of Public Services in Scotland (Christie, June 2011), which reported in 2011, highlighted, among other things, the need for public services to shift their focus more significantly towards prevention and to operate more effectively in partnership (including with the communities they serve).
18. The current priorities of the Scottish Government, reflected in the Programme for Government 2015-6 (The Scottish Government, 2015), combine an economic strategy centred on delivering inclusive growth; a clear and consistent focus on tackling inequalities; and a commitment to protecting and reforming public services.
19. Scotland’s Economic Strategy (The Scottish Government, 2015) recognises that more equal societies form the foundation for more sustainable and resilient economies. Social and economic policy goals are integrated within the strategy, for example in its emphasis on Fair Work; education, skills and health; place and regional cohesion; and tackling cross-generational inequality. As well as recognising that a more equally healthy and skilled country is necessary, the
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strategy seeks to support a fairer distribution of economic and social benefit across the population.
20. In 2015 the Scottish Government also took forward a public discussion on what a Fairer Scotland would look like in 2030 and the actions that would be needed to make that a reality. This process involved public dialogues in a range of formats, considering policy priorities for tackling inequalities. Health inequality was a central part of this conversation.
21. The Parliament’s Health and Sport Committee report in January 2015, and the subsequent Scottish Parliament debate on health inequalities, demonstrated cross-party political support for reducing inequalities and underlined the wider context for Public Health in influencing others to take action to address the social and wealth inequalities that drive health inequalities.
22. The Community Empowerment (Scotland) Act (2015) made provisions for a required focus on reducing socio-economic inequalities in relation to local and national outcomes, opening-up possibilities for greater power and decision- making at local levels. It seeks to ensure that individuals and communities are empowered and able to influence decisions, priorities and service delivery. This builds on the recognition of the contribution of Local Government in delivering local services responsive to need, providing enabling conditions for community wellbeing, and working in partnership to deliver priority outcomes.
23. Local Government is an essential partner with Scottish Government in public service reform. Public service reform in Scotland has included reinforcement of the important role for Community Planning Partnerships (CPPs), with shared ownership of priorities set out in Local Outcome Improvement Plans (LOIPs). CPPs provide the basis and potential for real collaborative working and leadership and influence to achieve effective public health measures through a whole systems approach at the level of Local Authorities and communities.
24. Greater integration of services is also being achieved by bringing together health and social care through the creation of Integration Joint Boards (IJBs). Together with NHS Boards and Local Authorities, these IJBs are required to demonstrate their contribution to tackling health inequalities and improving healthy life expectancy. Contributing processes include more joined-up working and budgets; a greater focus on prevention and population-based health improvement; and person-centred care.
25. During 2015-16 the Scottish Government is building on its 2020 Vision for Health with a national conversation on the future of health and social care to help shape a transformational change in Scotland’s approach to population health and the delivery of health and social care services by 2030. The narrative for this national conversation includes a focus on prevention, with more effort, creativity and resources going into stopping issues of ill health before they occur, and with individuals and communities being responsible for promoting, and being empowered to manage, their own health and wellbeing.
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26. In summary, new ways of working; a focus on inequality; a demonstrable shift to preventative approaches; and community empowerment are all prominent features of the language of public services and Government in Scotland, seeking innovative and effective ways to respond to increasingly constrained resources and growing demands and expectations. These policies offer opportunities for improved population health, and also require a more equally healthy population for their delivery.
27. Annex D sets out the main policy and legislative developments relating specifically to Public Health in Scotland since the late 1990s. These demonstrate a continued emphasis on the role of services in preventing ill-health and improving and protecting the public’s health and well-being. There are consistent messages, for example in relation to the importance of early years and the need for health impacts to be taken into account in all areas of policy. Public health core work has drawn on a wide evidence base and developed into a very broad set of issues and programmes of action.
28. The current Review of Public Health in Scotland considers how the public health function can develop further and how it can provide leadership and action in partnership with others to increase its effectiveness in shaping policy and responding to the current and emerging population health challenges facing Scotland.
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Public health capability and capacity
29. The organisational landscape within which the public health function in Scotland is structured is described in Annex E. This summarises the organisational responsibilities at national, regional and local levels, and the partnerships within which public health needs to operate to be effective. What follows is a description of the public health workforce and the capacity of the function within Scotland.
1. Core workforce 30. Public health is a multidisciplinary specialty in the UK, currently overseen by three Regulators: the General Medical Council (GMC), General Dental Council (GDC) and the UK Public Health Register (UKPHR). The UKPHR is responsible for regulating and keeping a register of accredited Public Health Specialists from disciplines other than medicine and dentistry.
31. There are three categories of specialists from disciplines other than medicine and dentistry in Scotland registered or aspiring to registration with UKPHR: generalist specialists trained through the conventional route, generalist specialists by portfolio and defined specialists by portfolio. The UK-wide Faculty of Public Health training scheme is expected to be the only future training route for all specialists, but does not provide the opportunity for NHS staff to train within current roles or for staff within other structures (e.g. local authority, third sector) to train.
32. A Public Health Skills and Knowledge Framework has also been developed and is overseen by the Public Health Online Resource for Carers, Skills and Training (PHorCast). Its purpose is to define skills required for public health in the broadest terms for employing organisations and practitioners to look at skills development and career pathways for the whole range of disciplines in public health, and to create pathways running from entry level to specialist level. NHS Education for Scotland (NES) and Health Protection Scotland (HPS) jointly sponsor work to promote the development of the health protection workforce. This includes implementation of the ‘Framework for Workforce Education Development for Health Protection in Scotland’ (NES /HPS) (from 2006) which is currently being reviewed.
33. Environmental Health in Scotland is a graduate only profession with Environmental Health Officers (EHOs) holding a degree level qualification awarded by a Royal Environmental Health Institute of Scotland (REHIS) accredited university. In addition, EHOs must also hold a Post Graduate Diploma in environmental Health awarded by REHIS before practicing as an EHO in Scotland.
34. The Centre for Workforce Intelligence (CfWI) was commissioned by NHS Health Scotland (NHSHS) on behalf of Scottish Government to carry out a mapping of the core public health workforce in Scotland. The approach taken was based on CfWI’s similar workforce mapping exercise in England in October 2014. The CfWI has defined the core public health workforce as: “All staff engaged in
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public health activities that identify public health as being the primary part of their role.”
35. There are some limitations of the data used in the report due to tight timescales for conducting the work. Data were collected from different sources and at different times. The report therefore provides an impression of scale and distribution of the public health workforce (see Table 3) rather than an accurate enumeration.
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Table 3: Summary of the core public health workforce in Scotland (2015) (Centre for Workforce Intelligence, 2015)
Role Summary description Estimated numbers (headcount) 1 Public health and Work at a strategic or senior dental public management level or at senior level of health scientific expertise to influence the 189 consultants, health of entire communities specialists and specialist trainees 2 Directors of Responsible for determining overall Public Health vision and objectives for public health (DsPH) both within local Health Boards (14) and [18] national Health Boards (4) [these are also included within Public Health consultants above] 3 Public health Lecturers, researchers and teachers academics employed in higher education, whose 360 primary focus is public health 4 Public health Work across the system and at all managers and levels delivering public health practitioners programmes in health improvement, 970 e.g. smoking cessation, alcohol dependency 5 Public health Perform scientific role in support of 50 scientists public health objectives 6 Intelligence and Staff employed in data analysis, knowledge informatics and presentation of public 370 to 660 professionals health information 7 Health visitors Work as part of a primary healthcare team, assessing the health needs of 2,185 individuals, families and the wider community 8 School nurses Nurses who advise and support pupils within schools on preventing illness and 500 remaining healthy 9 Public health Nurses who advise people in the nurses community on preventing illness and (excluding health remaining healthy. Work mostly in visitors and health protection, e.g. TB, infection 640 school nurses prevention and control, HIV which are listed separately)
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Role Summary description Estimated numbers (headcount) 10 Environmental Work in improving, monitoring and health enforcing public and environmental professionals health standards. Environmental health 980 officers are core to the delivery of health protection in Scotland, including the joint health protection team. 6,250 to Total 6,540
36. Taking roles 1 to 6 and 10 from Table 3 as comprising the core specialist public health workforce in Scotland yields a headcount estimate of approximately 3000. Half of these - at least 1515 staff - work in the NHS (Table 4). A significant number of academic staff (at least 360) contribute to the core public health function from posts out with the NHS. Environmental Health Professionals make up 980 posts in the core specialist public health workforce - the majority working within Local Authority environmental health departments. In addition, a number of EHOs work within other statutory organisations such as the Scottish Environmental Protection Agency (SEPA) and the Health and Safety Executive (HSE). Some work within the NHS and others in private industry or the voluntary (third) sector.
37. Looking at the data further, Table 4 shows that, of the 1515 NHS staff, approximately 25% work within National Boards and 75% within Territorial Boards. The majority of public health and dental public health consultants, specialists, specialist trainees and public health practitioners work in Territorial Boards; and a significant proportion (75%) of intelligence and knowledge professionals work in the National Boards (estimated as 215 within National Services Scotland (NSS), 30 in Healthcare Improvement Scotland (HIS) and 20 in NHSHS, excluding the Scottish Public Health Observatory (ScotPHO) staff). The CfWI report notes (CfWI table 9 (Centre for Workforce Intelligence, 2015) that a further 400 to 500 staff in analytical roles (not recorded as core public health) work within Public Health Intelligence in NSS.
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38. Table 4 Information in CfWI report on workforce within Territorial and National Boards (2015) (Centre for Workforce Intelligence, 2015) source Table 4, 5, 7, 8 and 9 of CfWI report
Role Territorial National Total Other Sum Board Board NHS (WTE) Territorial+ (WTE) (WTE) National + Other 1 Public health 145 16 161 28* 189 and dental (103.6) (12.9) (116.5) public health consultants, specialists and specialist trainees 2 Directors of [14] [4] 18 [18] Public Health Equivalent (DsPH) status 4 Public health 895 76 971 971 managers (785) (45) (830) and practitioners 5 Public health 35 35 20** 55 scientists (in HPS) 6 Intelligence 83 265 348 26*** 374 and (at least) (at least) (at least) knowledge professionals Total 1,123 392 1515 74 1589
[ ] DsPH have also been counted as Public Health consultants or specialists *28 UKPHR defined generalist or defined specialists working for Territorial Boards and National Boards in senior posts not formally appointed as consultants ** Public Health England (PHE) staff working in Scotland at the Centre for Radiation Chemical and Environmental Hazards at Glasgow *** ScotPHO staff
39. The report does not attempt to estimate the number of staff working in each of the public health domains. It instead refers to earlier work by ScotPHN, published in 2011, which identified 128 whole time equivalents as Consultants in Public Health employed in Scotland in February 2010, of whom 82% were Consultants in Public Health Medicine or Dental Public Health. A summary breakdown of their areas of focus indicated that:
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• Around half of Territorial Health Board consultants had generic roles, while a quarter focused on health protection, a fifth on health and social care services and a sixth on health improvement. • All but two of the 14 Territorial Health Boards had dedicated provision for health protection, but only about half had similarly dedicated consultant-level resource for health improvement and health and social care services. • There was expert provision nationally at consultant level for health protection, health improvement and health intelligence, but none for health and social care services.
40. Most Boards have access to dental public health consultants, but over the years posts have been difficult to fill and some have been shared across Board boundaries.
2. Wider public health workforce
41. In addition to the core public health workforce, many other professional groups, practitioners in different disciplines, organisations and individuals make an essential contribution to protecting and improving the public’s health and wellbeing. There is almost no limit to the range of groups and organisations whose staff fall into this category. Examples include: medicine; nursing; pharmacy; dentistry; allied health professions; police; fire and rescue services; teachers; social work and social care; licensing officers; welfare rights; housing; transport; planning; employability and leisure services; voluntary and community sector organisations (some focussed explicitly on health issues, such as community food and health initiatives and mental health projects; others contributing through action on wider influences on health, such as poverty and greenspace); and services located in government, scrutiny or private sector bodies, including those ensuring healthy and safe working environments; responsible for travel infrastructure; or setting welfare system parameters. Collectively these comprise the wider public health function. They clearly represent a considerable human resource, some of the potential of which remains to be realised.
42. The Scottish Health Promotion Managers’ Group (SHPM) described Public Health engagement with the wider workforce as “principally driven by an acknowledged shared common agenda that is not always defined by traditional health outcomes but will include outcomes known to contribute to positive health outcomes such as educational attainment; financial inclusion; community resilience etc. The pursuit of such outcomes is a function of public health. The wider workforce includes both statutory partners/players with responsibilities defined in legislation (e.g. Community Safety Partnerships) as well as voluntary sector / charitable agencies whose contribution to health outcomes is determined by organisational constitutions and governance structures (e.g. Charities). Additionally the wider workforce may contain individuals and community activators or action groups with specific aligned motivations. All of these players should be recognised as legitimate and valued partners.”
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Table 5 Core and Wider Public Health Workforce Local Authorities
• Elected Members WIDER: • Education committees NHS • • Licensing committees GPs and practice staff Other • Teachers • Allied health professions • Pharmacy • Social work • • Medical/Dental Third, Community Sector Leisure Services • Acute nurses/medics, District Nurses • Specialist services e.g. homeless and addictions Formal Partners and • Public Services Board policy and planning • Housing Associations • Healthcare scientists • Employability/skills services • Financial inclusion agencies NHS LA’s
Core Predominantly NHS but includes roles out with CORE • Public Health consultants & specialists including DsPH and Charities, social enterprises and trainees other voluntary organisations • Public Health Managers and and community sector Practitioners providing: • • Health Visitors, School & Public Health and social care Health Nurses service providers • • Intelligence and knowledge Advice and advocacy • Community Planning • Self-help, carers and peer professionals • Private and Partnerships support • Public Health Scientists Independent • Integration Joint Boards • Research and campaigning • Public Health Academics Businesses, • Police • Community food and • Environmental Health • Employers and • Fire and Rescue healthy living Professionals Employees • Prisons
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3. Resource Cost
43. In this report we have derived an estimate of core public health workforce costs. This estimate recognises the uncertainties associated with the staff numbers, uses available data sources to estimate salaries, and includes assumptions on staff grades and number of working time equivalents2. It is therefore presented as an indicative calculation for illustrative purposes. An estimate of staff costs associated with the core public health workforce, as defined by the CfWI, yields approximate workforce costs of £227 million per annum. This estimate includes NHS and non-NHS staff.
