Delivering for Health – One Year On
Autumn/Winter 2006
Contents Foreword 01 Foreword 02 Background I am very pleased to introduce this update on 03 Tackling health inequalities progress with Delivering for Health, one year on 04 Shifting the balance of care from its publication. 05 Long term conditions When I launched Delivering for Health, I made 07 e-Health clear my determination to ensure that NHSScotland 08 Diagnostics remains true to the founding principles of the service in the way in 09 Planned care 11 Unscheduled care which it responds to the challenges of improving health, tackling health 13 Rural healthcare inequalities, improving quality and making the best use of available 15 Mental Health resources. The past 12 months have seen us make good progress 15 Neurosciences towards realising this ambition. We have tackled one of the key 16 Tertiary paediatrics determinants of ill health through the introduction of smoke free public 16 Child and maternal health places, seen more progress on survival rates from the killer diseases 17 Workforce and reduced waiting times to their lowest ever levels. 18 Volumes and outcomes This supplement provides many fascinating Boards are taking up the messages from and interesting examples of the ways in Delivering for Health. Much of that work is which NHSScotland is responding to the paying off now, but real gains will continue changing healthcare needs of our people. to be made over the next five years as It looks, for example, at the investment we improvements come on line and the major are making in primary care centres, new capital investments are realised. All NHS approaches to the management of long staff have a role to play engaging with those term conditions, the development of an we serve and explaining the changes which electronic health record and the success of are underway and I hope that this supplement First Responder schemes in saving the lives succeeds in bringing the changes to life and of patients in remote and rural areas. It demonstrating the benefits they can bring shows that NHSScotland is moving in the to the people of Scotland. right direction as it looks to deliver models of care which anticipate problems before they become critical, involve patients and their carers as partners and embed services within communities throughout Scotland.
As I have travelled the country chairing the ANDY KERR, MSP NHS Board Annual Reviews it is clear that Minister for Health and Community Care 1 BACKGROUND
Delivering for Health, published in October 2005, set out NHSScotland’s response to the challenges posed by a combination of Scotland’s ageing population, increasing prevalence of illnesses that require long term care, the continuing rise in the number of emergency admissions to hospital involving older people and the need to tackle persistent health inequalities between Scottish communities. It took some of the conclusions reached in David Kerr’s report on the future of the NHS and set out a comprehensive plan for service improvement. This will bring about a shift in the balance of care, with a greater emphasis on the provision of “anticipatory care” to those at greatest risk of ill health, support and encouragement for self care and a commitment to embedding services within our local communities. An Implementation Board chaired by Dr Kevin Woods, Chief Executive, NHSScotland has been established to oversee the delivery of the programme and ensure that change occurs in a consistent and integrated fashion throughout the service. Health Department Directors and NHS Board Chief Executives have been identified to lead each of the 12 workstreams, each of which reports to the Implementation Board via a small team based in the Health Department. This team is also responsible for ensuring that appropriate links are made from the NHS to other providers of social and care services, and that the workstreams involve staff and patients in their work and adopt a consistent approach to issues such as finance, transport and communications.
Workstream Director Chief Executive
Shifting the Balance of Care Director of Primary and Community Care NHS Forth Valley (Fiona Mackenzie) (Paul Gray)
Tackling Health Inequalities Director of Health Improvement NHS Greater Glasgow (Tom Divers) (Pam Whittle) NHS Lothian (James Barbour) NHS Health Scotland (Graham Robertson)
Long Term Conditions Chief Medical Officer (Harry Burns) NHS Lanarkshire (Tim Davison)
Diagnostics Director of Delivery (John Connaghan) NHS Dumfries and Galloway (John Burns)
eHealth Director of Healthcare Policy and Strategy NHS National Services Scotland (Stuart Bain) (Derek Feeley)
Unscheduled Care Director of Healthcare Policy and Strategy NHS Fife (George Brechin) Scottish Ambulance Service (Adrian Lucas) NHS 24 (John McGuigan)
Actively Managing Hospital Director of Delivery NHS Grampian (Richard Carey) Admissions/Planned Care The Golden Jubilee National Hospital (Jill Young)
Rural Health Care Chief Nursing Officer NHS Highland (Paul Martin) Chief Executive (Roger Gibbins)
Mental Health Services Director of Healthcare Policy and Strategy The State Hospitals Board for Scotland (Andreana Adamson) NHS Tayside (Tony Wells)
Child and Maternal Health Chief Nursing Officer NHS Ayrshire and Arran (Wai-Yin Hatton)
Tertiary Paediatric Care Director of Healthcare Policy and Strategy NHS Education for Scotland (Malcolm Wright)
Neurosciences Chief Medical Officer NHS Borders (John Glennie)
Professor Sir Graham Teasdale, Chair NHSQIS and David Steel, CEO NHSQIS participate in the expert group on volume and outcome. 2 TACKLING HEALTH INEQUALITIES
Delivering for Health commits NHSScotland to working with partners to improve health and tackle the inequalities which continue to exist throughout Scotland. It looks to build on the advances that have come from smoke-free public places, active schools coordinators, the Hungry for Success programme and a range of other national and local initiatives. In particular, it signals our intention to move beyond efforts to raise the profile of health improvement and create the structures that are necessary to drive change. It calls on us to sharpen our focus on delivery, ensure that services are reaching those who need them most and demonstrate real health improvement in our most disadvantaged communities.
