Scottish Government

Section 2: Capability

It is essential that the capability of the NMAHP workforce is considered in relation to delivering on the key policy aims of Delivering for Health. The vision of NMAHP services in multi-disciplinary, multi-agency teams, firmly embedded in traditional values of caring and enablement and practising from an education and research base that promotes safe and effective care, must be central to this endeavour.

Delivering services closer to home

Delivering for Health makes a pledge to bring services closer to patients' homes - taking services to them rather than requiring them to go to services - and to ensuring the people in society most vulnerable to ill-health (often those who have least access to services) are recognised and engaged.

Delivering for Health recognises that there is much variability across communities in terms of population health needs. Communities also have different strengths and resources that come into play in addressing population health needs. This is a particular issue in remote and rural areas of Scotland.

All this essentially points to a transformational shift in the NHS towards developing community services, using available technology to create locally responsive services that ensure people get the care and treatment they need closer to home when that is the most clinically effective option. It means:

• taking services into those areas where uptake has been lacking
• ensuring prompt access to specialised services when necessary
• recognising family members and carers as a vital part of effective delivery of care closer to home, identifying their needs and enabling families and carers to access appropriate support for their caring role
• engaging with new ways of working in new types of organisations with new multi-disciplinary, multi-agency teams
• optimising the use of technology to support the provision of care to patients and carers.

NMAHPs are already practising flexibly across traditional service boundaries, finding new ways of working that retain and build upon the unique characteristics of nursing, midwifery and allied health professional practice. They make an important contribution to developing community services and delivering services closer to home through creative and flexible responses to patient need. The Review of Nursing in the Community in Scotland and the Draft Rehabilitation Framework will further promote this agenda (Box 2.1), and Delivering for Health now gives NMAHPs the opportunity to make their contribution even more telling.

Box 2.1 The Review of Nursing in the Community in Scotland and the Draft Rehabilitation Framework
Both these documents have emerged as action points from Delivering for Health.
The Review of Nursing in the Community sets out a new service model to deliver modern, appropriate, safe and effective services for the people of Scotland.
The model builds on nursing strengths to create nursing services in the community that help to:

• reduce health inequalities
• promote individuals', families' and communities' health and self-care abilities
• support people to live healthier in their homes for as long as possible
• develop career options that reflect the importance and value of nursing in the community to the people of Scotland.

The Draft Rehabilitation Framework focuses on core principles of rehabilitation specifically as they relate to older people, people with long-term conditions and people returning from work absence and aiming to stay in employment.
The framework:

• concentrates explicitly on the added value offered by rehabilitation through earlier anticipatory interventions and the prevention of unnecessary admissions to hospital
• explores how rehabilitation can produce health gains for individuals and communities through enabling return to productive activity and employment
• provides guidance to underpin the development of rehabilitation in a multi-agency context
• offers a clear vision for health and social care practitioners in delivering this agenda.

Support and protection of the public

NMAHPs, like all health and social care professionals, have a duty of care and responsibility to service users, families, carers and the public, and accordingly need to act in their best interests. Providing support and protection has always been a cornerstone of good nursing and AHP practice and is a central tenet of statutory midwifery supervision.

As front-line clinical workers, NMAHPs are often in a strong position to identify signs of abuse and neglect in people across the age spectrum and to trigger appropriate responses from services.

They are well-placed to advocate for people, ensuring their rights are upheld and their safety is assured as part of their contribution to fostering a public health approach to service delivery.

Currently, protection of children and young people has been identified as a national priority. This is an issue for all NMAHPs, not just those who have specialised in the care of children and young people. Most NMAHPs engage with children and young people as service users or family group members as part of their normal practice.

Embedding issues of protection of children and young people in the practice of all NMAHPs is necessary not only in relation to ensuring their safety, but also because the principles of protection of children and young people can be applied to the support and protection of all people. Adults can be vulnerable at specific times of their lives due to a number of causes, such as emotional, intellectual or physical incapacity, serious or long-term illness, economic and social disadvantage, inability to communicate effectively, or as a result of prejudice. They require NMAHPs to place a high premium on their support and protection.