44. The estimate for the core public health function workforce (roles 1&2, 3,4,5,6 and 10, in Table 6) is approximately £126 million. The best estimate of NHS-funded core public health function workforce costs (roles 1&2, 4, 5 and 6, in Table 6) is £74 million. In the context of wider NHS workforce costs of £5.6 billion per annum, the public health function workforce (£74 m) equates to around 1.3%3 .
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Table 6 Core Public Health Function resource costs (source: Scottish Government analysts)
Role Estimated Estimate headcount (staff cost £m) from Table 3 1 & 2 Public health and dental public health consultants, specialists and 189 17 specialist trainees includes role (2) DPHs 3 Public health academics 360 20 4 Public health managers and 970 33 practitioners 5 Public health scientists 50 2 6 Intelligence and knowledge 370 to 660 14 to 30 professionals 7 Health visitors 2,185 68 8 School nurses 500 11 9 Public health nurses (excluding health visitors and 640 22 school nurses which are listed separately) 10 Environmental health professionals 980 32 Total Core Public Health as £219m to £235m 6,250 to 6,540 defined by CfWI Midpoint £227m
2 Nurses: http://www.nhscareers.nhs.uk/explore-by-career/nursing/pay-for-nurses/; Environmental Health Officers: http://www.payscale.com/research/UK/Job=Environmental_Health_Officer/Salary, http://www.myworldofwork.co.uk/node/20268, https://nationalcareersservice.direct.gov.uk/advice/planning/jobprofiles/Pages/environmentalhealthoffi cer.aspx; Academics: average professorial salary https://www.timeshighereducation.co.uk/features/times- higher-education-pay-survey-2015/2019360.article, http://www.prospects.ac.uk/higher_education_lecturer_salary.htm. NHS staff costs: http://www.isdscotland.org/Health-Topics/Finance/Costs/ and average employer costs for public health medics in Scotland data source 2013/14 NHS pay bill file extract in ISD 3 NHS staff costs http://www.isdscotland.org/Health-Topics/Finance/Costs/ Table R100. Page | 25
Effective and resilient Public Health: capacity and cost-effectiveness
45. The OECD predicts that the cost of health care will double by 2050 based on current trends. A substantial proportion of costs are associated with health issues that may be reduced through effective population-based actions. For example, obesity accounts for 1-3% of total health expenditure in most countries; mental illness costs the economy £110 billion per year in the UK and represents 10.8% of the health service budget; the costs of health inequalities, in terms of total welfare loss, are estimated at 9.4% of GDP. Health and social care services alone cannot create the conditions required for a healthy, flourishing population. Moreover, the National Institute for Health and Care Excellence (NICE) has shown that many public health interventions are more cost-effective than clinical interventions (using cost per QALY) and some are even cost-saving (Kelly, 2012).
46. The case for investing in public health has recently been summarised by the WHO Europe (WHO, 2014). Recognising the significant and unsustainable increases in costs associated with ill-health, this report describes the economic and health benefits of taking a public health approach. It sets out the costs associated with failing to address current public health challenges, summarises evidence on the cost-effectiveness of public health approaches, and outlines the returns on investment achieved through delivery of preventive interventions.
47. It is estimated (WHO, 2014) that only 3% (range 0.6 – 8.2%) of national health sector budgets is currently spent on public health. Individual-level approaches cost five times more than interventions at the population level and, in general, investing in upstream population-based prevention is more effective at reducing health inequalities than more downstream prevention.
48. In Scotland we do not routinely estimate the total expenditure on public health. Within the Scottish Government Health Budget spend under the heading Improving Health and Better Public Health in Table 4.03 is an estimated £313.6 million in 2015/16 including £73.5 million for the Integration Fund4. This includes expenditure on immunisation of £20.9 million, central allocation of £40.09 million to tackle alcohol misuse and £55.6 million on health improvement and health inequalities. In addition a proportion of the expenditure of NHS Boards and National Boards in Table 4.02 of the Scottish Draft Budget 2015-16 (£9.47 billion) will be on public health departments and to support public health outcomes, and is at the discretion of Boards. The 2015/16 budget sees health resource spending increase by £409 million and takes total health spending to over £12 billion for the first time. While we cannot give an estimate of the percentage of public health expenditure, it will be a significant sum in its own right but a relatively small percentage of overall NHS spend. Improving Health and Better Public Health amounts to 2.6% of the total £12 billion NHS expenditure 5.
49. At the heart of this current Review of Public Health in Scotland is the need to ensure that this expenditure delivers maximum value for money. This will require
4 Scottish Draft Budget 2015-16: Table 4.03 5 Scottish Draft Budget 2015-16: Table 4.03
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a public health function which is resilient, has the right capability and capacity, and is directed at those activities where it can make the most impact.
50. A resilient and effective public health infrastructure ensures that the core functions can continue to be delivered in light of new public health priorities, emergent challenges and changing contexts. Dimensions of public health capacity that should be considered in this regard are summarised in Table 7. There is also the need for strategic resilience within public health to sustain the capacity and the relationships within health protection to manage outbreaks and public health incidents. The skills and competencies need to be maintained and the capability to escalate and sustain a response needs to be assured.
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Table 7: Dimensions of public health capacity ( Aluttis et al, 2014)
Dimension Description Organisational structures The infrastructural ability of a system to contribute to goals of public health Resources The allocation and provision of human and financial resources necessary to carry out public health activities Partnerships Collaboration between organisations for effective public health practice Workforce Qualified human resources with sufficient skills and knowledge; availability of training options Knowledge development The knowledge base that provides information on the health of the population and that supports evidence- based public health policy and interventions at all levels Leadership and governance The ability and willingness of governments to improve public health by developing and implementing effective public health policies and by expressing qualities in leaderships and strategic thinking Country specific context The political context and other characteristics of a country that may have an influence on public health policies and capacity building efforts
51. In assessing where a public health function can make most impact there has been recent work in Scotland and internationally exploring the cost-effectiveness of population health interventions. Best preventative investments for Scotland – what the evidence and experts say (NHS Health Scotland, 2014) examined available evidence (which it stated was limited but growing) coupled with expert opinion to identify the best investments for preventing poor health, reducing ‘failure demand’ and narrowing health inequalities. In its summary it stated that “in general, prevention ‘upstream’, addressing the economic, social and environmental causes of health inequalities, is cost-effective. It is more likely to reduce health inequalities than either treatment of illness or ‘downstream’ measures to change behaviours delivered to individuals”. ScotPHO has also modelled estimates of the impact of some interventions on health and health inequalities (The Scottish Public Health Observatory, 2014).
52. An international study ACE - Assessing Cost-Effectiveness in Prevention (University of Queensland and Deakin University, Melbourne., 2010), conducted in Australia, reviewed the cost-effectiveness of 150 preventive health interventions, addressing areas such as mental health, diabetes, tobacco use, alcohol use, nutrition, body weight, physical activity, blood pressure, blood
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cholesterol and bone mineral density. The largest impact on the health of the population arose from regulatory and tax measures. Other cost-effective measures included many screening programmes and immunisation and drug and alcohol treatment programmes, smoking cessation and preventative measures to improve mental health.
53. WHO has shown a wide range of preventive approaches to be cost-effective (WHO, 2014), including those that address environmental and social determinants of health (e.g. promoting walking and cycling, safer transport, green spaces, healthy employment), promote resilience (e.g. improving mental health and reducing violence), and support healthy behaviours (e.g. tobacco and alcohol legislation, reducing dietary salt and sugar, increasing physical activity, nursery toothbrushing), as well as vaccination and screening.
54. Focussing on the implementation of approaches, additional messages from previous UK reviews have emphasised the importance of population engagement with health issues (the ‘fully engaged’ scenario) to achieving a shift to prevention and the delivery of cost-effective interventions (Wanless, 2002 and 2004) and of taking action across the whole social gradient, not just with some segments in society, in order to reduce health inequalities (Marmot, 2010).
55. Two recent reviews have considered the focus of Scotland’s approach to tackling health inequalities and how current resources are used: NHSHS’s Health Inequalities Policy Review (Health Scotland, 2013) and Audit Scotland’s 2012 report on health inequalities in Scotland (Audit Scotland, 2012). The latter focused on how resources are allocated and on delivery mechanisms through Primary Care, CPPs and NHS Boards, reporting that the Scottish Government allocated an estimated £1.8 billion over the three financial years from 2008/9 – 2010/11 for issues related to health inequalities. Although these two reports focus differently on the approaches taken in Scotland – the former being more concerned with the policy content, the latter with governance, resource allocation and delivery mechanisms – both sets of recommendations suggest the need for a clearer focus on population health in Scotland, greater coordination across structures and levels of action, and the need for partnership-based action informed by public health intelligence and evidence.
56. The subject matter of these recent reviews – addressing health inequalities – reflects the ongoing need to make progress on that issue. In a number of other areas of public health Scotland is recognised as being at the leading edge. The leadership shown on tobacco control; the government’s commitment to tackling the price and availability of alcohol; the quality, uptake and effectiveness of our childhood immunisation programmes; the considerable improvements in oral health; the drop in violent crime achieved as a result of the country’s focus on violence reduction and safer communities; and the investment being made to ensure that Scotland’s children have a good start in life – all of these, and many other examples, illustrate public health achievements delivered through ‘the organised efforts of society’ for Scotland.
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57. In each case, there has been bold, committed, leadership with local and national political support; effective partnership working; an applied evidence-base; clear accountability and monitoring processes; a critical mass of effort and investment; and action at national, regional and local levels.
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2015 REVIEW OF PUBLIC HEALTH IN SCOTLAND: STRENGTHENING THE FUNCTION AND RE-FOCUSSING ACTION FOR A HEALTHIER SCOTLAND
PART 2: FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
58. The material described in Part 1 of this report was drawn from documentary and data analysis undertaken to inform the considerations of the Review Group and to ensure that the conclusions and recommendations made were informed by a good understanding of the history of public health, the nature and scale of the function in Scotland, current and future challenges, and wider policy issues.
59. Here, in part 2 of the report, findings are presented from the engagement processes undertaken by the review and the additional research evidence commissioned. These relate to the particular remit of the review, to examine:
• public health leadership and influence, both within the health sector and more widely; • opportunities for greater joined-up working and successful implementation of public health measures within the context of community planning, single outcome agreements, and health and social care integration; and • workforce planning and development, succession planning and resourcing within the multi-disciplinary core public health workforce.
60. The Review Group’s recommendations take account of material described in both Part 1 and Part 2.
Themes emerging from the Review of Public Health in Scotland 61. Some clear themes emerged from the material generated during the review process: from the contributions to the engagement exercise, the findings of the research review, and the policy and data analysis undertaken to inform the Review Group’s deliberations. Collectively these reflect a wide range of perspectives and information. Across these sources there were strong messages about: a. the importance of both national and local perspectives, and the need for greater coordination between these different levels; b. the need for greater visibility and a clearer identity for the public health function; c. the challenges and opportunities for public health, including the need to respond more effectively to large-scale strategic challenges (such as the desired shift to prevention) and to focus more clearly on identified priorities; d. the desire for strengthened leadership from individuals and organisations, and in partnership areas including IJBs and CPPs; e. the fundamental importance of effective partnership working as a prerequisite for better population health; and f. the nature of the workforce and the challenges of supporting and strengthening multi-disciplinary public health.
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62. What follows expands on these general themes under a number of headings, although many of the themes and issues are in fact interconnected. The report also mentions some additional specific issues highlighted through the review process and provides additional information and commentary where these relate to specific conclusions and recommendations.
1. Organisation 63. There was seen to be a cluttered public health organisational landscape in Scotland, with more clarity needed on organisational roles and responsibilities and, importantly, how they join up.
64. The responses to the review made frequent reference to the need for clarity about what might best be done at national, regional and local levels, which prompted this specific question being asked of stakeholders at the engagement workshops. There was a widespread sense that coordination between levels was currently weak, and that the status quo could be improved. The importance of balancing national or regional approaches with local activity was emphasised.
65. There was general agreement that activities that could be categorised as being delivered “once for Scotland” would be best taken forward at national level, and a view that some activities were currently being duplicated by 14 local public health functions. Stakeholders noted the opportunities for greater efficiencies where more could be done at a national level than currently, leading to greater coordination, resilience and a reduction in duplication. It would be necessary to maintain and enhance speed and flexibility of response, and important to recognise that local level arrangements/implementation may differ (for example in rural compared with urban areas).
66. Responsibility for the different domains of public health lies in different national bodies. NHSHS has the predominant national responsibility for population health improvement and tackling inequalities. HPS, within NSS, has responsibility for health protection at a national level. While ISD, as part of the Public Health and Intelligence Strategic Business Unit within NSS, has a national role in providing health intelligence, there is no national body specifically responsible for public health intelligence, and a number of national bodies make a contribution. There is no single organisational locus for the public health contributions to improving health services. These organisational arrangements potentially contribute to the lack of coherent, coordinated public health leadership in Scotland. Moreover, there remain questions about the balance of resource and effort between national, regional and local activity in each of the domains of public health.
67. The local positioning of much of public health was seen as a strength: it enables public health staff to interact with local decision making structures; to be an integral part of the planning and delivery of local services; to build strong relationships and partnerships; and to influence local partners. Stakeholders noted the need to engage with local communities and organisations, and to act at a local level. Access to local-level data and information was also regarded as being important in order to understand the composition, health needs and assets of local populations and trends in the determinants of population health.
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Research and evaluation of local policies and approaches was seen as a highly valued public health role.
68. Responses highlighted the need for clear links between the public health function and Local Authority and Community Planning structures, particularly in relation to strengthening action on the wider determinants of population health. There was recognition that some local communities face multiple challenges and that this calls for multi-faceted responses, working closely with communities themselves to develop more holistic approaches which meet their needs as well as possible. A number of respondents commented that the public health function should be better aligned with, and more accountable to, local community planning arrangements (Griesbach & Waterton, 2015).
69. There was less clarity about the role of regional structures, including those that might coordinate work across several NHS Board or Local Authority areas. Stakeholders noted the potential for more shared services approaches including, for example, for the health protection function (Griesbach & Waterton, 2015). The value of the North of Scotland Public Health Network, in its particular context, was also clearly recognised. The need for better integration at national level also raised issues about the potential benefits of some further regional-level arrangements.
70. The written engagement questions specifically prompted reflection on how best to organise the public health landscape in Scotland to ensure the most appropriate balance of functions at national, regional and local levels. Respondents recognised that the delivery of the public health function may need to change in response to the changing organisational and policy landscape, including the emphasis being placed on organisational and partnership responsibilities for addressing health inequalities and the wider determinants of health. Some responses suggested there needed to be a single strong national public health organisation, while others saw threats in the possible reorganisation of the public health function, with concern about the centralisation of the public health resource impacting on local relationships and responsiveness to local needs (Griesbach & Waterton, 2015). At the same time there was a concern that the drive towards localism may make it harder to deliver change on a national basis (Griesbach & Waterton, 2015). In short there was general recognition that some organisational change may be necessary, but no consensus about what that change should be.