A series of five “Keep Well” pilots represent the first key achievements of this workstream. Originally called Prevention 2010, these pilots aim “to increase the rate of health improvement in deprived communities by enhancing primary care services to deliver anticipatory care”. By providing additional resources and support, they will allow primary care teams to identify and target those at particular risk of preventable, serious ill health, including those with undetected long term conditions, and offer appropriate interventions, services, monitoring and follow up in order to improve their health and quality of life.
The initial pilots are taking place in Edinburgh, North and East Glasgow, Dundee and North Lanarkshire. The pilots will be monitored closely as they begin to impact on these communities. Our aim then will be to use the evidence that emerges to inform a more general and widespread application of the “anticipate and prevent” approach to healthcare in Scotland.
Edinburgh City is one of the pilot areas in the Prevention 2010 project. About 16 General Practices in Edinburgh that serve the most deprived populations in the capital will participate in four geographical clusters. This grouping will allow the practices to develop links with each other and with local projects in the areas involved.
The practices will use a variety of methods to involve people aged 45-64, offering them assessments focusing on cardiovascular disease. The aim is to identify those at risk and to provide them with advice and/or treatment. The objective is a reduction in cardiovascular disease in these communities. In Edinburgh there are about 25,000 residents who may benefit. The scheme will encourage an holistic approach to assessment, building connections between primary care and community initiatives.
Specially employed senior nursing staff will help practices establish the necessary systems. They will work with partners such as community pharmacists and mental health teams, the voluntary sector, and others. Outreach workers will provide ongoing support for patients who need follow up attention but find it hard to engage with health and other services.
In circumstances where people ignore health problems because they have other more pressing concerns, these will be recognised and help given towards tackling them.
Practices will aid, or advise on, the drug treatment of hypertension or high cholesterol, smoking cessation, weight management and dealing with alcohol-related problems.
3 SHIFTING THE BALANCE OF CARE
Delivering for Health sets out a strategy for shifting the balance of care, which will see us provide services as locally as possible in a variety of different settings. This requires us to ensure that we have strong, multi-disciplinary teams working within Scottish communities and local facilities which can provide a range of services such as specialist outpatient clinics, diagnostic tests and day surgery.
The Primary and Community Care Premises Modernisation Fund 2006 – 2008 is being used to make this vision a reality. It has, for example, channelled investment into the projects shown below.
Partick Community Centre for Health
Here there is a range of health and community services including a day nursery. Its award winning design helps promote greater awareness of health issues.
The original design allowed for future extension and development and Phase 2 is currently being planned. There will be enhanced accommodation for such facilities as: • Children’s services – integrated health and social work services; • Adult mental health – bringing together a wide range of community based mental health services, and integration with social work; • Improved access to General Medical Services – relocation of a local GP practice into improved accommodation; • NHS dental services – an additional dental surgery with adjoining recovery room; and • Outreach services – with more space for secondary care services to undertake assessment and treatment activity. This project will be completed by March 2008.
Springburn Health Centre
This Health Centre was opened in 1982. Its phased redevelopment will extend its existing primary care services and add a range of new and more locally accessible facilities. In addition to finance from the Primary and Community Care Premises Modernisation Programme, a £1.2m contribution has been made from the NHS Greater Glasgow and Clyde’s Capital Programme. The three phases of the Springburn scheme are: • NHS dental services – expanded and upgraded accommodation has been created for the General Dental Practice and the Community Dental Service; • In the new build extension – there will be extra space for existing basic and outreach services including a new community sexual health service hub; and • Extending and upgrading the accommodation for all GP practices – a new main entrance incorporating an expanded, and more appropriately sited, community pharmacy and full general access for people with disabilities.