NMAHPs have a clear responsibility to remain vigilant to the possibility of protection-related issues arising with patients, families, carers and the public and to initiate appropriate supportive and protective measures. This may, on occasion, require them to share patient information with appropriate authorities in the interests of public protection. Specific legal stipulations apply to this practice, and all NMAHPs should be aware of their legal responsibilities in this regard.

Key Message
Providing support and protection is an integral part of the public health role of all NMAHPs and must be reflected in their practice within the context of multi-disciplinary, multi-agency team working.

Supporting older people

The demographic picture in Scotland, as set out in Delivering for Health, shows a rising number of older people in the population over the next 20-30 years. This is likely to lead to two consequences:

• increasing numbers of frail older people needing hospitalisation for multiple episodes of care, with longer stays when in hospital
• many more people living with long-term conditions in the community.

More needs to be done within nursing and the allied health professions to promote supporting older people as an attractive career option. Supporting older people, whether they be patients, family members or carers, is part of every nurse and AHP's role. There are increasing numbers of older people accessing services across the spectrum, or who are supporting patients in acute hospitals, intensive care settings, mental health and learning disability services, and in the community.

Supporting older people is therefore 'core business' for nurses and AHPs, regardless of their service setting. Yet for far too long, providing services to older people hasn't been accorded the value it deserves within the professions, with higher status being conferred on other areas of practice. Delivering for Health changes all that by placing the needs of older people and people with long-term conditions at the centre of attention.

The new NHS will be a service primarily focused on helping older people to stay well and remain engaged with their communities and, if they fall ill, providing them with appropriate access to services locally or in specialist centres. Nurses and AHPs in all areas of service - not just those specialising in supporting older people - have a great opportunity to help achieve this policy aim by designing, delivering and evaluating services that focus on improving older people's health and well-being, developing their self-management skills, and providing quick and effective responses to health changes.

This is a responsibility that all nurses and AHPs who provide services to older people in the line of their work should accept with enthusiasm and apply with vigour. Clinical leadership will be necessary to show the way, promoting a high sense of value in supporting older people and ensuring older people's needs are addressed through service redesign and delivery of care.

Key Message
The benefits and value of supporting older people must be promoted within the professions, emphasising the opportunities it creates for nurses and AHPs to put the professions' fundamental values of caring and enablement into practice and to make a significant contribution to delivering the new health policy agenda.

Unscheduled care and planned care

Developing unscheduled care and out-of-hours services is a key element of Delivering for Health. NMAHPs are helping to take this agenda forward throughout the country in a range of initiatives, some of which are nurse or AHP-led, and which include the implementation of the Unscheduled Care Collaborative programme set up to reduce waits and delays and improve the patient and carer experience of emergency care.

The largest number of new or developed roles in this service involve nursing staff, but there are now education programmes and service roles across NHSScotland in which nurses, AHPs and paramedics are learning and working together in new and exciting ways. For example, work is being taken forward to enhance AHP input to unscheduled care/out-of-hours services, both in terms of ensuring availability of specialist skills and in enhancing generalist skills.

It has become apparent that there is a need to develop the following to support NMAHPs' further contributions to these vital services:

• education programmes and competency frameworks to support NMAHPs in developing flexible and sustainable unscheduled and out-of-hours services and enable transferability of roles
• role development opportunities to enable NMAHPs to assess, diagnose and treat patients with defined problems, so avoiding the need for them to attend hospital, and to ensure patients are referred appropriately to hospital when necessary
• structured career pathways in unscheduled care/out-of-hours services
• greater multi-disciplinary, multi-agency working to develop unscheduled care/out-of-hours services
• structured supervision and support for practitioners
• greater use of information technology ( IT) within practice to support patient progression through services.