71. Stakeholders also felt that the mechanism for connecting national and local public health roles and responsibilities could be improved in Scotland. Supporting evidence for this emerged from the research analysis commissioned by the Review Group (Curnock, 2015). This examined evidence on the relative merits of different governance and accountability structures. Among the different approaches adopted internationally there is a dynamic balance between the scope and scale of national and local infrastructures for public health. This balance changes over time and varies between countries according to their political context, structures, social attitudes and history of participative decision- making (Allin et al., 2004; Brownson et. al., 2012; Jakubowski & Saltman, 2013). International country case studies (including England, France and Sweden)
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demonstrate the tendency to counterbalance devolved responsibilities with national accountability and direction.
72. The benefits of a nationally-led and largely centralised public health infrastructure include: the capacity to employ strategic approaches to addressing health issues with global roots, with clear alignment between vision, strategy and objectives; the ability to address inequalities of access and resource when implementing and coordinating actions; and stronger core infrastructure for issues such as IT and health intelligence. These strengths sit in tension with the benefits of power being devolved to localised regions, which include: more democratic decision-making with greater engagement and access to the population; locally responsive strategies with opportunities for experimentation; and the ability to utilise local drivers for implementation. However, localised governance may be susceptible to inefficiencies of scale, unnecessary variation and exacerbation of inequalities, and individual interest agendas (Allin et al, 2004) (Jakubowski & Saltman, 2013) (Rayner, 2007).
73. The research analysis (Curnock, 2015) concluded that there “will always be a shifting dynamic balance between local and national, and therefore there is no single ‘right’ solution. There is no apparent direct relationship to better population health outcomes and the balance between local and national governance for public health. Each country seeks to find the balance between these that best fits its culture, politics and values.”
2. Strategy 74. The Review Group and respondents noted the current lack of an overarching public health strategy for Scotland, including priorities, clear responsibilities and anticipated outcomes. Through the review process the development of a national public health strategy was proposed as one of the main mechanisms to bring about a more cohesive and coherent approach across Scotland.
75. By providing a coherent national approach and an agreed set of priorities, a national strategy would also provide a focus for the public health leadership effort. In particular a national strategy would provide the basis for a new set of leadership arrangements (more clearly aligned to national priorities), as well as improving the accountability of leaders (Griesbach & Waterton, 2015).
76. There was strong support from the engagement responses for directing the public health endeavour towards reducing inequalities in health and for making this more explicit in the focus for public health in Scotland. This would require bold leadership, reallocation of resources to areas of greatest need, tailoring of interventions to better meet the needs of different groups, and a focus on empowerment and social renewal. National Government would need to lead the way and create the context for all public services to demonstrate these features. The engagement responses noted the threats to population health from austerity and current welfare reform policies, and their effects on the most vulnerable individuals and families in Scotland.
77. The research analysis highlighted that no single approach can be identified as the basis for a highly effective public health function. “The effectiveness of the
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public health system is dependent not only on the skills, leadership, cohesion and adaptability within the various components and levels of that system, but also on the wider political, cultural and resourcing context in which the public health system operates” (Curnock, 2015). In line with this, one of the conclusions of the research analysis concerned the need for clarity about the ‘leadership ask’ in relation to both the specialist public health function and to the wider challenge of improving the public’s health in view of emergent priorities (such as an ageing population, socioeconomic inequalities and the globalised social and cultural context).
3. Leadership 78. The importance of strengthening public health leadership was clearly expressed during the review process from a range of quarters, and engagement responses identified that Public Health needs to be more visible and the vision more clear.
79. In considering the dimensions of leadership that are needed, the following features were recognised: a. enhanced leadership at all levels within and across the public health function (not solely located within a few senior leaders); b. leadership that is cross-functional, working across the whole system that promotes and protects population health; c. leadership (including advocacy) for priority public health issues; d. leadership of the specialist public health workforce.
80. The research analysis and engagement analysis both highlighted the challenges facing public health leadership in Scotland. Stakeholders commented specifically on the challenges arising from changes to the public sector landscape and the need for the public health function to have a clear locus in influencing local structures, in particular CPPs and the new IJBs. Both areas of work recognised the need to provide leadership over complex systems, extending beyond NHS and health boundaries, to influence wider agendas, policies and programmes (Griesbach & Waterton, 2015). Stakeholders also wanted to see the public health leadership role of professional leads and interaction between Scottish Government and external organisations more clearly articulated e.g. Chief Medical Officer (CMO), Chief Dental Officer (CDO), Chief Pharmaceutical Officer (CPO), public health roles of Scottish Government, NHSHS, and Joint Improvement Teams, etc. (Griesbach & Waterton, 2015)
81. Improving population health, and within this the focus on prevention and tackling inequalities, is a strategic approach and should be an integral part of how leaders plan and make use of available resources to improve outcomes, prevent harm and ensure sustainability of public services in future years. There are a number of existing senior leadership forums in Scotland6 which provide the opportunity to strengthen the role of Public Health and to increase public health understanding and practice in other disciplines.
6 Health and Social Care Leadership Advisory Board, The National Leadership Unit (NLU) in NES, Scottish Leaders Forum (SLF)
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82. Through the engagement processes respondents stated that leadership at national level was vital. This should include leadership from Scottish Government, COSLA, national organisations, and professional groups (e.g. Scottish Directors of Public Health (SDsPH).
83. The Scottish Government’s commitment to public health was well regarded and seen as being demonstrated in both policy and legislation. Stakeholders welcomed the Scottish Government’s ‘strategic focus on inequalities’ and its recognition of the impact of the wider determinants of health, but there was a desire for more focus from the Scottish Government on public health as a key component of the health portfolios and for better coordination across ministerial portfolios on the wider determinants of health and inequality. (Griesbach & Waterton, 2015)
84. Stakeholders continued to see serious threats to the public health endeavour from powerful multi-national business interests (Griesbach & Waterton, 2015) and mentioned the crucial role of Government in developing more effective responses. More generally, the complex cultural change required to organise the efforts of society in order to protect and improve the public’s health implies a role for Government in enabling that change to take place. Examples given to the Review Group included the need for a shift in focus from target setting to more ‘upstream’ activity, and from traditional performance management to an approach that supports systems change and enables long-term action, prevention, shared partnership responsibilities, and new types of relationships with communities.
85. Stakeholders also emphasised that leadership and action should reflect the breadth of the public health endeavour. Public health leadership needs to be demonstrated in areas as diverse as employment, education and skills development, poverty and welfare reform, planning, housing, children’s services, and climate change (Griesbach & Waterton, 2015). Some of the engagement responses specifically stated the importance of non-NHS staff, including third sector and community champions, taking on leadership roles in these areas (Griesbach & Waterton, 2015).
86. The research analysis (Curnock, 2015) stated that emergent public health challenges (such as an ageing population, socioeconomic inequalities and the globalised social and cultural context) require new approaches to public health leadership (Beaglehole, R & Bonita, R , 2004); (Czabanowska et al, 2014); (Hanlon P. , 2013). In addition, the number of potential stakeholders with a public health agenda is ‘wider than ever’ (associated with increased recognition of the social determinants of health) and the nature of public health practice has shifted (Czabanowska et al, 2014) (Davies et al, 2014) (Koh H. K., 2009). Table 8 summarises some of these leadership functions, both in relation to the public health workforce and the wider agenda of improving population health.
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Table 8: Features of leadership
Specialist and practitioner public health workforce Shaping, organising, networking, connecting, advocacy, gathering disparate groups together with a shared focus on a specific outcome (Day, M., Shickle, D., & Smith, K., 2014) (Koh H. K., 2009); (Mackenbach, J., & McKee, M., 2013) Identification of opportunities within seemingly „chaotic‟ constantly changing environments with uncertain outcomes and an ability to employ systems-thinking (Czabanowska et al, 2014) (Hunter, 2009) (Koh H. K., 2009)
Enthusiasm, vision and credibility underpinned by a commitment to social justice (Czabanowska et al, 2014) (Griffiths, S., & Hunter, D. J., 2007) (Koh H. K., 2009) (Rechel, B. 1., & McKee, M, 2014) Collaborative, flexible leadership as a function of group aims or values (as opposed to authoritarian or technocratic models) situated in a relational community rather than attached to individuals or specific roles ( (Brownson, 2012) (Czabanowska et al, 2014) (Howieson et al, 2013) (Koh H. K., 2009) (Rayner, 2007)
Wider leadership to improve population health „Leadership without authority‟ embedded within multi-sector alliances; galvanising civil society through traditional and social media; building bridges with academia and practitioners; national bodies who can serve as a convener of diverse organisations; encouraging the cultural shift toward active citizenship; participation in emergent public fora that nurture „public interest leadership‟ (Davies et al, 2014) (Drehobl et al, 2014) (Howieson et al, 2013); (Lachance et al, 2015) (Mackenbach, J., & McKee, M., 2013)
Influence through political astuteness and persuasion (Hunter, 2009) (Koh H. K., 2015); (Mackenbach, J., & McKee, M., 2013) (Rayner, 2007) (Rechel, B. 1., & McKee, M, 2014)
Environments of innovation, creativity, imagination and continuous learning (Czabanowska et al, 2014) (Rayner, 2007) (Czabanowska et al, 2014) (Rayner, 2007)
4. Directors of Public Health 87. The Directors of Public Health (DsPH) in Scotland have an important national and local leadership role to play, and the local role is perhaps more clearly described in expectations set out by Territorial Boards in the Faculty of Public Health‟s
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specimen job description for a Director of Public Health in Scotland (Faculty for Public Health, 2013) . The job description describes the high profile senior leadership qualities required as the most senior advocate for public health within the Board and on behalf of the populations served by the post: The engagement responses yielded a similar list of features and skillset that stakeholders are looking for from Public Health Leadership in Scotland (Griesbach & Waterton, 2015): • Being a ‘population advocate’: This would involve advocating and lobbying on ‘upstream’ issues that affect public health (e.g. welfare reform, local development planning, etc.). • Being independent: The independence of the public health voice was emphasised as this would allow public health leaders to challenge policy makers at a national level, to say things that were ‘uncomfortable’, and to address poor performance at a local level. • Engaging with local communities: Respondents highlighted the need for greater engagement and better communication between public health leaders and local communities – to give communities greater ownership of health improvement and prevention. • Being more visible: This would involve building relationships with key partners in health, social care and third sector agencies, being able to influence their agendas effectively. It would also involve building and maintaining the profile of public health at all levels. • Making the case for public health: This would involve making an effective case for increased priority and resources for public health. • Understanding the evidence: In order to ensure that organisations which distribute resources for public health and public health interventions do this in an effective – and cost-effective – manner, leaders in public health should have a good understanding of the evidence base. • Working in partnership: Respondents highlighted the importance of good leadership in strengthening partnerships. • The ability to work strategically within complex systems. • The ability to work across organisational boundaries with a wide range of stakeholders to influence and facilitate system-wide change. • The ability to look beyond current pressures to understand future challenges and opportunities to do things better. • Evidence synthesis skills and the ability to communicate evidence succinctly, and translate it into effective practical action. • Good people and management skills, including team building, networking, building trust, negotiation and facilitation skills. • The ability to consult and work with communities using asset-based approaches to co-produce local solutions to public health problems.
88. Stakeholders emphasised that DsPH are valued locally. They have a vital role to play in linking the domains of public health, using public health intelligence to advocate for population health, supporting the role of partnerships, and raising
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the profile of public health. The local leadership role is evolving in relation to supporting the new IJBs, local authority committees, and CPPs.
89. Stakeholder responses also indicated, however, that the DPH role had become diluted over time and could be strengthened, including in relation to its contribution to national policy (Griesbach & Waterton, 2015). DsPH were seen as providing a link to the Scottish Government and there was an expressed desire to develop their role in bridging local and national policy. There is an expectation that DsPH should provide local leadership and also deliver coherent national leadership as a Group of Directors.
90. In addition, the Review Group recognised that there are currently vacant DPH posts in Scotland and the potential for further vacancies in the near future. A focus on workforce planning and talent management, with investment specifically made in a future cohort of DsPH, will be of critical importance for the resilience and effectiveness of the function.
5. Evidence for action 91. The importance of data, information, intelligence, research and evidence featured prominently in the review process, with stakeholders emphasising the need for action and interventions to be informed by the best possible public health intelligence. This need was recognised both at a national level (national level data sets) and a local level (translation of data into local level action).
92. In general the available data, information, intelligence and analysis and evidence are of good quality. However, the review process highlighted the need for more coordination to ensure that the public health research and intelligence activities undertaken in Scotland are relevant to priorities; evidence is clearly presented and duplication is minimised; and for research processes to focus on processes of change and address the gap in translation of evidence into practice.
93. Academic Public Health and other research organisations could be better connected to policy and delivery processes: the intention would be to foster an environment for exchange of information, expertise and (potentially) resources between organisations.
94. The review has recognised the scale and value of the public health data, research and academic assets in Scotland, and the developments taking place in research-service collaborations. Scotland is a highly regarded host of international conferences and has conducted public health research which is genuinely world leading. These are strengths on which Public Health can build.
6. Collective responsibility: advocacy and partnership 95. To address the determinants of population health, as well as particular health priorities, responsibility for public health needs to be shared widely across different organisations, sectors, communities and individuals. Greater emphasis should be placed on this sense of collective responsibility. The core public health workforce should lead the collective effort, recognising that many population health challenges are the type of ‘wicked problem’ that can only be overcome
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through partnership working and a shift to prevention within and across systems. Political leaders have a critical role to play in this regard.
96. The research analysis highlighted that this sense of collective responsibility is reinforced internationally through the Health in All Policies (HiAP) approach � a cross-sector approach that systematically takes into account the health implications of decisions across public policies in order to improve population health and reduce inequalities. This plays an important role in the European Health 2020 policy framework (Leppo et al, 2013) (McQueen, 2014). Conditions which reinforce and sustain this approach include a supportive political context with legal backing, development of policy proposals across sectors with an ability to seize policy-making opportunities, processes for inter-sectorial communication and implementation, resources (such as joint budgeting or delegated financing), and the technical skills and governance structures to implement policy decisions and evaluate their impacts on health and its determinants (Leppo et al, 2013) (McQueen, 2014) (Ståhl et al, 2006) (Wismar et al, 2012).