This project will be completed by March 2008.
4 LONG TERM CONDITIONS
The effective management of long term conditions lies at the heart of Delivering for Health. Our aim is to reduce the traditional reliance on episodic care delivered in acute hospitals and move towards a system which puts increasing emphasis on continuous care delivered, where appropriate, within local communities. This requires a team-based approach, support for self care and a commitment to involving patients and carers in the way in which services are designed and delivered.
The Chief Medical Officer is leading a programme of work to oversee and shape Scotland's strategy for the care of people with long term conditions. This includes collaborative working between the Health Department, NHSScotland, other public sector bodies, and critically, patients and their carers. It will begin with a series of open space events throughout Scotland, where people with an interest in the management of long term conditions will have the chance to guide the way in which services develop in the future. More information about these will be given in the next NHS Bulletin.
The Scottish Executive is working with Long Term Conditions Alliance Scotland to take this work forward. The Alliance is an umbrella group bringing together voluntary and community organisations across Scotland to meet the needs of those with a long term condition. Its vision is for these patients to have better control over their health and live life to the full. It also values patients’ knowledge and expertise about their condition, and encourages them to participate in their care. These aims and values are consistent with Delivering for Health.
A practical way to bring about the services set out in Delivering for Health is the self-assessment toolkit which Community Health Partnerships (CHPs) will use. Measuring their performance against the toolkit’s criteria will enable CHPs to evaluate their approach to supporting those with long term conditions, giving them the opportunity to improve services year by year. The toolkit is currently out for consultation and will be issued in its final form before the end of the year.
As a first step towards providing better, more integrated care for this group of patients, Delivering for Health also called for the development of a predictive way of identifying those at high risk. In order to meet this aim, SPARRA (Scottish Patients at Risk of Readmission and Admission) was launched in June this year by the Information Services Division of NHSScotland. Someone’s chances of being admitted as an emergency during the next twelve months are strongly affected by their admissions pattern over the past few years. The SPARRA programme quantifies this and uses the information to assess how likely a future admission is. The greater the number of previous admissions, the older the patient is, the more deprived the area in which he or she lives, the higher the chance of a future admission. Such patients need to be assessed so that they get the right level of integrated, continuous, preventative care to make sure they do not end up in hospital unnecessarily.
There has been a positive response to SPARRA. Several NHS Boards are already using the listings to help identify candidates for integrated care management. The vast majority of CHPs/NHS Boards already have been in touch to discuss SPARRA’s potential and it will be rolled out across Scotland over the next few months.
5 Introducing a Joint Care Management Initiative in Lanarkshire
NHS Lanarkshire has developed a model of Integrated Care Management to provide people with longterm conditions with the best attention in the most appropriate settings for their needs.
Integrated Care Management is an intensive approach targeted at the more complex and rapidly changing cases. It coordinates a person’s medical and community care needs and, where appropriate, takes account of the other social issues they might face.
The benefits include: • Better results for individuals, their families, carers and communities; • Improved access to services; • Reduction in the use of unplanned care; • Improved agreement with medication; • Reduction in the number of professionals involved in an individual’s care; • Improved choice; • Greater continuity of support/care/involvement; • More control in the package of care/support provided; • Improved and speedier decision making; • Involvement of individuals through active participation in the process; and • Better partnership working. NHS Lanarkshire’s Care Management pilot began last month. The SPARRA tool described previously helped identify those with highly complex or unstable multiple long-term conditions who are at the highest risk.
Services will for the most part be delivered to patients living in communities where need is greatest. Specialist services provided in hospital settings will be used when required.
The pilot will focus on three areas because of the different information available from each: • Clydesdale, for rural aspects; • East Kilbride, for issues associated with an ageing population; and • Coatbridge, because of its districts of high deprivation. Once evaluated, an effective multi-agency approach will be developed and introduced across Lanarkshire.
Working in partnership is essential to the success of care management. The approach in Lanarkshire was developed in conjunction with North and South Lanarkshire Councils, as well as patients and carers. It is set out in the joint Lanarkshire Long Term Conditions Strategy and an inter agency project board has been set up.
The staff involved have come together into locality implementation groups and they will ensure an integrated approach, cutting across organisational boundaries. Preparations are nearly complete on the relevant protocols, training and the forging of links with all the services which will be involved in the pilot.