Investment and support work put in place by NHS Education for Scotland is already enabling much of this agenda to take shape in practice (Box 2.2).

Box 2.2 NHS Education for Scotland Education Framework for Nursing and AHP Role Development in Unscheduled Care/Out-of-Hours

• Development of competency framework for unscheduled care/out-of-hours to describe nursing, AHP and other health professions' contribution to service.
• Mapping of nursing and AHP roles against the framework using three-stage model to support service planning.
• Direct pump-priming education investment to NHS Boards to support nursing and AHP role development for primary care unscheduled care/out-of-hours and hospital at night services.
• Mapping of higher education institutions' ( HEI) programmes and skills development provision against competency framework to ensure appropriate provision/purchasing.
• Funding support for new online programme provision for unscheduled care/out-of-hours.
• Partnership working with Scottish Ambulance Service and NHS 24 to encouraged service integration.
• Piloting of standard for assessment and supervision of unscheduled care practitioners in partnership with NHS Boards and HEIs.

For further information, access: www.nes.scot.nhs.uk/ooh

Key Message
The right education, service and support infrastructure must be in place to support NMAHPs' contributions to unscheduled care and out-of-hours services.

Delivering for Health emphasises the need to manage acute admissions to hospital to meet patient needs in new and better ways and to adhere to waiting times targets. Programmes of work are under way to re-profile accident and emergency service provision to ensure that:

• patients with minor illnesses and injuries can receive more appropriate care and treatment closer to home
• specialist accident and emergency services are focused on managing patients with serious and life-threatening conditions who are likely to require hospital admission.

This re-profiling activity is presenting many opportunities for professionals working in multi-disciplinary, multi-agency teams in settings such as community hospitals, general practices and accident and emergency departments to redefine their roles in assessing, diagnosing and treating patients with a wide range of minor and serious conditions.

Key Message
NMAHPs should seize the opportunity Delivering for Health presents to develop their emergency care roles and practice in a range of settings.

At the same time, it is important to ensure that the NHS works toward reducing planned admissions to hospital. Delivering for Health sets out five simple changes that will help NHS Boards to achieve reductions in planned admissions:

• treat day surgery as the norm for planned procedures
• improve referral and diagnostic pathways
• actively manage admissions to hospital
• actively manage discharge and length of stay
• actively manage follow up.

A range of initiatives has been launched to ensure progress on each of these changes, with the combined aim of reducing planned admissions by managing patients more appropriately in alternative settings and, consequently, reducing waiting times.

NMAHPs are playing key roles in these initiatives. They are taking their places within new systems to ensure that patients:

• have easy access to hospital services (either unscheduled or planned) when they need it
• receive care from integrated teams practising according to defined care pathways (where they currently exist)
• are being discharged promptly when safe to do so (without the need for unnecessary delays).

NMAHP actions in relation to initiatives on managing planned hospital admissions must improve patient experience and outcomes by ensuring patients receive the right care, from the right person, in the right place, at the right time.

Almost without exception, an admission to hospital marks an interruption and a disruption in a person's life. He or she has to put 'on hold' normal family, social, employment and education activities. Offering patients alternatives to hospital admission when appropriate to their health needs and trying to make necessary admissions as brief as possible are therefore not only markers of a high-quality, integrated service, but are also liable to make the patient's experience of services much more positive, and enable him or her to get back to normal life as quickly as possible. Managing planned admissions is, first and foremost, a quality of care issue.

Charge nurses and senior nursing staff in hospital wards and hospital-based AHP leaders have a clear responsibility to ensure that patients admitted to their units have been placed in the environment that is best suited to providing them with maximum health benefits, and to act appropriately when they feel this is not the case. They must also ensure that all appropriate arrangements are in place to guarantee a safe discharge for the patient when the time is right.