97. Effective partnerships are essential for an effective public health function. Recent policy in Scotland seeks to strengthen partnership working across public sector bodies, with the third and independent sectors, and with communities. This is a supportive cultural and policy environment which aligns with the public health agenda.
98. The engagement responses echoed these themes and stressed the need for partnerships to be appropriately resourced, with a request for more dedicated public health capacity and also for increased time to nurture, build and sustain partnerships (Griesbach & Waterton, 2015). The engagement responses proposed an inclusive approach for partnerships, utilising contributions from the wider public health workforce; the voluntary and third sectors; Local Authorities; communities; and the public (Griesbach & Waterton, 2015). The focus of the responses was on supporting existing partnership structures.
99. The engagement process also highlighted a current lack of understanding both about the scope of public health and the activities which comprise it (Griesbach & Waterton, 2015). There was a request for clarification on the various contributors to the public health endeavour and how they join up (the development of a national strategy was felt to be a helpful mechanism for achieving this). Respondents felt that there would be significant value in achieving a better (shared) understanding of the public health function and priorities, and of the partnership endeavour associated with improving health and reducing inequalities.
100. Stakeholders indicated that a clearer articulation of the partnership contribution made by the public health workforce (for example through its population health perspective, population needs assessment, evidence and prevention focus) would also be helpful. This would help to raise the profile and understanding of this contribution and to make clear that this role extends beyond ‘health’ initiatives to advocacy and action on the wider determinants of health and inequality. The need for a shared language within partnerships to describe and build a better understanding of public health was also highlighted. Establishing
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shared partnership outcomes was regarded as essential for successful partnerships and for working towards longer term change.
101. The responses received in this review process argued that genuine sharing of resources (financial, human, physical assets, data, evidence, and other forms of intelligence) across organisational boundaries needs to be at the heart of partnership. It was felt that the contracting/funding arrangements in Scotland should support and reinforce partnership working between the public, private and voluntary sectors.
102. There is extensive research literature which describes factors that facilitate (or provide challenges to) successful partnerships. These are summarised in Table 9 below.
Table 9: Task and people focused facilitators of partnership working, categorised in relation to Implementing (Imp) or Sustaining (S) phase
Task focused facilitators of Partnership People focused facilitators of Working Partnership Working Consideration given to alternative Senior representation and senior approaches to achieving outcomes; engagement (I) explicit consideration of the degree of Source: (Boydell & Rugkasa, 2007) involvement of each group to maximise (Stern & Green, 2005) resources; and agreement of pre- determined exit strategy (I) Source: (Carlisle, 2010); (Graham et al, 2015) (O'Mara-Eves et al, 2015) Clear success criteria / goals / aims / Participation of ‘boundary spanners’ – purpose (I) individuals who bridge organisations Source: (Boydell & Rugkasa, 2007), (‘across’), connect with the policy (Graham et al, 2015) (Hunter & Perkins, agenda (‘upward’) and with 2012) (Shaw et al, 2006), (Taylor- communities (‘downward’), partners Robinson et al, 2012) with local or ‘insider’ status, boundary spanning mechanisms. (I) Source: (Carlisle, 2010) (Eilbert & Lafronza, 2005); (Oliver, 2013); (Powell, Thurston & Bloyce,, 2014) (Rugkasa, Shortt & Boydell, 2007) (Stern & Green, 2005) (Taylor- Robinson et al, 2012) Transparent frameworks and fair conduct Where there is community involvement: for decision-making (I) community and front-line workers are Source: (Marks, 2007) (Shaw et al, 2006); primary drivers (engagement is (Stern & Green, 2005) (Taylor-Robinson et empowering rather than consumerist), al, 2012) not just for ‘representation’ (I) Source: (Carlisle, 2010) (Carr et al, 2006) (Eilbert & Lafronza, 2005) (Marks, 2007); Marks, 2007; (Stern & Green, 2005)
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Clear accountability structures and Collaborative leadership rather than governance requirements which are ‘control and command’ (S) similar across organisations or an ability to Source: (Carr et al, 2006) (Ferlie et al, adapt to alternative structures; 2010) (Hunter & Perkins, 2012) organisational performance management systems that include collaboration within criteria of each partner (I) Source: (Boydell & Rugkasa, 2007) (Carr et al, 2006) (Hunter & Perkins, 2012) (Marks, 2007); (Powell, Thurston & Bloyce,, 2014) (Stern & Green, 2005)) Sufficient funding, infrastructure and Appropriate communication, shared resources; willingness to share information language, responsiveness (S) and resources; joint appointments (I) Source: (Carr et al, 2006) (Shaw et al, Source: (Carlisle, 2010) (Ferlie et al, 2010) 2006) (Taylor-Robinson et al, 2012) (Hunter & Perkins, 2012) (Marks, 2007) (O'Mara-Eves et al, 2015) (Stern & Green, 2005) (Taylor-Robinson et al, 2012)
Connections and ‘joined up thinking’ Time and space to develop trust and between local and national agendas and goodwill and enable ‘emergence’ and between different national agendas, as ‘evolution’ of activities; capacity to work well as policy stability (I) through conflict; protection from top- Source: (Carr et al, 2006) (Hunter & down restructuring (S) Perkins, 2012) (MacGregor & Thickett, Source: (Boydell & Rugkasa, 2007) 2011) (Shaw et al, 2006) (Carlisle, 2010) (Carr et al, 2006) (Hunter & Perkins, 2012) (MacGregor & Thickett, 2011) (Marks, 2007) (McMurray, 2007); (Shaw et al, 2006) Shared geographical boundaries with an Job security, organisational stability and approach to planning organised at a low turnover of staff; previous history of similar level (I) working together (S) Source: (Carlisle, 2010) (Marks, 2007) Source: (Carr et al, 2006) (Hunter & (Taylor-Robinson et al, 2012) Perkins, 2012) (Marks, 2007) (Powell, Thurston & Bloyce,, 2014) (Taylor- Robinson et al, 2012) Permission to experiment to solve Shared values and priorities built on an problems; ability for local ‘customisation’; evidence base that spans sectors; and an ability to frame problems and support for ‘off-line’ development solutions differently from what training spaces where different perspectives and professional customs may suggest (S) can be discussed (I) Source: (Ferlie et al, 2010) (Hunter & Source: (Carlisle, 2010) (Eilbert & Perkins, 2012) (Pate et al, 2010) Lafronza, 2005) (Ferlie et al, 2010) (Fischbacher & Mackinnon, 2010) (Stern & Green, 2005) (Taylor- Robinson et al, 2012) Commitment to outcome evaluation with Secure professional and organisational published results; shared perceptions of identities set within the context of ‘good evidence’; access to high quality strong identity for the partnership itself data; capacity to track multiple inputs and and the removal of unnecessary outputs over a long period; adaptive organisational symbols that emphasise
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system to enable feedback from learning; cultural differences (S). continuum of outcome achievement (short Source: (Ferlie et al, 2010) (Pate et al, and long-term) (S) 2010) Source: (Carr et al, 2006) (Eilbert & Lafronza, 2005) (Graham et al, 2015) (Hunter & Perkins, 2012) (Powell, Thurston & Bloyce,, 2014) (Taylor- Robinson et al, 2012)
103. Designated support from the public health function will be needed to support CPPs and Health and Social Care Partnerships (HSCPs) to maximise their public health contributions and to assess impact. Both offer opportunities for a partnership focus on prevention and public health. An important role of the specialist public health function within wider partnerships is to counter pressure to shift attention away from the preventative agenda towards high-profile downstream issues by locating health issues within an evidence-based public health framework.
104. There is also a need to support specific partners within CPPs, including providing support to Local Authorities. The necessity to support these partners and partnerships has implications for how the public health workforce is deployed. Responses to the review highlighted the very real challenge of ensuring the provision of support to local partnerships while maintaining the necessary critical mass needed to ensure a comprehensive public health function and avoiding dilution of input to key strategic organisations.
105. Review findings specific to Health and Social Care Integration, Community Planning, NHS Boards, Local Authorities, the third Sector and Communities are summarised in the following sub-sections.
6.1 Health and Social Care Integration 106. The overarching statement for health and social care integration set out in the National Health and Wellbeing Outcomes Framework is that “health and social care services should focus on the needs of the individual to promote health and well-being, and in particular to enable people to live healthier lives in their community” (Scottish Government, 2015). “Key to this is that people’s experience of health and social care services and their impact is positive; that they are able to shape the care and support that they receive; and that people using services, whether health or social care, can expect a quality service regardless of where they live” (Scottish Government, 2015).
107. Currently there is one core outcome for integration related to the wider public health endeavour. The National Health and Wellbeing Outcomes also require Boards, Local Authorities and Integration Authorities to contribute to reducing inequalities through the services that they provide. The Scottish Government has issued a number of Guidance and Advice documents to support the Public Bodies (Joint Working) (Scotland) Act 2014.
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108. From a public health perspective the engagement responses sought to ensure that HSCPs are also created as public health organisations. At IJB (or equivalent) level the over-riding purpose should be for strategic plans to reflect the needs of their population, reduce the health gap and give appropriate priority to population health improvement, health protection and prevention of ill-health, alongside delivery of health and social care services.
109. The engagement responses identified that Public Health specifically has an important role in supporting this process through strategic and service needs assessment; the provision of quality information, evidence and advice; and supporting capacity building and organisational development for IJBs or equivalents. Health Improvement Teams are an integral part of HSCPs in most areas and have an important role in working with communities, providing health improvement services, and connecting national policy and local activity.
110. The engagement analysis also noted specific opportunities arising from closer integration between the NHS and Local Authorities, including working together for shared outcomes; raising the profile and effectiveness of public health approaches in primary care (e.g. via GP and pharmacy contracts) and social care; and facilitating a population approach to service planning and opportunities for combined efforts, resources, and training.
6.2 Community Planning Partnerships 111. CPPs were seen in the engagement responses to be at the centre of the public health endeavour and the main mechanism by which improvements in public health can be achieved at a local level (Griesbach & Waterton, 2015) with a clear link to the determinants of health. CPPs can be a key way through which local partners collectively coordinate and tackle public health challenges as part of work on shared local priorities. Community Planning LOIPs will reflect the priorities set by the CPP based on their understanding of local needs and circumstances, and there is a crucial role for Public Health to provide the evidence and expertise to inform and support the priorities for improvement within CPPs.
112. The 2012 Audit Scotland report on Health Inequalities (Audit Scotland, 2012) highlighted the leadership role of CPPs, alongside the leadership role of Government, for tackling health inequalities, recognising that activity to tackle inequalities involves bringing together organisations, clarifying roles and responsibilities, and ensuring sufficient shared ownership of initiatives across a range of sectors, organisations and boundaries. This report also noted the associated challenges, given different organisational cultures and governance. The report described mixed CPP performance with different levels of priority being given to health inequalities in different CPP areas. The engagement process for the current review similarly portrayed a mixed picture.
6.3. NHS Boards 113. NHS Boards have corporate responsibility for the protection and improvement of their population’s health and for the delivery of frontline healthcare services. Prevention and whole population approaches have long been a core role for NHS
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Boards. Health Boards should be visible leaders of public health through their own strategies and services, prioritisation and planning processes, and communications.
114. This was also recognised in the 1999 Review of Public Health in Scotland which saw Health Boards developing as "public health organisations", working closely with Local Authorities and others, and having the central role in protecting and improving population health at regional level with health improvement as the raison d’être of Boards. In practice the 1999 Review suggested that this would be evidenced through the following features: “
• The Board will provide high profile leadership for public health; • Its organisational development will reflect public health values and methods; • Many of its resources will be devoted to the public health function; • Clear and shared public health goals and responsibilities will be reflected in the corporate activity of the Board and its partner Local Authorities; • Board business and decision-making will be driven by public health principles, and informed by the best possible public health intelligence; • The Board will drive the development of effective, well-managed multi-agency partnerships for health, with particular emphasis on partnerships with Local Authorities; and • Boards are accountable for their role in health improvement and need a framework for public health governance.”
115. Currently each NHS Board has a Local Delivery Plan (LDP) which contains within it the performance contract between the Scottish Government and the Board. From 2015/16 NHS performance is measured against LDP Standards (previously HEAT targets and standards) and Improvement Priorities (which contribute towards delivery of the Scottish Government's Purpose and National Outcomes; and NHS Scotland’s Quality Ambitions). These Standards are largely focused on treatment and waiting times, including some with a specific focus on improving performance in areas of deprivation. ‘Health Inequalities and Prevention’ is one of six key strategic priorities and ‘Antenatal and Early Years’ is another, also strongly recognising the role of prevention. There is still, however, some way to go towards delivering on the recommendation in the 1999 Review which described a position where public health principles would be central to the ways in which Boards operate. The information gathered for the current review indicated that the performance targets and public/political expectations of Boards have tended to emphasise other priorities which guide investment and attention away from a focus on population health improvement, prevention and health protection.
116. This shift requires a change in thinking about health policy, recognising the respective roles of health care and the determinants of health in shaping the health of populations (Wilkinson & Marmot, 2003). The challenge for Health Boards is to reflect the wider perspective of creating the conditions for good health in their corporate functions and the services they provide (in a similar way to the repositioning of the fire service from treating to preventing fires). This would be apparent from Health Boards’ ambitions and exemplar activities where there is a direct role – e.g. as an employer, procurer of services, and in
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implementation of Health Promoting Health Service duties; as a member of wider partnerships; in ensuring equity of access to services; and in their relationship to local communities.
6.4 Local Government 117. Local Government is also an important and equal ‘sphere of government’ in Scotland which is directly accountable to its electorate. The political leadership and democratic accountability for public health improvement offered by Local Authorities, individually and collectively, is essential to the public health and wider prevention agenda.
118. Local Government plays a pivotal public health role given the prominence, scope and scale of its contribution to supporting public health outcomes and addressing health inequalities. During the review Local Authorities were also regularly recognised for their role as statutory partners within CPPs. Like NHS Boards, Local Authorities have a number of facets to their public health role, both as a partner to the collaborative effort and also in their own right. The challenges for Local Authorities is similar to that of Health Boards - to operate as public health organisations through demonstrating their impact on population health through their corporate processes, core functions and services.
119. Local Authorities provide specific services and functions which impact on the public’s health and are often underpinned by statutory duties (for example, environmental health and consumer protection are directly responsible for contributing to public health and safety). Local Authority responsibilities for key service areas such as social care, housing, education, employability and leisure also have a relatively well defined relationship with health inequalities and health improvement while wider responsibilities in relation to licensing, welfare reform, anti-poverty measures, planning and community development are often less well recognised for the important contribution they can make to public health.