6 e-HEALTH
Delivering for Health promises a comprehensive health information system based on an Electronic Health Record. It argues that this is vital in achieving a shift away from a reactive, acute-orientated response, towards anticipatory, preventative and continuous care. The eHealth strategy is about providing such a comprehensive system. Only a year after the publication of Delivering for Health, the core of the electronic health record is already being put in place. It includes: • Emergency Care Summaries (ECS) with current medication and allergies. This now extends to 4.5 million patients in Scotland. Currently in use by out of hours doctors and a number of A&E departments. It is planned to extend access to more A&E units and NHS 24; • Modern information support systems for A&E Departments; • Picture Archiving and Communications Systems (PACS) for storing digital images such as x-rays; • A successful programme for Diabetes collaboration between GPs in acute care clinics; • SCI Store for laboratory test requests and results transmission between primary and secondary care; and • SCI Gateway to ensure electronic transmissions are kept secure. Lab results can now be accessed by 99% of GPs electronically. More than 60% of referrals to hospital are created and sent electronically. Each of the three cancer networks in Scotland will have access to the care records of patients with specific cancers and multi-disciplinary team working will be better supported. It is also going to be possible to collect data from which all cancer patients’ waiting times can be determined. It is likely that we will buy a mix of necessary equipment because there is no single system currently covering all of our requirements.
7 DIAGNOSTICS
The Diagnostics Collaborative Programme Establishing a Diagnostics Collaborative Programme was one of the early commitments in the Diagnostics workstream of Delivering for Health. Launched in April 2006, with funding for two years this will improve services and thereby help to reduce anxiety and delays for patients and ensure that any treatment that is necessary starts as soon as possible.
The programme’s aim is to cut potential stress for patients and their carers by reducing waiting times in the diagnostic process. Further improvements under consideration include:
• Pooling of waiting lists between consultants, so that a patient is seen by the first available consultant rather than the one to whom they happen to be referred (unless a particular expertise is needed);
• Regular checks of waiting lists (both clinically and administratively) so that patients who do not need to be on them are not sent appointments unnecessarily;
• Developing improved booking arrangements to help give patients a greater choice about appointment times. This reduces the effort wasted on investigating cancellations, which, in turn, helps to cut waiting times generally; and
• Using proven approaches to issues such as coordinating annual leave, to reduce hospital–instigated cancellations caused by the absence of suitably trained staff.
There are already many examples of improvements.
At the Western General Hospital in Edinburgh’s endoscopy unit, a complete review and validation of waiting lists has been undertaken so that Patient Focused Booking could be implemented smoothly. After a review, 70 patients were removed from the gastro-intestinal and colorectal list, because it was discovered they no longer needed the procedure. Also, patient focused booking has now begun, giving patients an opportunity to choose a time and date for their procedure.
Since May 2006, the radiology staff at NHS Fife have extended the department’s working day and so increased their MRI capacity by a third. An evening MRI session most weekdays means there are now three sessions a day instead of the previous two. Out of a total of 327 people having such a check in July, 119 people were seen in the evening. As a result the number of people waiting longer than 9 weeks for an MRI scan dropped from nearly 400 in January 2006 to 66 in July 2006.
8 PLANNED CARE Planned Care Improvement Programme – Five Simple Changes
The Planned Care Improvement Programme is an 18 month initiative that will assist the NHS to make the sustainable changes necessary to meet current and future patient access targets. In particular it will help NHS Boards to improve their performance and ensure that they systematically implement the Five Simple Changes described in Delivering for Health.
1.Treating day surgery as the norm
2.Improving referral and diagnostic pathways
3.Actively managing admissions to hospital
4.Actively managing discharge and length of stay
5.Actively managing follow up.
The Programme, which was officially launched at the end of September by the Minister for Health and Community Care, will deliver results that impact on day case rates, access and waiting time targets, lengths of stay, patient journey time and whole system capacity. NHS Boards will be encouraged to remodel services based on improved patient flows that shift the balance of care, increase throughput and support a sustainable reduction in waiting times.
The Programme’s targets are:
• to assist Boards to increase day surgery rates making such surgery the norm;
• to achieve a maximum patient journey of 36 weeks, comprising a maximum of 18 weeks for outpatients, 18 weeks for inpatients and day cases;
• to have a whole patient journey target for cataracts of 18 weeks from referral to completion of treatment; and
• to fulfil a 16 week target for cardiac intervention following referral to a rapid access chest pain clinic.
An extensive consultation process has been undertaken with key stakeholders from across the NHS, and the first tranche of funding has been released enabling NHS Boards to set up projects and teams to support the programme’s implementation.