Increasingly, AHPs are providing services to accident and emergency departments and admission units that support the prevention of unnecessary admissions to hospital. Rapid response teams and early supported discharge teams - often therapist or nurse-led - are facilitating smooth transitions from hospital to home and providing home-based rehabilitation or support as required. AHPs and nurses are also jointly leading the development of rehabilitation wards within acute settings which reflect the rehabilitation/enablement philosophy of care and support effective discharge management and transitions between care settings and home.

Midwives have a similar responsibility to promote early discharge from hospital of women who have had a normal birth. This calls for strong leadership and decision-making skills.

Key Message
The length of stay of patients admitted to hospital should be as short as possible consistent with maximum health benefits for the individual, and discharge must be appropriately planned.

Anticipatory care, improving health, public health and reducing inequalities

Delivering for Health calls for greater emphasis to be given to preventive health care and earlier intervention, particularly in areas where health is poorest. It states:

'We believe the most significant thing we can do to tackle health inequalities is to target and enhance primary care services in deprived areas. Strengthening primary care teams and promoting anticipatory care in disadvantaged areas will reduce health inequalities by:

• targeting health improvement action and resources at the most disadvantaged areas
• building capacity in primary care to deliver proactive, preventative care
• providing early interventions to prevent escalation of health care needs.'

This is the essence of anticipatory care. It is an agenda NMAHPs have sought to address since the launch of Nursing for Health - a Review of the Contribution of Nurses, Midwives and Health Visitors to Improving the Public's Health in Scotland in 2001, and from the publication of Building on Success.

Nursing for Health highlighted the principles of needs assessment, care management, building health programmes to meet population needs and developing health co-ordination roles across a range of settings as being central to nursing and midwifery practice.

Building on Success stated:

'Empowering individuals and communities to achieve better health in partnership with social care, education, housing and voluntary agencies is central to improving health … Allied health professionals are committed to health improvement, which is often integral to their specific clinical role. Many are involved in health screening, health promotion, public health, social inclusion and participation initiatives and in advising individual people who access their services.'

It then went on to set out a series of actions focusing on AHPs' contributions to improving health and well-being and to exploring opportunities for a preventative or pre-habilitative approach, such as falls prevention and early interventions for mild to moderate mental health problems.

NMAHPs are forces in ensuring a change in NHS culture from one of illness and treatment to one of promoting public health, health promotion and illness prevention, even though they have yet to realise their full potential in this regard. They should consider every health care contact as an opportunity to promote and encourage health improvement.

NMAHPs are also adept at working with disadvantaged individuals and communities, addressing inequalities and promoting equity by reaching out to members of the population who traditionally have poor access to services, such as homeless and travelling people, older people, those with mental health problems or learning disabilities, people who are being abused physically, sexually, emotionally or financially, and those who are marginalised through poverty, prejudice or incapacity. Like other health professionals, however, NMAHPs need to develop confidence in the positive outcomes that can be achieved by moving from an ill-health model to one of health promotion.

To develop this confidence, they need an organisational context which systematically identifies and provides enhanced services for those at risk through disadvantage and other life circumstances. Delivering for Health sets the policy agenda from which this confidence can grow; it will lead to new ways of working in redesigned services which tackle disadvantage and promote greater equality of access and outcomes.

Key Message
Delivering for Health's identification of anticipatory care as a central element of NHS services opens the door to NMAHPs carrying out more of this vital work.

Improving Health in Scotland - The Challenge ( SEHD, 2003a) recognises that different policy strands and action programmes for improving health need to be linked and, where possible, integrated. Links among health service, local authority, social services, education, social justice, environment, employment, recreation and sports services are also important. The report sets out to build upon existing programmes focusing on health improvement to describe four key 'themes' for action - early years, teenage transitions, the workplace and the community.

Delivering for Health notes the significant advances that have already been made in areas such as tobacco and alcohol use, children's health, oral health and mental health, in healthy life expectancy and in coronary heart disease mortality. Inequalities persist in the most deprived areas of Scotland, however, and new challenges have emerged, such as the increasing incidence of obesity.