6.5 Third Sector and Communities 120. The engagement responses highlighted the opportunity for public health agencies and leaders to develop stronger partnerships with the third / voluntary sector, enabling this sector to be “third among equals” in partnerships, with its skills and experience being better utilised. In its report, Living in the Gap, Voluntary Health Scotland suggests that the third sector lacks influence over statutory services (Voluntary Health Scotland, 2015). The third sector engagement responses to the review expressed the view that the relationship between the statutory and third sectors needs to change so that there is greater mutual trust and respect (Griesbach & Waterton, 2015). The third sector can enhance the public’s health. In particular it has access to marginalised groups and an important role to play in reaching, working with, and empowering local communities.
121. Community empowerment, reinforced through legislation, has been a key theme in the review. The redistribution of power, and the associated enabling of a sense of control, can contribute to tackling health inequalities. Increased involvement in decision making within one’s community can also increase feelings of belonging and participation. Stakeholders have highlighted, through
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the engagement process, that partnerships could be improved and strengthened if they engaged more effectively with communities. Strengthening asset-based approaches in working with communities was felt to be a valuable way of focussing on capacities and capabilities, rather than on need and deprivation. Community empowerment and co-production present a major opportunity for public health, not least in terms of building resilient communities.
122. There was general agreement that public health practitioners should be ‘doing things with, not to’ local communities and that activity should focus on supporting and developing co-production approaches to achieving outcomes (Scottish Public Health Network (ScotPHN) , 2015). The roles of Local Authorities, NHS Boards and other bodies in supporting community development and the individual and community resilience, which significantly contributes to better health outcomes, was also emphasised. The vital contribution to be made by the third sector and wider workforce in this wide context was highlighted.
123. The importance of co-production to reforming public services in Scotland, empowering communities and reducing inequalities, has been referred to as part of the “Scottish Approach” which covers (Ferguson, 2015): 1. assets or strengths of individuals and communities; 2. Co-production: policy developed with, rather than done to, people; and 3. Improvement – local ownership of data to drive change. This clearly underlines the importance of public health building on the good work that already exists to strengthen and value the role of communities in public health work.
7. Workforce 124. The current workforce was described in the responses to the review as being highly skilled, professional, knowledgeable, committed and enthusiastic (Griesbach & Waterton, 2015). Other qualities included objectivity, the ability to offer an independent view and voice, advocacy for the public health function, flexibility, adaptability, and responsiveness. (Griesbach & Waterton, 2015). The CfWI report - mapping the core public health resource in Scotland (Centre for Workforce Intelligence, 2015) - shows a relatively small (compared to NHS staffing), but nevertheless significant, core and specialist public health workforce in Scotland. However, the public health workforce is dispersed, risks further dilution, and lacks a clear programme and structure for development.
125. The workforce priorities in Scotland identified through the review relate to the core workforce at all levels (practitioner, specialist, consultant, directors of public health) and also to the wider workforce. They include: • development of a public health resource that is clear in its own identity; • development of leadership capacity (as described in paragraphs 78 to 86); • development and implementation of succession planning and career pathways which support/accelerate a multidisciplinary workforce (all disciplines, including medical); • maximising the potential of the NHS workforce to contribute to, and influence across, the three domains and enhance intelligence; • structured approach to developing the wider workforce contribution to public health.
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7.1 Workforce Development 126. The different levels of the core workforce and the wider workforce– all have specific needs. Leadership (covered earlier) is important at all levels. Engagement responses commented on the training requirements of the workforce. There was a general view that leadership and influencing skills could be improved and more training opportunities were needed, both for the core and wider public health workforce. There was also comment that there should be greater opportunities for senior people from backgrounds other than medicine to take on public health leadership roles. There was a view that public health leaders require considerable skill in influencing, lobbying and advocating for local populations.
127. It was noted that the development of leadership and management capabilities across the NHS is a key priority of the 2020 Workforce Vision. Responses noted the value in the leadership programmes currently provided within the NHS in Scotland. However there was a view that a specific public health leadership training programme could be beneficial for the core (specialist) public health workforce. There were also comments that the leadership aspect of post- specialist public health training could be developed further and that the inclusion of leadership skills in postgraduate courses and continuing professional development should be more systematic and consistent.
128. There has been a strong call for practitioner registration (whether the purpose is for the assurance of individuals themselves through professional value or for the public through quality assurance) and the Scottish Public Health Workforce Development Group (SPHWDG) (a cross-disciplinary group in Scotland chaired by NHSHS on behalf of the CMO) has agreed in principle to consult on a scheme to support public health practitioners towards registration, seeking views from stakeholders.
129. The workforce development group has also agreed to re-activate a scheme to help people to meet the requirement of the specialist registration scheme for a defined period. This would run in addition to the UK-wide Faculty of Public Health training scheme.
130. The multi-disciplinary nature of public health raises equality issues also. Despite the progress made to date with support for multidisciplinary public health, there are still historical barriers in Scotland relating to appointments, and to equal pay and performance structures for specialists from a non-medical background. During the review the Specialist Group in Scotland argued for a more systematic and equitable structure for career development that links across disciplines, and practitioner and specialist career pathways. It argued that this evolution would better utilise the existing resource, create standardised practice and strengthen succession planning.
7.2 Career progression 131. The engagement responses called for career pathways to be developed from the wider workforce into the core workforce, with the potential for progression within the core workforce to the specialist workforce by recognised routes. The
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development of pathways from the NHS into the wider workforce and other sectors should also be a goal.
132. The engagement responses also noted that the (older) age profile of the existing workforce and decreasing numbers of experienced staff warranted attention to workforce succession and development planning in order to sustain and make the best use of the specialist public health resource. REHIS, in its response to the review, similarly noted concerns with regards to the falling numbers of EHOs and Food Safety Officers (FSOs) employed by Local Authorities and the need to act to safeguard environmental health services in Scotland.
133. Public health is distinctive as an area of practice in the health sector and it reaches into other sectors of public and voluntary service where important resources also lie. There are conventional routes toward specialist practice, originally medical but (as noted above) now spreading out to other disciplines to reflect the potential that wider contributions and backgrounds can bring. This change reflects the need to nurture the wider, practitioner and specialist workforce, and create career progression pathways that balance:
• the changing challenges for public health; • workforce requirements and future capability; • the need for a pipeline of future leaders and talent management to ensure their development to meet capacity requirements and fulfil key functions; • expectations of people with public health skills who wish to progress; and • the blend of traditional routes to career progression with new and atypical routes, encompassing the contributions of specialists and leaders from other disciplines and sectors.
7.3 Recognising and supporting the wider workforce 134. The engagement responses highlighted that there are opportunities to develop the public health roles of wider NHS and other public service staff, building an inclusive approach to the contribution of people from diverse backgrounds and all sectors. There are specific opportunities to acknowledge, more overtly, the particular contribution to be made by primary and community care professionals. Respondents argued that the robust development of the wider public health workforce was essential to enhance influence and impact and deliver public health outcomes, not only in terms of health behaviour change, but also in reducing health inequalities. These points reflect the importance of investing in the wider workforce, as set out in recent reports from The Royal Society for Public Health (RSPH) (Royal Society for Public Health, 2015) and (Royal Society for Public Health, 2014).
135. The wider workforce is already engaged in public health activity in Scotland in many ways. However engagement responses indicated that plans to harness the potential of the wider workforce need to develop still further, particularly in ways to structure or facilitate involvement of the wider workforce. It will be useful in Scotland to monitor and draw from the work of the RSPH on wider workforce. The review supports the RSPH view that health is everyone’s responsibility and
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that there is the opportunity to grow the contribution of the wider workforce as part of the organised efforts of society towards improving health and wellbeing and reducing health inequalities.
Recommendations
136. Based on the above findings and conclusions, and informed by the wider context described in Part 1 of this report, the following recommendations are made by the Review Group.
1. Organisational Arrangements 137. The current organisational arrangements for Public Health in Scotland should be reviewed and may need to be rationalised. This should explore greater use of national arrangements (including for health protection, public health intelligence and other areas deemed „once for Scotland‟), more collaboration between Boards at a regional level, activity that should clearly remain at local level, and how the three levels connect.
138. The NHS Scotland Shared Services Programme7 has identified Public Health services for review within its „Health Portfolio‟. In taking this forward the findings of the Public Health Review should be used to define the strategic direction for public health in Scotland. The shared services work should also be used to underpin the development and delivery of the overarching review of organisational arrangements for public health in Scotland.
139. The Health Protection Oversight Group and the Scottish Government should build on the creation of the Health Protection Network to ensure effective leadership and coordination for health protection in Scotland..
140. The engagement responses noted a cluttered public health organisational landscape in Scotland, with more clarity needed on the roles and responsibilities of different bodies and, importantly, how they join up. Objectives to be met in considering alternative structures include: a. Achieving greater national cohesion, accountability and leadership across the various domains of public health. The current arrangements, with responsibility for different domains sitting within different organisations, lessens the effectiveness, awareness and understanding of the totality of the public health effort. The Scottish Government should consider any additional measures needed to provide a more coherent and more widely owned organisational structure. This should include allocating national responsibility for each of the domains of public health and the underpinning public health intelligence function, either clearly to existing national organisations or to a single national public health organisation. b. Achieving a clearer allocation of the public health responsibilities sitting at national, regional and local levels, and associated accountabilities.
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c. Sharing of resources across public bodies to ensure the most effective use of Health Intelligence Services, and the development of local strategies for health intelligence. d. Supporting all public bodies, and specifically Health Boards and Local Authorities, to become more overtly exemplar Public Health Organisations, demonstrating core public health principles and activities. The core work of Health Boards should recognise the central place that prevention should have in promoting and protecting the health of the population, while maintaining the existing important focus on safe, equitable and effective care services. These principles are equally applicable to Local Authorities and other public facing organisations. Public health should be made more explicit as part of the remit for public sector bodies and be reflected in how they carry out their activity.
2. Strategy for public health 141. A shared vision should be developed for public health with common goals and outcomes agreed as part of a Public Health Strategy for Scotland. The strategy should include the following features: a) focus on identified public health priorities (including (in)activity, diet and nutrition, obesity, mental wellbeing); b) provide a clear public sector and public health focus on addressing inequalities; c) support the necessary shift to action on prevention; d) make tangible the health in all policy approach − a cross-sector approach that systematically takes into account the health implications of decisions across public policies in order to improve population health and reduce inequalities; e) channel knowledge of what works into practical action; and f) demonstrate governance to ensure accountability and measurement of progress against outcomes.
142. The absence of a clear national strategy for public health was reflected in the perceived lack of cohesion in the public health work being carried out in Scotland. There is the potential for a Public Health Strategy, together with the National Clinical Strategy (in development), to provide an overarching strategic context for the delivery of health and care services in Scotland reflecting the triple aims of: improving population health, improving the quality and safety of care, and securing best value from health and social care services. The Public Health Strategy would also reflect the wider determinants of health and involve action by other sectors and services.
143. Delivery of an ambitious strategy for public health in Scotland will require attention to the infrastructure, capacity, effectiveness and resilience of the public health function. The following recommendations are intended to support this.
3. Leadership 144. There has been strong public health leadership from many individuals and on a range of issues in Scotland, but the current and emerging challenges require strengthened leadership on a number of fronts.
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145. The role and contribution of the Directors of Public Health should be clarified and strengthened . The DPH role is pivotal to an effective public health function and there is a need to support DPH leadership individually and as a group. This will require: (a) clarity about expectations and accountability in light of new organisational landscape and the move to multi-disciplinary public health (b) the development of a more effective national leadership group with real impact at national level, determine resourcing of Group, including dedicated resource for a Chair, and clarify relationship to Government) (c) coordinated recruitment and development for a new cohort of leaders to fill vacancies and ensure ongoing succession planning.
146. The new Public Health Strategy should be used to generate a stronger public health voice and more coherent action at all levels. More consistent messages echoed throughout Scotland by all sectors will be essential and will help to raise the profile and increase the influence of public health. Political leadership is also needed to achieve improvements in public health, demonstrated jointly from Scottish Government and Local Government, with strong cross-portfolio commitment reflecting the wide policy responsibility for determinants of health.
4. Public health intelligence and evidence for action 147. Public health intelligence underpins the three domains of Public Health and should continue to underpin public health activity in Scotland and the work that follows on from the review. The mapping of the core public health workforce in Scotland (Centre for Workforce Intelligence, 2015) identified the significant scale of the public health research and academic resource. Through the review there have been consistent messages about the importance of evidence-based interventions; the need for population-based data sets, at national and local levels, to inform priorities; and the strength of the existing resources in Scotland. To build on these strengths, the following recommendations are made.
148. Action should be taken to achieve greater coordination of academic public health in Scotland, building on successful models of collaboration in other fields, to develop a more strategic collaborative mechanism for public health research in support of the national strategy.
149. Priority should be placed on ensuring that public health policy and practice is more strongly underpinned by research and evidence – and that the research and intelligence functions in public health are focussed on being policy and practice-relevant. This will require culture changes within policy, delivery and research organisations, as well as collaborative action to build the evidence base, incorporate a range of types of evidence, and to demonstrate the effectiveness and value for money of public health approaches.
150. Technological and other data developments provide opportunities that the public health function needs to grasp. It is, therefore, also recommended that the public health intelligence specialists in Scotland should rise to the information age opportunities in public health through greater use of big data and technological responses, underpinned by a public health data and technology strategy.
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5. Partnership 151. Public Health consultants and other core public health staff should be highly visible and play a strategic influencing role in CPPs and HSCPs. Recommendations include: a) Public Health, as a discipline, needs to be represented and contribute effectively to the work of senior CPP and IJB groups such as the Strategic Planning Group in all local areas. b) The Director of Public Health Report will continue to provide independent advocacy and a voice for public health actions and responses across the Board’s area and reflect the specialty’s wider responsibilities for the population’s health. The Report will reflect the priorities for action set by Community Planning Partnerships, Integration Joint Boards, NHS Board services and Local Authorities, and help to inform ongoing activity as part of the collective effort to improving population health and tackling inequalities.
152. These recommendations are contained within guidance set out by the Review at Annex F on the public health contribution needed by Local Authorities, IJBs and collectively through CPPs in order that the impact on population health can be strengthened. An important dimension will be to consolidate the public health contribution to be made by the third sector as part of these partnership arrangements.