Progress is being made quickly towards improving the patient experience of planned care throughout Scotland.
9 West of Scotland Regional Heart and Lung Centre
Since 2003, NHS Greater Glasgow and Clyde, NHS Lanarkshire and the Golden Jubilee National Hospital, have worked together to establish a new specialist heart and lung unit of excellence for the West of Scotland at the Golden Jubilee National Hospital, whilst continuing to provide locally accessible cardiothoracic and thoracic outpatient services within hospitals in Greater Glasgow and Lanarkshire.
NHS Greater Glasgow and Clyde and NHS Lanarkshire held a public consultation on the proposal in early 2005, and it was approved by the Minister for Health and Community Care in January 2006. A Partnership Board was established to oversee the scheme and it is expected that the Centre will be operational in summer 2007. It will be one of the largest specialist units in the UK for the investigation and surgical treatment of cardiac and cardiothoracic patients, and will concentrate clinical expertise, as well as the latest diagnostic and treatment techniques and equipment in one place. There should be a number of benefits for patients and NHS staff, including:
• the provision of timely, high quality, treatment for patients in the West of Scotland;
• better planning of patient care, since no additional pressures will be created by emergency medical admissions;
• assisting in the development of future cardiothoracic services;
• providing access to the latest diagnostic and treatment techniques;
• the ability to reduce waiting times and so provide swifter treatment for patients;
• concentrating teaching and other academic activities on a single site. This will offer better training opportunities for junior doctors, which, in turn, should result in more and better cardiothoracic surgeons for the future;
• enabling clinicians to specialise in complex and diverse areas of work due to the larger number of patients treated;
• more specialised nursing staff, with greater opportunities for development, within a larger, integrated unit;
• the bringing together of the medical staff will enable a European Working Time Directive compliant on-call system to be established; and
• more efficient use of expensive specialist equipment and facilities.
10 UNSCHEDULED CARE
Delivering for Health signals our intention to redesign the model of unscheduled care throughout Scotland. Our aim is to develop and implement a stratified system of care which will improve integration, quality and productivity by maintaining care at a local level for the majority of cases, allow for a greater separation of planned and emergency care so that scheduled operations do not have to be cancelled in order to deal with emergencies and achieve a more efficient use of specialist staff and resources.
NHS Greater Glasgow and Clyde (NHS GGC) are showing how these changes can be delivered in practice. The NHS Board has just signed a contract to build two new hospitals, the New Victoria and the New Stobhill which will open in early 2009. These will have crucial roles in delivering the area’s 21st century healthcare, providing a range of diagnostic facilities as well as outpatient and day care. Three other hospitals – Gartnavel General, Glasgow Royal Infirmary and the Southern General will have in-patient facilities, with the latter two including full emergency trauma services.
The separation of planned and unscheduled care will lead to many benefits for patients. Focusing purely on elective day surgery ensures that scheduled operations do not have to be cancelled to accommodate emergencies. It is planned to offer people day or overnight-stay surgery wherever possible. Dedicated diagnostic resources will help shorten waiting times and allow the development of more ‘one stop clinics’.
The two new hospitals will also have Community Casualty Units. NHSGGC is examining how these units might bring together the GP emergency medical service, the Emergency Nurse Practitioners who run the Community Casualty Units, the minor illness service and the emergency dental service. In the future, as part of a network of unscheduled care centres across Glasgow, the Community Casualty Units will treat up to 70% of urgent cases. Waiting times at these units will be lower than in the traditional A&E setting. There will also be Community Casualty Units alongside the major accident and emergency and trauma units at the Royal Infirmary and Southern Glasgow Hospitals and also at Gartnavel Hospital. NHSGGC is committed to keeping most unscheduled care locally based, maintaining easy access for patients and their carers.
11 Unscheduled Care
In Grampian, more than 5000 patients with minor injuries have now been treated using Telemedicine. These consultations have avoided unnecessary transfers to Aberdeen in approximately 80% of the cases. In addition, new systems for delivering unscheduled care in remote and rural situations have been successfully developed, including an e-mail based ECG Interpretation Service, a European Union collaboration to provide telecare to offshore oil rigs and a Minor Illness Service for residential facilities.
Even with all this activity the Network has still not reached its full potential. Work goes on to develop alternative systems for providing unscheduled care in the community. Training of community and minor illness nurse practitioners and “see and treat” paramedics is continuing. Trials are about to start involving community practitioners using Telecommunications, to enable home or community care of patients, thereby safely reducing the need for hospital attendances. The Grampian Video Conferencing Network will have a key role in delivering such support to Community Hospitals.