Building on Success identified the need for a collective multi-disciplinary, multi-agency approach to improving health, promoting public health and reducing inequalities. AHPs acknowledge that they could contribute more effectively to this goal and recognise that they need to work more closely together and with other professional colleagues. Shifting the focus of existing services from being reactive to ill health to being proactive in improving health, as advocated by Delivering for Health, calls for AHP leaders and employers to recognise and define specific contributions to health improvement when reviewing job descriptions and ensure that AHPs get the opportunity to contribute to local health improvement initiatives.

There are likely to be significant opportunities for AHPs in the field of vocational rehabilitation, supporting individuals to return to the work place, improving their health status and helping them to avoid dependency on benefits. This is a key strand of the Draft Framework for Rehabilitation currently out for consultation, and also reflects a UK-wide commitment from the Department of Work and Pensions.

Nursing for Health describes measures to re-establish nursing and midwifery's expertise in the vital areas of improving health and public health, including:

• positioning nursing and midwifery in the mainstream of health improvement
• developing nursing and midwifery's contribution to public health as full and legitimate partners in the health improvement process
• adopting public health approaches in nursing and midwifery work
• working in multi-disciplinary, multi-agency partnerships.

Public health nurses are seen to focus on health and social needs, working in collaboration with other disciplines to develop evidence-based services. This includes mapping needs evaluations of services and demonstrating positive outcomes. In addition, Scotland has growing numbers of public health practitioners, many of whom have nursing, midwifery and allied health professional backgrounds.

But while these professionals provide a specialist public-health focused service, public health is the concern of allNMAHPs, regardless of specialty or area of practice. All NMAHPs in hospital and community settings must consider how public health and health improvement approaches sit with their current roles and how they can creatively be integrated into their practice.

Key Message
Public health approaches and awareness must be integrated into all NMAHP roles and practice.

Supported self-care, patient empowerment and managing long-term conditions

One of the most powerful means of preventing unscheduled hospital admissions - a key objective of Delivering for Health - is to promote supported self care among patients and empower them to access and use health service resources in their community.

Promoting supported self care is an established function of nurses and AHPs across children's, adults, older people, mental health and learning disability services, and in midwifery. It draws upon existing approaches to practice in which NMAHPs work as partners with patients, families and carers, sharing expertise and experience with the goal of increasing self-management skills. There is, however, a pressing need for a model that will enable NMAHPs to support patient self care and empowerment and help patients effectively to manage their own care. The model should be evidence based and should be evaluated in a range of different settings. Excellent examples of such models exist in the mental health and learning disability literature, and these may be transferable to other contexts with suitable adaptations.

Key Message
Models of practice are needed to enable NMAHPs to support patient self care and enable patients effectively to manage their own care.

Working with patients and carers in a way that enables supported self care calls for NMAHPs to possess abilities in creating positive, therapeutic relationships with service users, applying significant levels of self awareness, engagement skills and advanced interpersonal skills in their practice.

The accent is on enabling patients to be as independent as possible, supporting them to recognise their own signs and symptoms and knowing how to manage them. This will require NMAHPs to share skills directly with patients and to develop thinking on identifying individual needs from the patient's perspective.

It is recognised that patients may be dependent on others for care during the course of an acute illness or long-term condition, but they should be encouraged and supported to become more actively involved in self care as they are able. Each patient requires an individual approach.

In the past, nursing and midwifery practice has not tended to focus on developing self care. Rather, it has emphasised how nurses and midwives can manage care and exert control over service users' experiences of services. Truly enabling and supporting service users' empowerment calls for nurses and midwives to practice in a different way.

This change of direction will not be easy for some nurses and midwives to accomplish. Those who value their roles as 'helpers' will have to step back and begin to see themselves as 'enablers', reaching decisions on how they can really help service users by enabling them to help themselves. This might be difficult for some, but it is absolutely essential in ensuring nurses' and midwives' contributions to services are best placed to secure the future health and well-being of the people of Scotland. There is much nurses and midwives can learn from AHPs in adopting this kind of enabling approach.