6. Workforce 153. There should be a workforce development strategy for public health in Scotland Features should include: a. Workforce vision which supports delivery of the public health strategy; provides a leadership statement; describes the breadth (both NHS and wider) of the current workforce; supports multidisciplinary public health; strengthens the role of NHS workforce in Public Health; and recognises the role and requirement for engagement with local government, third sector and, more generally, the wider workforce in delivering public health outcomes; b. Workforce development covering leadership development, supporting and developing staff in existing roles, post specialist development, talent management and preparing staff for future roles, developing the public health roles of the NHS workforce; c. Workforce Planning including: workforce deployment, development of a career pathway for the core public health workforce and succession planning; d. Training: identify opportunities for training across all domains of public health and cross professional joint training to ensure a progressive, integrated and cohesive approach to education and training informed by the well-developed NES approach for Health Protection; e. Registration: to consult on and develop progressive arrangements for practitioner registration where this adds value to the public health endeavour; and f. A structured approach to informing, supporting and utilising the contribution of the wider workforce in pursuit of public health outcomes.
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7. Conclusion 154. This Review of Public Health in Scotland has identified the need for the function to be clearer about its priorities and delivered in a more coherent manner. The changing organisational context (including the clear emphasis on partnership and integration, and the importance of community empowerment and engagement) has implications for how public health is organised and operates. Major public health challenges such as obesity, mental health problems and inactivity, together with the persistence of health inequalities, require a concerted population health response, achieved through the organised efforts of society. They cannot be addressed solely through treatment. The evidence received by the Review Group emphasised the cost-effectiveness of preventive approaches and a wide appetite for a more active public health effort in Scotland. Our recommendations seek to support that through: a. A review and rationalisation of organisational arrangements for public health in Scotland, including national coordination of the health protection function; b. The development of a national public health strategy; c. Clarification and strengthening of the role of the DsPH, individually and collectively; d. Supporting more coherent action and a stronger public health voice in Scotland; e. Achieving greater coordination of academic public health, prioritising the application of evidence to policy and practice, and responding to technological developments; f. An enhanced role for public health specialists within CPPs and IJBs; and g. Planned development of the public health workforce and a structured approach to utilising the wider workforce.
155. Implementation of these recommendations will require an overarching implementation plan to ensure that all elements are taken forward as a subsequent phase of the public health review. Delivery of a future public health strategy will require the contribution and collaboration of many partners, recognising that responsibilities for addressing public health issues sit not only within the health sector but also national and local governments; public, private and third sectors; and communities and individuals.
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Annex A. Terms of Reference for the Public Health Review Group:
The public health function, with its strong focus on prevention, equity and quality, is integral to health service values and aims in Scotland, and to public services reform. The focus for the review is on how to widen and deepen the influence of Public Health –both as a public service function and an important outcome for Scotland. The core question is: “How can we be more effective in tackling health and social inequalities and increasing healthy life expectancy in Scotland in a sustainable way?” In light of this the Review Group has been asked to progress the following.
To undertake a review of public health systems and the delivery of all public health functions in Scotland, with a strong focus on how public health contributes to improving health and wellbeing across the life-course and on reducing health inequalities for the future.
To examine: • public health leadership and influence, both within the health sector and more widely; • workforce planning and development, succession planning and resourcing within the multi-disciplinary core public health workforce; and • opportunities for greater joined-up working and successful implementation of public health measures within the context of community planning, single outcome agreements, and health and social care integration.
To make recommendations to: • strengthen the contribution of Public Health in Scotland in light of current and future population health challenges and the emerging policy and organisational contexts; • maximise the effectiveness and efficiency of the public health resource in Scotland; • achieve consistency where this will enhance quality and impact; and • ensure the responsiveness and resilience of the public health function for the future.
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Annex B. Membership of the Public Health Review Group
1. Dr Hamish Wilson (chair) (Vice Chair Healthcare Improvement Scotland). 2. Professor Marion Bain (Medical Director, NHS National Services Scotland and Co-Chair, Scottish Association of Medical Directors) 3. Calum Campbell (Chief Executive, NHS Lanarkshire ) 4. John Carnochan OBE (Co-founder of the Violence Reduction Unit. Technical adviser to the World Health Organisation) 5. Dr Derek Cox (Retired Director of Public Health) 6. Ron Culley / Paula McLeay (Chief Officer Health and Social Care, COSLA) 7. Dr Aileen Keel CBE (Director, Innovative Health Care Delivery Programme, Farr Institute) 8. Angela Leitch (Chief Executive, East Lothian Council) 9. Dona Milne (Consultant in Public Health, NHS Lothian) 10. Prof Sir Lewis Ritchie (James Mackenzie Professor of General Practice, Centre of Academic Primary Care, University of Aberdeen; former Director of Public Health, NHS Grampian) 11. John Ross Scott (Chair, Orkney NHS Board) 12. Susan Siegel (Public Partner) 13. Mr Grant Sugden (Chief Executive, Waverley Care) 14. Professor Carol Tannahill (Director, Glasgow Centre for Population Health) 15. Margie Taylor (Chief Dental Officer, Scottish Government) 16. Fraser Tweedie (Public Partner) 17. Dr Kevin Woods (Former Director-General for Health, Scottish Government and former DG of Health, New Zealand.)
Support at Scottish Government 1. Heather Cowan – Policy Lead , Public Health Division 2. Fee Goodlet – Business Manager, Public Health Division 3. Donald Henderson – Deputy Director, Public Health Division 4. Dr Duncan McCormick – Senior Medical Officer
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Annex C. Methodology for the Public Health Review
(a) Analytical input provided by the Scottish Government.
8. (b) Comments sought openly from individuals and organisations in relation to five questions contained in an engagement paper on the subject of public health strengths, weaknesses, opportunities and threats (SWOT analysis) and on leadership, partnership and workforce. 117 responses were received and independent research consultants were appointed to undertake analysis and have provided a full report which is available at www.gov.scot/publichealthreview-analysisofresponses-engagementpaper.
(c) A series of four regional engagement events organised on behalf of the Review Group by the Scottish Public Health Network (ScotPHN), to explore further some of the themes emerging from the responses. These were held in Dundee, Edinburgh, Glasgow and Inverness and attended by a mix of attendees from public health, the wider NHS, Local Authorities, the third sector and the public. ScotPHN have made available a report and the outputs on their website http://www.scotphn.net/projects/public-health-review-engagement/
(d) Meetings conducted by Heather Cowan and Hamish Wilson, on behalf of the Review Group, with key interest groups including: the Scottish Directors of Public Health, the Multi-Disciplinary Specialist Public Health Network, the Scottish Public Health Registrars Group, the Scottish Health Promotion Managers, the Scottish Public Health Network, the North of Scotland Public Health Network, Consultants in Dental Public Health Networks, National Specialist Training Committee for Public Health/Medicine, Royal Environmental Health Institute of Scotland (REHIS). Also meetings and/or telephone conference calls with individuals to inform the review including : Sir Harry Burns,former Chief Medical Officer for Scotland and Professor of Global Public Health, International Prevention Research Institute, Strathclyde University; Cerilan Rogers, retired Director National Public Health Service for Wales; Dr Carolyn Harper, Director of Public Health and Medical Director for Northern Ireland's Public Health Agency; Shirley Cramer CBE, Chief Executive Royal Society for Public Health; Dr Kate Ardern MBChB, MSc, FFPH, Executive Director of Public Health for the Borough of Wigan.
Following a number of these meetings, further material was generated for the Review Group‟s consideration.
(e) Research analysis was carried out which covered analysis of evidence/research literature, including a review of international evidence on health policies and different governance and accountability structures to inform the Review Group. A Summary report is available at www.gov.scot/publichealthreviewresearchreport-keyfindings
(f) A series of meetings of the Review Group to consider this material alongside additional presentations from experts including: Jonathan Marron, Director of Strategy, Public Health England; Tracey Cooper, Chief Executive, Public Health Wales; Claire Stevens, Chief Officer, Voluntary Health Scotland; Andrew Fraser, Chair, Scottish Public Health Workforce Development Group.
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Annex D. Public health policy: recent history
1. The 1999 White Paper Towards a Healthier Scotland (Scottish Executive, 1999 ) established the public health agenda in Scotland following devolution. It set out a 3-level approach to better health involving action focussed on life circumstances, lifestyles and health topics, with an overarching focus on tackling health inequalities. It called for a concerted drive to improve child health, a sustained focus on priority diseases, and established a cross-government approach supported by local demonstration projects.
2. Around the same time the 1999 Review of the Public Health Function in Scotland (Scottish Executive, 1999) was carried out. It confirmed the need for public health to have a high profile within Health Boards and Local Authorities, recommending that Boards develop as public health organisations and that there be a “health in all policies” approach to policy making. Like the current review there was a focus on strong leadership and on relationships and partnerships. The 1999 Review of the Public Health Function in Scotland focused largely on the specialist workforce, and there was a subsequent Review of Nurses’ Contributions to improving the Public’s Health (Scottish Executive, 2001). Following the 1999 Review of the Public Health Function in Scotland there was activity and enthusiasm, particularly around the creation of the Public Health Institute for Scotland. Nevertheless, despite the passage of time, some of the issues identified in the 1999 review remain relevant now and tackling them has become even more important.
3. In 2003, the Scottish Executive’s paper Improving Health in Scotland – The Challenge (Scottish Government, 2003) described the health improvement challenges and the importance of clarity and shared aims with cross-sector senior level leadership. The paper detailed the Government response, with 44 actions across four areas: early years, teenage transition, the workplace and the community. These actions included the creation of a new Directorate for Health Improvement within the Scottish Executive, and the creation of NHSHS (through merging the Public Health Institute for Scotland with the Health Education Board for Scotland) to lead national activity on health improvement.
4. HPS was established by the Scottish Executive in 2005 to strengthen and co- ordinate health protection in Scotland. Health Protection Scotland took over the functions of the Scottish Centre for Infection and Environmental Health (SCIEH), and has since developed as part of a Division of NHS National Services Scotland.
5. Scotland has a strong tradition of specialist dental and oral public health. In 2005 the Scottish Executive published An Action Plan for Improving Oral Health and Modernising NHS Dental Services which set out the strategic direction, inter alia, for tackling poor oral health. The measures identified, supplemented by further developments after 2007, have involved both upstream and downstream approaches for tackling a public health problem. The crucial role of partners in the community (e.g. child development officers in nursery schools) was also emphasised.
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6. In 2007 the Scottish Government launched Better Health, Better Care: Action Plan for NHSScotland (Scottish Governement, 2007). Its central message was the development of a “mutual” NHS in Scotland, with patients as partners in care and the opportunity for individuals to take more control of their own health and to have more say in how the NHS is run. The action plan supported delivery of a ‘Healthier Scotland’, with actions to make progress on health improvement, tackling health inequality and improving the quality of health care.
7. As part of the Better Health, Better Care Action Plan, the Scottish Government established a Ministerial Task Force on Health Inequalities, which reported in 2008. This report, Equally Well (Scottish Government, 2008), reinforced the cross-government approach needed for tackling inequalities and the role to be played by all sectors in society. It established a set of principles for policies to have a greater impact on health inequalities, identified critically important roles for the NHS, re-stated the importance of activity in the early years, and examined the interface between health inequalities and the Government’s commitments to make Scotland Greener, Safer and Stronger, and Wealthier. The report identified a number of actions brought together in an implementation plan. There have been subsequent reviews following publication of Equally Well in 2008. The most recent, reporting in March of 2014, established a central role for CPPs, emphasised the need for a greater focus on delivery and highlighted the need for inequalities work to more successfully broaden out noting that Equally Well had largely remained a health and well-being initiative.
8. The Public Health etc. (Scotland) Act 2008 set out the duties of Scottish Ministers, Health Boards and Local Authorities to continue to make provision to protect public health in Scotland. These are without prejudice to existing duties imposed on the Scottish Ministers and Health Boards in the National Health Service (Scotland) Act 1978 and existing environmental health legislation. Protecting public health is defined in terms of “protecting the community, or any part of the community, from infectious diseases, contamination or other hazards that constitute a danger to human health”.
9. A Force for Improvement: the Workforce Response to Better Health, Better Care (Scottish Government, 2009) was published in 2009 and emphasised the role of all NHS staff in Scotland in promoting better public health, with every interaction offering an opportunity for health improvement and for individuals and communities taking responsibility for their own health and wellbeing. It set out the workforce response in the context of five core workforce challenges: tackling health inequalities; shifting the balance of care; ensuring a quality workforce; delivering best value across the workforce; and moving towards an integrated workforce.
10. The Health Works, a review of the Scottish Government’s Healthy Working Lives Strategy published in 2009 (Scottish Government, 2009) underlined the Scottish Government and COSLA commitment to working together to tackle the causes of ill health and social inequalities. It emphasised the importance of addressing health as a barrier to work as a key mechanism for reducing poverty and deprivation; contributing to the Scottish economy through increased productivity; and helping individuals to sustain and improve their own health and wellbeing.
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Recommendations were also made about improving access to support for employees with ill-health and for improvement in the understanding by healthcare professionals of the links between health and work, and the importance of encouraging return to work as a key health outcome. A review in 2013 (Scottish Government, 2013) looked at implementation of the 25 key actions that aimed to encourage employers to be more proactive in supporting the health and wellbeing of workers and noted the increasing awareness that work is a key social determinant of health.
11. The Health Protection Stocktake Working Group was established in autumn 2010 to ensure that the arrangements put in place in Scotland in 2005 were still effective. The final National Health Protection Stocktake report was published in 2012 (Scottish Government, 2012). Further work, published in 2013, carried out by the National Planning Forum on behalf of the NHS Chief Executives, included a number of key recommendations, one of which was the establishment of a national health protection governance structure for Scotland. This newly formed obligate network, the Scottish Health Protection Network, consists of a number of topical and enabling groups and is overseen by the National Health Protection Oversight Group.
12. The Scottish Government’s Healthcare Quality Strategy for NHS Scotland (Scottish Government, 2010) is a development of Better Health, Better Care (2007). In 2011 the Scottish Government set out the 2020 Vision, which gives the strategic narrative and context for taking forward the implementation of the Quality Strategy. The Vision is that by 2020 everyone is able to live longer healthier lives at home or in a homely setting. These two strategic documents, together with the major programme of reform through the integration of health and social care under The Public Bodies (Joint Working) (Scotland) Act, provide the main strategic and legislative context for health and social care services today. The Scottish Government is currently building on its 2020 Vision for Health to shape a transformational change in Scotland’s approach to population health and the delivery of health and social care services by 2030.
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Annex E. The structural and organisational landscape
1. Scottish Government 156. The Scottish Government has devolved responsibilities which include health, education, justice, rural affairs, housing and the environment. Its stated purpose is to “focus government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth”. The Scottish Government sets out five strategic objectives underpinning this purpose, including a “Healthier Scotland”, and 16 National Outcomes which include people living “longer, healthier lives” and “tackling the significant inequalities in Scottish society”, as well as giving children “the best start in life”. The National Performance Framework supports an outcomes-based approach to performance. Public health work is central to the delivery of a number of the national performance indicators.