The existing Network has been used in other ways. The North East of Scotland Tele-Education Group continues to organise training via the Network. In addition the facilities were used in a recent CCI funded Tele-neurology Project. Patients in Aberdeen had sessions with a neurologist in Belfast and Orkney patients were seen by Aberdeen neurologists. The neurology waiting list in Orkney has been eliminated. Early initiatives are being consolidated with equipment being procured and sited in the Neurology Department at Aberdeen, leading to the expansion of the service.
All this success has led to the North of Scotland Planning Group allocating continuing funding to maintain and improve the Network. The challenge now is to extend it throughout Scotland. The Scottish Centre for Tele-health is being set up. Its tasks include a national needs analysis, development of a technical infrastructure and deployment of the most successful area projects across Scotland. A launch event will take place on the 25th and 26th October in Dunblane. The widespread adoption of these successful initiatives will give added impetus to making the best use of resources in delivering care locally.
12 RURAL HEALTH CARE
Delivering for Health requires NHSScotland to develop and implement a framework of care designed specifically for remote and rural communities. This will address a range of issues related to the recruitment, training and development of staff, the need for a resilient transport system for urgent cases and the future development of Community and Rural General Hospitals.
Community First Responders Scheme The Scottish Ambulance Service (SAS) has set up more than 40 Community First Responder Schemes across Scotland with new areas volunteering to take part each week.
The SAS undertake training of community volunteers in basic first aid and life saving skills and provide the right equipment so that early treatment can be given to a patient while an ambulance is on its way. Those involved are alerted by the Ambulance Service’s Emergency Medical Dispatch Centre.
The speed of intervention can be critical when responding to 999 calls. This initiative creates an even faster response time for patients and is linked to existing ambulance resources. In a medical emergency it is often the simple act, like making sure an airway is clear, that saves a life. SAS staff work locally with volunteers to ensure ongoing refresher training. As a result of advances in technology many interventions, which were previously performed only by highly skilled individuals, can now be tackled by people with much less training. This includes use of small, easy to operate, external defibrillators (shock boxes) and lightweight oxygen delivery systems.
For some rural areas, geography means that an ambulance may be 15 to 20 minutes away, so local people who have life saving skills can make a real difference. These are often districts which only have a few emergency calls each month.
Since being introduced in Scotland, Community First Responder Schemes have been responsible for saving several lives, as well as improving the recovery and quality of life for many patients. The average response time for an emergency ambulance in Scotland is 8.5 minutes and it is not unusual for First Responders to be in attendance in less than half that time.
13 Galloway Community Hospital in Stranraer
Delivering for Health places great importance on Community Hospitals and the key role they play in treating patients who cannot be cared for at home, but who do not require the specialist care provided by a more distant hospital. The new £12.5 million Galloway Community Hospital in Stranraer is a wonderful example of such a facility. Funded by NHS Dumfries and Galloway and the Scottish Executive, it replaces the two existing Stranraer units, The Dalrymple and The Garrick. It is designed to provide enhanced healthcare services for people in Stranraer and Wigtownshire – a mainly rural population of about 30,000. Seventy-five miles by road from the Board’s District General Hospital, the Dumfries and Galloway Royal Infirmary, The Galloway Community Hospital offers facilities including: • Day Surgery; • Assessment and Rehabilitation; • Acute Medicine Maternity; • Renal; • Palliative Care; • Accident & Emergency; • Investigation and Diagnostics; • Outpatients Dental; and • Day Hospital and Out-of-Hours. Patients from The Dalrymple have already transferred to the new hospital and those from The Garrick are scheduled to move in November. The Galloway Community Hospital was completed in August 2006 and altogether there will be around 300 staff based in the hospital. A key factor in the development has been the tremendous support received from the local community, in particular fundraising from MacMillan Cancer Relief and the local Order of St John. This has resulted in the provision of two palliative care beds and a MacMillan Information and Support Suite complementing the services provided by the Stranraer Cancer Drop in Centre which has been running in the town since 2000. Also in South-West Scotland this autumn there is the development of a new Castle Douglas Primary Care Centre which will have accommodation for health and social care services as well as provision of two dental surgeries.