Key Message
Nurses and midwives, working in partnership with AHP colleagues, must undergo transformational change in delivering the new health agenda by becoming, first and foremost, enablers and supporters of service users' self-care and self-management abilities.

Leadership

Delivering for Health recognises that for the transformational changes it sets out to happen in practice, the culture and climate of change in the NHS needs to be further developed. Clinical leadership will be vital to achieving this aim.

Much has been achieved in promoting clinical leadership in NHSScotland in recent years. Delivery through Leadership ( SEHD, 2005b), the NHSScotland leadership development framework, was published in June 2005. The framework and its supporting implementation plan aim to build leadership capacity and capability in NHSScotland and grow new leaders to meet the service change agenda. It represents a single, national approach to leadership development in NHSScotland focused on the needs of the service, teams and individuals.

Significantly, the framework places great emphasis on the importance of personal qualities, service priorities and organisational culture in developing leadership capacity, and much less on seniority and hierarchy. Developing leadership potential is recognised as appropriate for people throughout the service, from support workers to senior managers. All can learn, and all can contribute.

The importance of leadership in developing NMAHP services and in strengthening clinical teams is widely acknowledged. A raft of initiatives has taken forward leadership development for NMAHPs, including:

• Scottish Executive funding support for practitioners to undertake the RCN's clinical leadership programme
• the NES-sponsored midwifery leadership framework and subsequent development centre activity
• the Scottish Executive AHP leadership programme, 'Change Weavers' (see Box 2.3).

Box 2.3 Change Weavers
The success of Change Weavers is evidenced by the programme evaluation:

• 78% of those surveyed rated their learning as highly sustainable and making an ongoing impact on their leadership development in NHSScotland
• 94% indicated they had a significant impact on their team and its performance as a result of their learning experience, with 87% strengthening their capacity to develop the team-based culture
• significantly, 72% felt they were better prepared to work with patients and carers as partners in their care.

Capturing the vital role NMAHP clinical and strategic leads can play in driving service improvement, delivering better care and enablement and enhancing health outcomes is now critical. NMAHPs make up 72% of the clinical workforce of NHSScotland. Strong and vibrant leadership is necessary to release the potential of this workforce and to support the significant contribution each individual practitioner and support worker can make to enhancing the patient's experience of services.

The development of consultant nurse, midwife and AHP posts, each of which has a defined leadership function and responsibility, also marks a significant benchmark in taking clinical leadership forward.

The Scottish Executive Health Department is launching a Review of the Role of the Senior Charge Nurse/Midwife in NHSScotland, which will focus on creating modern roles that will enable frontline clinical leaders to maximise their contribution to delivering safe and effective care (see Box 2.4).

Box 2.4 Review of the Role of the Senior Charge Nurse/Midwife in NHSScotland
The review includes all senior nurses and midwives who lead a team providing care to patients within NHS settings. It does not include nurses or midwives who predominantly provide care to patients within their own home, but key links will be made with the Review of Nursing in the Community in Scotland.

The objectives of the review are to:

• provide a framework that will identify the potential for change and determine future requirements of the role to ensure a visible, authoritative, credible and accessible presence for patients and families
• provide mechanisms that will give assurance to patients and the public that senior charge nurses/midwives are accountable leaders and managers of safe and effective care
• describe the clinical co-ordination, leadership and management functions of senior charge nurses/midwives to the wider multi-disciplinary team, highlighting their role as key decision makers who impact significantly on the delivery of safe and effective care to patients and carers
• provide guidance for NHS Boards on developing the roles of senior charge nurses/midwives in the context of local organisational change
• test the implementation of recommendations in a number of pilot sites through facilitated action, with senior charge nurses/midwives using the agreed set of Clinical Quality Indicators to demonstrate the impact of the nursing/midwifery team on the delivery of safe, effective and assured patient-centred care.