157. Since November 2014 there have been three Ministers sharing portfolio responsibility for aspects of public health: Cabinet Secretary for Health, Wellbeing and Sport; Minister for Public Health; and Minister for Sport, Health Improvement and Mental Health.
158. The Scottish Government has a Public Health Division (since October 2015, operating as two divisions: Health Protection and Health Improvement and Equality) and, since January 2015, a Directorate of Population Health Improvement, which includes within it the Public Health Divisions and which works closely with Health Analytical Services and the Chief Medical Officer’s Directorate. The dental public health strategic component falls within the Dentistry Division, under the Chief Dental Officer. All have a direct role in improving the public’s health, as well as working with other areas of the Scottish Government which also have a direct contribution to make.
2. NHS Scotland 159. Most of the core public health workforce in Scotland is employed within NHSScotland in the 14 Territorial Boards and four National Boards. The wider NHS workforce also makes a crucial public health contribution, including through the delivery of services, employment practices, leadership and resource allocation decisions, and partnership working.
2.1 Territorial Board 160. The 14 Territorial Health Boards have corporate Board level responsibility for the protection and improvement of their population’s health and for the delivery of frontline healthcare services. Each has a public health team led by a Director of Public Health (DPH). These public health teams are responsible for providing services across all of the domains of public health and for working in partnership within the Health Board and with external organisations and communities to improve population health outcomes. In a few areas the DPH is a joint appointment between the NHS Board and the Local Authority. Public Health Directorates vary in size, organisation and linkages.
161. The development of IJBs (HSCPs) in Local Authority areas (and the lead agency model in Highland) has led to Health Improvement Teams being located
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as part of these integrated bodies in some parts of the country. Other specialist public health inputs are provided from Territorial Boards and National Boards.
2.2 Directors of Public Health 162. The DsPH role is central to the effectiveness of public health across the country, ensuring locally-sensitive responses to national priorities and policies. A ScotPHN report (Scottish Public Health Network (ScotPHN), 2010) on the Role of the Director of Public Health described 13 functions agreed to be part of the role, as follows.
Table 10: Role of the Director of Public Health (i)providing public health advice to the NHS Board; (ii)providing public health advice to the Local Authority; (iii) contributing to corporate leadership of the Board; (iv) producing an independent annual report; (v) providing leadership and advocacy for protecting and improving health and reducing health inequalities; (vi) managing the Board’s specialist public health team and associated support staff and resources; (vii)ensuring the Board and its staff have access to timely, accurate and appropriately interpreted data on population health; (viii)ensuring the implementation of NHS components of Scottish Government public health or health improvement policies; (ix) overseeing the coordination and effectiveness of screening programmes; (x) communicating with the public via the media on important public health issues; (xi) contributing to emergency planning; (xii)* ensuring all appropriate infection and environmental surveillance and control measures were in place; and (xiii)* ensuring health needs assessments were carried out.
* i to xi form part of DPH role consistently across Scotland, xii & xiii agreed to form part of the role in all but one and two regional boards respectively.
163. Additionally, DsPH meet collectively and have scope to ensure appropriate consistency of approach across Scotland.
2.3 National Boards 164. The four National Boards with specific strategic roles impacting on public health are NHS Health Scotland (NHSHS), NHS National Services Scotland (NSS), NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS).
165. NHSHS is the national health improvement body which works with others in the public, private and third sectors to reduce health inequalities and improve health and wellbeing. It is involved both in developing and disseminating evidence and in shaping policy and programmes to help achieve a fairer, healthier Scotland. ScotPHN and the Scottish Centre for Healthy Working Lives are part of NHSHS.
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166. NSS provides a number of support services to the NHS and other bodies in Scotland. NSS also commissions and manages national screening programmes for Scotland. HPS is part of NSS and delivers specialist national services and provides advice, support and information to professionals and the public to protect people from infectious and environmental hazards. NSS also runs the Information Services Division (ISD) which provides a range of statistical information and analysis. HPS and ISD are both part of the Public Health and Intelligence Strategic Business Unit within NSS.
167. NES provides education and training for those who work in the NHS in Scotland, including its core public health workforce, and ensures that the wider workforce’s contribution to protecting and improving population health is supported.
168. Healthcare Improvement Scotland is the national organisation responsible for providing quality improvement support to healthcare providers in Scotland and for delivering scrutiny activity. It supports and delivers health and care activities which impact on public health, including evidence-based guidelines; public involvement processes; and health care quality and effectiveness assessments.
2.4 Observatory 169. The ScotPHO collaboration is responsible for providing a clear picture of the health of the Scottish population and the factors that affect it, including through improved collection and use of routine data on health, risk factors, behaviours and wider health determinants. It is co-led by ISD and NHSHS, and includes the Glasgow Centre for Population Health, National Records of Scotland and Health Protection Scotland.
3. National Public Sector Bodies 170. There are also a number of public sector bodies with a specific public health remit which operate nationally in Scotland, working with the NHS, Scottish Government, Local Authorities, business and industry, consumers and others. For example, the Food Standards Scotland (FSS) is responsible for ensuring that information and advice on food safety and standards, nutrition and labelling is independent, consistent, evidence-based and consumer-focused. SEPA is the principal environmental regulator, protecting and improving Scotland’s environment.
4. Local Government 171. Local Authorities in Scotland play a pivotal role in delivering preventative, universal services; addressing the social inequalities which underpin health inequalities; and improving health outcomes. They are a key partner in the overall effort to improve the public’s health and prevent ill-health. Local Authorities can also provide public health leadership through their ability to operate as public health organisations, focusing on the health impact of their own decisions and actions, and by contributing to partnership structures that are similarly concerned with improving population health and wellbeing and reducing health inequalities.
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172. Local Authorities share statutory responsibility with Health Boards for the control of communicable disease. They have prime responsibility for environmental health and employ core public health staff, most notably Environmental Health Officers. Local Government services also contribute to the public health function through important work within education, economic development, employability services, cultural and leisure services, responsibilities for the physical and social environments, and a range of other duties.
173. Local Authorities are statutory partners in CPPs and, together with Health Boards, are parent bodies for establishing integrated partnership arrangements under the Public Bodies (Joint Working) (Scotland) Act 2014.
174. The Health and Wellbeing Executive Group provides a focus for COSLA’s considerations of public health issues, with COSLA’s Leaders’ meeting setting policy.
5. Community Planning 175. There is one CPP for each Local Authority area. Under the Community Empowerment (Scotland) Act 2015 public bodies work together and with the local community in CPPs to plan for, resource and provide services which improve local outcomes and reduce inequalities in the area. The National Community Planning Group, with membership drawn from strategic leaders in public services and the wider community, helps to inform strategic policy direction for CPPs. As a matter of policy, CPPs are encouraged to focus efforts on addressing a small number of priorities for their area which reflect their understanding of the key needs and circumstances of the area and its communities (likely to include particular deep-rooted and entrenched social and economic challenges) and on which partners can make the most significant impact through effective joint working. Public health challenges frequently feature within these local priorities, either in their own right or as part of related themes.
176. CPPs have Single Outcome Agreements (SOAs) which are intended to demonstrate a clear and evidence-based understanding of place and communities, including the inequalities facing different areas and population groups. Under the Community Empowerment (Scotland) 2015 Act Single Outcome Agreements are given the title of local outcome improvement plans (LOIPs), which CPPs are required to prepare and publish.
177. Community planning brings together all partners responsible for action on wider determinants of health and inequality and for promoting early intervention and preventative approaches. These partners include the Local Authority, Health Board, IJB, enterprise body, Police Scotland, the Scottish Fire and Rescue Service, regional colleges and Skills Development Scotland. Participation with communities lies at the heart of community planning involving the third sector and any community body that has the potential to make a contribution to the CPP.
6. Integration Partnerships 178. The integration of adult health and social care services is required, from April 2015, by the Public Bodies (Joint Working) (Scotland) Act 2014, through Health Boards and Local Authorities establishing integrated partnership arrangements
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for local adult services and deciding locally whether to include children’s health and social care services in their integrated arrangements. Two models of integration are available: Lead Agency (delegation of function and resources between the Health Board and the Local Authority) and IJB (delegation of functions and resources by Health Boards and Local Authorities to a body corporate). This will mean Health Boards and Local Authorities working together effectively to deliver good quality, sustainable care services at local level, including through locality planning arrangements. National outcomes for health and wellbeing apply, and the Integration Partnership is responsible for joint strategic commissioning plans (widely consulted upon with non-statutory partners) for delivery functions and for the integrated budget under their control. Where children’s health and social care services are not included within integrated arrangements, they will continue to be planned for and delivered on the current basis by Health Boards, Local Authorities and third and independent sector providers.
7. Third sector 179. There are a wide range of voluntary and community sector organisations with health interests, and even more with a focus on the determinants of population health. These all contribute to the wider public health function in Scotland. The third sector health organisations come together collectively through national intermediaries including Voluntary Health Scotland, Voluntary Action Scotland, the Health and Social Care Alliance and the Community Health Exchange. Voluntary Health Scotland is the national intermediary and network for Scotland’s voluntary health organisations. The Alliance is the national third sector intermediary for a range of health and social care organisations, including for people who are disabled, living with long term conditions or providing unpaid care. Voluntary Action Scotland develops Third Sector Interfaces (TSIs) to support the third sector locally. The Community Health Exchange (CHEX) supports community development approaches to health improvement.
180. The Scottish Council for Voluntary Organisations (SCVO) is a membership organisation for a wide breadth of Scotland’s charities, voluntary organisations and social enterprises. It estimates that there are around 45,000 formal voluntary organisations across Scotland with over 23,000 organisations regulated as charities by the Scottish Charity Regulator (SCVO/Office of Scottish Charity Regulator, 2010/2011). Health is estimated to comprise 22% of charitable purposes and beneficiary groups are estimated to be children and young people (46%), the community (46%), older people (22%) and people with disability/health problems (22%) (The Work Foundation , 2010).
8. Academic public health 181. Public health teaching and research takes place in all of Scotland’s Universities and many members of the core public health workforce are employed in academic public health within Universities and Research Units. Public Health Research Units in Scotland include the Social and Public Health Sciences Unit in Glasgow, the Scottish Collaboration for Public Health Research and Policy in Edinburgh, and the Health Economics Research Unit in Aberdeen − all of which receive core funding from the Government’s Chief Scientist Office alongside research council funding. The Farr Institute, a collaboration between
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six Scottish universities and NSS, uses electronic patient records and other population-based datasets for research purposes. The Scottish School of Public Health Research is another cross-university collaborative mechanism to achieve a more focussed academic contribution to public health in Scotland. As a specific investment to develop evidence and insights to tackle urban inequalities, Scottish Government, NHS Glasgow and Greater Clyde, Glasgow University and Glasgow City Council collectively support the Glasgow Centre for Population Health.
182. The Academy of Medical Sciences is undertaking a project that aims to identify the main health challenges the UK population will face by 2040. One of the major focuses of the Academy’s activities is to facilitate strong and equitable partnerships between academia, industry and the NHS - along with promoting effective engagement with regulators and policy makers.
183. There are also a number of issue-specific collaborations, such as MESAS (Monitoring and Evaluating Scotland’s Alcohol Strategy) for alcohol policy, the Commonwealth Games legacy evaluation process, and Scotland’s smoke-free legislation evaluation. In dentistry, the strategy for oral health research has given priority to public health, and the dental academic establishments, particularly in Dundee and Glasgow, are working together to ensure research is relevant and best use is made of resources. What Works Scotland, which was established in 2014, is an initiative involving public health academics working alongside other researchers and service-providers. It is funded by Scottish Government and the ESRC to improve the way local areas in Scotland use evidence to make decisions about public service development and reform, working in an applied way.
9. Networks 184. A number of networks of public health professionals operate in Scotland to enable sharing of expertise, coordination of efforts and collaboration to undertake joint work. There are networks for specific disciplines (e.g. the Dental Public Health Network and Pharmaceutical Public Health Network /Community Pharmacy Network), for special interests (e.g. the Alcohol Special Interest Group), geographical areas (e.g. the North of Scotland Public Health Network (NoSPHN)), and obligate networks such as the Scottish Health Protection Network (SHPN).
185. The Scottish Public Health Network (ScotPHN) is responsible to the SDsPH and NHSHS and its role is to bring together the public health resources within the fourteen Territorial NHS Boards, the National Health Boards, academic public health departments and wider public health agencies, including Local Authorities and the independent sectors. As well as facilitating information exchange, ScotPHN undertakes national prioritised pieces of work. Given the size of Scotland, there is also strength in informal networks which operate (e.g. in a given field/speciality) where core staff know one-another and can agree between them what activity needs to be undertaken and how to resource it.
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Annex F. Public Health Contribution to Community Planning and Health and Social Care Partnerships
Public Health Function 1. A public Health function needs to work across all structures to successfully support and influence partners to deliver public health outcomes: NHS, local government, private and voluntary sector, Health and Social Care Partnerships and Community Planning Partnerships. In many areas this is already happening. The Public Health Review endorses this approach and seeks increased leadership and visibility of an appropriately resourced public health function within the NHS and across these partnerships.
2. The work by the Royal Society for Public Health (RSPH) has provided a definition of the contemporary public health workforce encompassing consultants and specialists, public health practitioners and a wider workforce across the academic, public and third sectors (Rethinking the Public Health Workforce (Royal Society for Public Health, 2015) and Tackling health inequalities: the case for investment in the wider public health workforce (Royal Society for Public Health (RSPH), 2014)). Within NHS Board and wider Partnership work there are examples where the local public health workforce can work effectively to common goals for population health and wellbeing and for better services, sometimes using the local Director of Public Health annual report or a needs assessment as a stimulus for action. The Public Health Review has the potential to strengthen synergy and collaboration between the work of public health staff in local and national Health Boards, and between Boards and local partnerships and voluntary organisations, in order to improve local services, leading to better outcomes and contribute to reducing inequalities.
3. Public Health can provide oversight, advocacy and facilitation to help reduce duplication across agencies and maximise outcomes. Public Health has expertise in, and responsibilities for, surveillance and assessment of population health and wellbeing; identification of health problems and hazards in the community; and evaluation of the quality and effectiveness of personal and community health services. This role should drive the analysis and mapping of the activity that supports Health and Social Care Partnerships and Community Planning Partnerships, as well as work within NHS Boards and Local Authorities. It should ensure that the collective effort maximises the potential input and positive impact on the population’s health.