14 MENTAL HEALTH SERVICES
The Mental Health Services work stream aims to ensure delivery of structured high quality care, management, and facilities to all patients with mental health problems ranging from mild, moderate anxiety or depression to severe and enduring illness. The first stage is the development of a National Mental Health Delivery Plan which will be in place by December 2006 and work on this is well underway. In April, 190 interested people attended a meeting in Crieff and a further 200 have already registered for a similar event to be held shortly in Edinburgh. These meetings provide an opportunity for users, carers and representatives of the voluntary sector to share their views with the NHS and local authority staff. The clear message from the Crieff meeting was the need to do more to address issues such as equality, diversity and discrimination. At the same time people providing mental health services would like to have a status equal to their counterparts in the other main clinical priorities of cancer and coronary heart disease. This means setting commensurate targets and standards, and moves are underway towards developing key commitments and objectives related to the delivery, quality and effectiveness of services. Benchmarking and performance management will help compare like with like and show where change and success are being achieved. All this work is being backed by a National Support Programme.
NEUROSCIENCES
Neurosurgery and neurosciences in general provide good examples of the way in which the principles of Delivering for Health can be applied to the design of highly specialised services. Our aim is to create services which start in the community, giving people the ready access they need to specialist neurosurgical opinion and providing the support they require during rehabilitation. These services will link to a range of neurological procedures which can be delivered across Scotland’s four neurosurgical units in Aberdeen, Dundee, Edinburgh and Glasgow. These in turn, will link to a single, specialist, neurosurgical centre, where we will concentrate the most complex adult and child neurosurgery, in order to ensure the best possible outcomes for patients. Decisions about the procedures which can be delivered by existing units, and those which need to be concentrated on the prime site, will take into account amongst other things, the further work being done on volume and outcomes.
John Glennie, Chief Executive NHS Borders, has been appointed to lead a group of experts, charged with developing and implementing these changes. This group includes nurses, Allied Health Professionals, members of primary care teams and a range of representatives from various specialisms within neurosciences who have been identified with the help of the Scottish Neurosciences Council.
Over the next few months, the new group will start work on the development of the service model and supporting initiatives such as minimum data sets and audit arrangements. This will be shaped and guided by a process of engagement with patients, their families and carers and NHS staff which will seek views from all parts of Scotland.
The process will contribute to the final report which the group aims to submit to Ministers by the end of 2007.
15 TERTIARY PAEDIATRICS To meet the challenges identified in Delivering for Health the Scottish Executive has set up a National Steering Group for Specialist Children’s Services. Malcolm Wright, Chief Executive of NHS Education Scotland is leading this initiative. Expert clinical advice is being provided by Professor Sir Alan Craft, the former President of the Royal College of Paediatrics and Child Health, and Morgan Jamieson, National Clinical Lead for Children and Young People’s Health in Scotland. The Steering Group, which has met twice, has representatives on it from NHS Boards, Regional Planning Groups, Information Services Division and National Services Division, as well as staff directly involved in providing care. A number of services have been prioritised for review, including paediatric intensive care, metabolic services and children’s cancer services. Others are in the process of organising reviews by the end of September, for example – general surgery, endocrinology and immunology. Reports have already been produced on respiratory and gastroenterology services and these are now in the process of being evaluated. The cross cutting themes that have been identified are the development of a Managed Clinical Network Strategy, workforce information, age-appropriate care and communication. It is intended to involve a wide range of organisations and individuals in addressing these issues over the next few months and events are being planned for Aberdeen, Dundee, Edinburgh, Glasgow and Inverness. An important element in this project is the Scottish Executive’s commitment to the opening of new children’s hospitals in Edinburgh and Glasgow, and to the continued support of existing facilities including the recently built Royal Aberdeen Children’s Hospital and recently-opened children’s hospital in Dundee. The work of the National Steering Group is well under way and it is intended to produce a National Delivery Plan for Specialist Children’s Services in Scotland by the autumn of next year. CHILD AND MATERNAL HEALTH Good child and maternal health are vital to general well being and to achieving the aspirations of Delivering for Health. Efforts are being made nationally, regionally, and locally to meet this challenging agenda. In the last year Child Health Regional Planning Groups have been established across all three integrated regions in NHSScotland. These, through links to the national Children and Young People’s Health Support Group, chaired by Malcolm Wright, Chief Executive of NHS Education Scotland, are developing a comprehensive agenda for planning, implementation and delivery on a range of issues. These include Child and Adolescent Mental Health Services (CAMHS), in-patient psychiatric provision for children and young people, workforce projections and acute care for children and young people. In the summer of 2006, the extensive consultation on Delivering for a Healthy Future: an action framework for children and young people’s health was concluded. Responses are being analysed and the project team will ensure that the final Action Framework document takes into account all relevant views. Maternal health underpins child wellbeing and Delivering for Health was explicit in reinforcing the need for safe and accessible maternity services across Scotland. Principles were set out in A Framework for Maternity Services, published in 2001, and the report of the Expert Group on Acute Maternity Services in 2002. These are consistent with the overall approach of Delivering for Health and encourage patient-led facilities provided as locally as possible. Delivering for Health recommended the establishment of a national group to oversee maternity services and maternal health across Scotland. This has been established, with Wai-Yin Hatton, Chief Executive of NHS Ayrshire and Arran as its chair. It has begun to establish its extensive plans which involve NHS Boards, Regional Planning Groups and other stakeholders. 16 WORKFORCE
In their Workforce Plans, NHS Boards are considering the implications for their staff of the changes resulting from implementing Delivering for Health. Their responses include redesign of services and development of staff roles. These are all part of the necessary modernisation to ensure the future delivery of health services that meet patients’ needs. The NHS Boards’ Workforce Plans will be published annually and their progress reviewed.