Context for partnership working 4. The Public Bodies (Joint Working) (Scotland) Act 2014 provides an environment for more consistent and effective application of public health expertise in preventing premature, disabling illness and death and improving services and quality of life for people who are frail or vulnerable across many health and social care functions of Local Authorities and Health Boards.
5. The Public Health etc. (Scotland) Act 2008 requires NHS Boards, in consultation with Local Authorities, to develop a local Joint Health Protection Plan which provides an overview of health protection (communicable disease and
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environmental health) priorities, provision and preparedness for the NHS Board area. The plan reflects agreed local priorities and supports joint health protection working through maintaining local links and delivering joined up approaches.
6. The reforms to community planning contained in the Community Empowerment (Scotland) Act 2015 specify Local Authorities, Health Boards and Integration Joint Boards (health and social care) and others, as statutory partners in Community Planning.
7. The Community Empowerment Act extends the statutory duty of cooperation beyond health, local authority and education, and places a responsibility on all partners to work collaboratively to carry out community planning and to take account of the local outcome improvement plans in carrying out the partner’s own functions and to contribute staff, funds and other resources as appropriate.
8. This provides the opportunity for Health Boards and Public Health Departments to get even more involved in supporting Community Planning Partnerships and Integrated Joint Boards, as well as NHS Board services and Local Authorities, in delivering the stated outcomes and also in working closely with partners to inform strategy and delivery so that they can provide a greater contribution to improving population health, tackling inequalities in health, and improving access to services. This opportunity should be capitalised on now as the intention is that partners should already be supporting community planning consistent with the principles in the Community Empowerment Act leading up to its enactment. Public Health can contribute to a public sector prioritising early intervention and preventive spend as envisaged by the Commission on the Future Delivery of Public Services in 2011.
9. In addition Health Boards and Local Authorities, as governance partners under the Act, become collectively responsible for effective community planning. The Public Health Review recommends that NHS Boards make more explicit their specialist public health contributions to working closely with partners to take forward these efforts. This should include advice and support to improve the health, wellbeing and sustainability of local communities; deliver equitable services that reduce inequalities; and evaluate their impact. This will include providing leadership and skills to help ensure that all areas implement a Health in All Policies approach; undertake integrated impact assessment of strategies, policies and plans, particularly resource allocation; and equity audit service delivery.
10. The expectation that Boards should use this ongoing opportunity, exhibit the behaviours and embrace the principles of community planning is contained in the current Local Delivery Plan guidance for NHS Boards for 2015-16 (December 2014), which asks NHS Boards to “indicate how they will continue to strengthen their approach to community planning during 2015/16, through both their direct contributions and how they demonstrate leadership within the CPP. This should focus on how the CPPs act to improve local priority outcomes which relate to health and wellbeing, and how they shift activity and spend towards tackling inequalities, prevention and community empowerment.”
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Public Health role in partnerships 11. Public Health’s focus includes developing and improving evidence-based health and social care through the careful assessment and planning for health needs, and the inclusion of prevention strategies, quality considerations, efficiency, equity, and ensuring health impact at a population level over the longer term. There is a synergy between the delivery of health improvement interventions that are integral to the provision of effective health care - such as adult immunisations, that are delivered within Health and Social Care Partnerships - and the work at neighbourhood level to improve local outcomes and reduce inequalities within the context of community planning. Public Health teams have the skills required to ensure that these synergies are realised to achieve better population health and wellbeing outcomes.
12. The potential impact of Public Health working with Community Planning Partners is wider still given that community planning involves a broader range of partnership structures and a clearer focus on reducing inequalities and responsibility around wider determinants of health. For example, Public Health can contribute expertise to Local Housing Partnerships to ensure Local Housing Strategies are drafted with population wellbeing across the life course in mind. Public Health can also effectively contribute to Local Authorities and other partnership work covering areas such as Planning, Education, Transport, Employment and Criminal Justice.
13. Integration Joint Boards’ remit also includes strategic planning and performance monitoring across a broad range of health and social care services, incorporating the input of the voluntary agencies, independent sector and others. Public Health can provide support for the development of services that reduce health inequalities while delivering improved health and benefit at a population level by preventing disease and improving health-related outcomes through equitable and appropriate access to, and utilisation of, effective health and care interventions. Similarly, Public Health can provide support for effective delivery of Local Authority services to those most in need, including a focus on early intervention and reducing inequalities.
14. There also needs to be strong links to the shape and balance of wider services provided directly by NHS Boards, primarily acute services. To do this they must ensure equity of current provision of prevention, treatment and care, but also need to make a contribution to Community Planning Partnership work on factors affecting the health and wellbeing of the population. The effects of improvements to care and service developments can last for decades, leading to sustained improvement in population health and sustained delivery against organisational goals and priorities.
15. The Director of Public Health Report will continue to provide independent advocacy and a voice for public health actions and responses across the Board’s area and reflect the specialty’s wider responsibilities for the population’s health. The Report should encompass delivery of all of the essential public health operations while highlighting existing strengths and current and emerging challenges to health and wellbeing. The Director of Public Health Report will reflect the priorities for action set by Community Planning Partnerships,
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Integration Joint Boards, NHS Board services and Local Authorities, and help to inform ongoing activity as part of the collective effort to improving population health and tackling inequalities. It is recommended that Public Health, as a discipline, needs to contribute effectively to the work of senior Community Planning Partnership and Integration Joint Board groups such as the Strategic Planning Group in all local areas.
Summary of Public Health input into Health and Social Care Partnerships and CPPs:
Strategic • Enable organisations to take a “Health in All Policies” approach at national and local level. • Provide leadership, advocacy and support to partners to reduce health inequalities, such as by shaping actions to reduce barriers to health and improved living and working conditions. • Advise on approaches to prioritisation to help ensure that our services focus on areas of greatest population need whilst also ensuring a balanced approach to maintain equitable access to more specialist or intensive services for groups of people who have high or particular needs for which effective intervention exists. • Provide advice and input on integrated impact assessment, and to help ensure that service evaluation and equity audit are undertaken and that robust prioritisation processes are in place, e.g. that proposals for investment, development and change are assessed for likely effectiveness, opportunity cost (foregone alternative use of resources), affordability and value. • Embed early intervention, preventive and quality improvement approaches at partnership level. • Public Health, as a discipline, needs to contribute effectively to senior CPP and IJB groups, such as the Strategic Planning Group, in all local areas and within NHS Boards and Local Authorities. • Joint planning of health protection to ensure resilience of health protection function through Joint Health Protection Plan.
Health Intelligence and Analysis • Provide advice and oversight and develop a shared understanding across NHS Board areas; Local Authorities; with the IJB; CPP; and other key partners, on population health and wellbeing including patterns of health and disease and the main determinants of health for defined populations. • Provide independent interpretation of published evidence; available data or other relevant and important knowledge sources; and inform and support evidence-informed and value-based decision making, with the aim of ensuring equitable access to effective, safe, person-centred and integrated health care services. • Lead and provide support for Health Needs Assessment to identify need and support service redesign and improved resource allocation through the
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identification of populations that are most able or most likely to benefit from care. • Support the use of (integrated) health impact assessment to ensure unintended impacts on people with high levels of need are identified and addressed, and delivery of services tackles health inequalities. • Support capacity building in HSCPs and Local Authorities through training in epidemiology, demography, data interpretation, and support with more complex analyses (such as health economics) including monitoring and evaluation. This can be facilitated by DPH oversight of allocation of NHS time of academic public health staff, links with academic units and other sources of expert knowledge and skills.
Delivery of services by IJBs/HSCPs, Local Authorities and NHS • Support the design and delivery of services that meet the needs of all groups, promote accessibility and effective use by the most vulnerable, i.e. proportionate universalism including specific services for vulnerable and marginalised groups, recognising their particular and often greater complexity and level of need, e.g. welfare advice in health settings, inequalities in service access, social support, supported self-management. • Specialist Public Health directly coordinates and quality assures specific population health programmes such as for screening and immunisation. • Provide leadership for evidence-based health improvement interventions across Health Board, IJB, Local Authority, third sector and Community Planning, including assets based approaches. • Maintain local links and delivery of local health protection priorities as identified in the Joint Health Protection Plan.
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Annex G. Glossary of Terms
2020 Vision: Set out by the Scottish Government in 2011 to give the strategic narrative and context for taking forward the implementation of the Quality Strategy. The Vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.
Chief Dental Officer (CDO): The professional advisor to the Scottish Government and civil service on all matters relating to dentistry.
Chief Medical Officer (CMO): The most senior advisor on health matters in a government. In the Scottish Government the CMO heads up a Chief Medical Officer Directorate responsible for working with Ministers, delivery partners and other stakeholders to protect and improve public health, promote sport and physical activity and to support the generation of robust evidence, and to oversee the clinical effectiveness of healthcare services in Scotland.
Communicable Disease: Any disease transmitted from one person or animal to another; also called contagious disease.
Community Planning Partnership (CPP): There is one CPP for each Local Authority area. Under the Community Empowerment (Scotland) Act 2015, public bodies work together and with the local community in CPPs to plan for, resource and provide services which improve local outcomes and reduce inequalities in the area. Public sector partners include the Local Authority, Health Board, enterprise body, Police Scotland, the Scottish Fire and Rescue Service, regional colleges, Skills Development Scotland, IJB and others.
Consultants in Dental Public Health: Dentists who complete specialist training in epidemiology strategic planning, statistics, health promotion, leadership and management. They fulfil a dual role of principal advisor to the NHS Boards on all matters relating to dentistry and improving the oral health of the public.
Consultants in Public Health Medicine/Specialists in Public Health: Professionals from medical and non-medical backgrounds who train to become consultants/specialists in public health through demonstrating knowledge and competency in nine key areas. Their competence and validity to practice is assessed by the Faculty of Public Health.
Core public health workforce includes DsPH, Consultants/Specialists and those who specialise in one or more of the Domains of Public Health.
Domains of Public Health: There are three key domains of Public Health, defined as Health Improvement, Improving Services and Health Protection. All are underpinned by public health intelligence (information and evidence).
Directors of Public Health (DPH): Heads of the Directorates of Public Health in each Scottish Health Board; chief source of expertise and advice to the Health Board about action needed to protect and improve the health of people in the area.
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Engagement Responses: Responses to an engagement paper and through stakeholder engagement workshops. The engagement paper asked 5 questions on the subject of public health partnership, leadership and workforce. The responses were analysed by an independent external research company to inform the consideration of the Review Group. Stakeholder engagement workshops were also held to build on the themes identified in the engagement responses.
Environmental Health: Environmental health is the branch of public health that is concerned with all aspects of the natural and built environment that may affect human health
Faculty of Public Health is the standard setting body for specialists in public health in the United Kingdom.
Health inequalities are systematic differences in health between different groups in society which are potentially avoidable and deemed unacceptable.
Healthy Life Expectancy: Life expectancy (LE) is an estimate of how many years a person might be expected to live, whereas healthy life expectancy (HLE) is an estimate of how many years they might live in a 'healthy' state.
Integration Joint Board: Established to bring together adult health and social care services, as required from April 2015 by the Public Bodies (Joint Working) (Scotland) Act 2014. The alternative integration model is the lead agency model adopted in Highland.
Non-Communicable Disease (NCD) is a medical condition or disease that is, by definition, non-infectious and non-transmissible among people.
Public Health: the activity associated with "the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society".
Public Health Practitioners work as part of the core public health workforce, often as part of a team led by someone working at a higher level, but also operating independently. They have responsibility for specific areas of work (e.g. smoking cessation, infection control) and work in a wide range of settings and sectors.
Quality Strategy: Scottish Government strategy - Healthcare Quality Strategy for NHS Scotland (Scottish Government, 2010).
Research analysis commissioned specifically for this Review to cover analysis of research literature, including a review of international evidence on health policies and different governance and accountability structures to inform the Review Group.
Scottish Directors of Public Health (Scottish DsPH): Group bringing together all Directors of Public Health in Scotland, regularly meeting with the CMO and Scottish Government.
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Shared Services: portfolio of programmes, originating from the NHS Senior Leaders’ (formerly the guiding coalition) and project managed by NSS, to provide vision for shared services (collaboration, partnership working, joint management arrangements, contractual arrangements to deliver services on behalf of others etc.) which includes within its scope public health and business intelligence (the latter having potential relevance to public health intelligence).
Single Outcome Agreement (SOA): A strategic document produced by each Community Planning Partnership based on the terms of a Scottish Government and COSLA agreed Statement of Ambition on community planning and reflects SOA guidance on priorities, issued by Scottish Government and agreed with COSLA. Under the Community Empowerment (Scotland) Act 2015 these will become known as Local Outcome Improvement Plans (LOIP).
Single Outcome Agreements: Collective term for Single Outcome Agreements of all CPPs. Under the Community Empowerment (Scotland) Act 2015 these will become known as Local Outcome Improvement Plans (LOIPs).
(Social) Determinants of Health: the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequalities.
The public health function (or endeavour) can be defined as “a robust, adequately resourced system that can secure and sustain the public’s health, addressing health and associated policy issues at a population level and leading a co-ordinated effort to tackle underlying causes of poor health”.
The public’s health, population health: The aggregate health status of people in a defined geographic area, as measured using standard indicators of health and wellbeing.
Wider public health function/workforce: In addition to the core public health workforce, many other professional groups, practitioners in different disciplines, organisations and individuals make an essential contribution to protecting and improving the public’s health and wellbeing. Collectively these form the ‘wider public health workforce’.
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Annex H. Abbreviations
AHPs: Allied Health Professionals
CDO: Chief Dental Officer (in the Scottish Government)
CDPH: Consultant in Dental Public Health
CfWI: Centre for Workforce Intelligence
CMO: Chief Medical Officer (in the Scottish Government)
CPPs: Community Planning Partnerships
DPH: Director of Public Health (in Scotland)
EHOs: - Environmental Health Officers
HEAT: Hospital Efficiency and Access Targets
HIS: Healthcare Improvement Scotland
HLE: Healthy Life Expectancy
HPS: Health Protection Scotland
HV: Health Visitor
IJB: Integration Joint Board
ISD: Information Services Division (of NSS)
LOIP: Local outcome improvement plans
NES: NHS Education for Scotland
NHS: National Health Service
NHSHS: NHS Health Scotland,
NSS: NHS National Services Scotland
OECD: Organisation for Economic Co-operation and Development
PHorCast: Public Health Online Resource for Carers, Skills and Training
PSR: Public Service Reform
ScotPHN: Scottish Public Health Network
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ScotPHO: Scottish Public Health Observatory
SDsPH: Scottish Directors of Public Health (as a Group)
SHPMs: Scottish Health Promotion Managers
SOA(s): Single Outcome Agreement(s)
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