One new role being looked at is the Physician Assistant (PA). This was developed in the United States to provide medical support to doctors. The American PA model has been successfully evaluated and there are now more than 60,000 practising throughout the States. They go through an intensive two year Masters level programme which closely follows medical training, they then sit a national certifying examination before they are allowed to practice. In addition they have to undertake 100 hours of compulsory formal education every two years and re-sit the national examination every six years. PAs provide a higher level of patient care, but always under the supervision of a doctor, freeing him or her, to take on other, more important tasks. The PA concept is attractive in that it is a proven one, but also because PAs do not have to come from a healthcare background. This avoids the ‘robbing Peter to pay Paul’ problem, as well as offering a means of widening access to NHSScotland’s clinical workforce. A two year pilot project, managed by NHS Education for Scotland, starts this autumn. Approximately 20 experienced US PAs are being recruited to various posts in NHSScotland. This trial will be evaluated independently and its outcome will determine whether NHSScotland develops its own PAs.
Delivering for Health offers significant opportunities for nurses to work differently within the clinical team. Roles are being developed at support worker level, which make best use of staff who have completed national programmes such as SVQ 2 and 3. This is particularly noticeable in primary care where nursing teams are changing to provide faster, more responsive care. At the other end of the spectrum there has been significant growth in Advanced Nurse Practitioner (ANP) roles, within Hospital at Night Teams in acute services and in Out of Hours services in primary, community and acute care. ANPs are highly experienced and educated members of the care team who are able to diagnose and treat healthcare needs or refer on to an appropriate specialist if needed.
The Allied Health Professions continue to develop the skill mix and roles within the services they provide. Working in multi professional and multi agency teams this diverse range of professions are developing support staff roles such as Assistant Practitioners enriching the skill mix and enhancing services. These roles are supported by new opportunities and training modules have been developed at HNC level for therapy and diagnostic radiography, physiotherapy and speech and language therapy. The first cohort of radiography support staff will commence their HNC training this autumn. The development of AHP Consultant roles provides the opportunity for AHP clinical leaders to lead service and practice change in a wide variety of clinical and service areas. The current national initiative has already supported the development of four such posts in areas as diverse as; Cancer Services; Therapy Radiography; Orthopaedic Services; and Physiotherapy. These roles will have a direct bearing on patient care and how services are delivered.
17 VOLUME AND OUTCOMES
Delivering for Health argues that the complex relationship between volume and outcomes could potentially have a bearing on how we organise health services. If it were clear that a greater volume led to much better outcomes, this would encourage less dispersed services. But if a lower volume were to be more beneficial, this would suggest, other conditions permitting, more localised facilities.
There are many elements in the volumes/outcomes debate, for example:
How complex is the procedure to carry out?
Should we look at the volume performed in a particular location, or performed by a specific practitioner?
If the latter, we also need to recognise that more experienced practitioners are likely to deal with more difficult cases?
Is it the volume of a specific procedure which is relevant, or does higher volume in general lead to better outcomes?
What bearing does the size of the medical team have on outcomes?
Where greater volume seems to lead to better outcomes, is it actually the volume which is having this effect, or, for example, the availability of high dependency care at the same location?
Professor Sir Graham Teasdale is leading a group of experts to examine the evidence around these and other questions. This will investigate what further analysis is needed to help decide future policy in Scotland.
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