Communications with key stakeholders and frontline nurses and midwives are acknowledged as being important to the success of the project. An inclusive, collaborative model has been developed that will allow patients, the public, frontline nurses and midwives and other stakeholders the opportunity to inform the outcome of the review.

In maternity services, a nationally co-ordinated programme of work will be launched to identify how midwives can develop the culture, competencies and capabilities to assume leading roles in caring for women during pregnancy episodes (see Box 2.5).

Box 2.5 Nationally Co-ordinated Midwifery Programme of Work
The programme will link with NHS Quality Improvement Scotland, NHS Education for Scotland, the Royal College of Midwives (Scotland) and other stakeholders and will have a number of defined streams:

• developing midwifery leadership capability
• supporting a national evidenced-based practice development programme for midwives
• maximising informed choice for women throughout the pregnancy episode
• exploring the potential for a defined pathway of care for low-risk women.

Key Message
Clinical leadership is critical in ensuring the transformational change necessary to implement the Delivering for Health vision. Initiatives and role developments aimed at promoting NMAHP leadership must be progressed.

Professional leaders need support across management, education and research spheres. There is a significant pool of talent among the NMAHP workforce from which NHS Board Nurse Directors and AHP Leads, working in partnership, can identifiy and nurture potential leaders in preparation for assuming strategic leadership roles. Any exercise in growing leaders needs to consider succession planning and development of leaders of the future, and the Scottish Executive Health Department has commissioned NHS Education for Scotland to develop a succession development programme for nurse, midwife and AHP consultants.

Key Message
Potential strategic NMAHP leaders of the future must be identified, with support and development mechanisms set in place to ensure the cadre of potential leaders in the workforce continues to grow.

eHealth

Delivering for Health sets out a two-pronged strategy for developing eHealth (see Box 2.6) in NHSScotland.

Box 2.6 eHealth
The expression 'eHealth' reflects the need to address a broader agenda than is implied by the term 'information and management technology' (sometimes referred to as information and communications technologies).

Information management and technology is about the information NHSScotland needs to deliver effective health care, the technology needed to deliver that information to the right person at the right time, and the range of processes (such as training and support services) needed to make it happen.

eHealth encompasses much more than the deployment of computer technology. It conveys the message of electronics in support of health and stimulates debate about the broad range of issues and opportunities technology offers in health care settings to professionals and patients.

eHealth includes the development, application and implementation of technology to improve effectiveness in health care, but just as important, it is focused on taking technology out to the people who will most benefit from its use. It's about making it happen across the service.

eHealth includes the use of telemedicine and clinical systems used for diagnosis and care pathways and relates to policies and protocols that assure the confidentiality and security of sensitive data. More than anything, it includes those elements that support major change in working practices - training, support and organisational development.

The first part of the strategy concentrates on developing core strands such as:

• the Community Health Index ( CHI) number uptake
• a national Picture Archiving and Communication System ( PACS)
• a single, national, computerised Emergency Care Summary ( ECS)
• a national software system to support patients' journeys within accident and emergency settings.

The second aims to develop a single, electronic health record ( EHR), which is seen as a central element of the entire Delivering for Health policy agenda.

The EHR will be much more than a patient care and treatment record. It will also offer the capacity to engage with other core elements of patient care, such as scheduling appointments, requesting investigations and collecting epidemiological data.

Delivering for Health states that a common information and communications technology ( ICT) system is essential if NHSScotland is to deliver the integrated care services the Scottish Executive is calling for. It acknowledges the fact that health care providers around the world recognise the opportunity for 'faster, safer, more efficient and more patient-centred services that ICT offers'.

This doesn't necessarily mean that all NHSScotland organisations will need to use the same ICT system. Rather, it is envisioned that a suite of ICT systems will emerge, complying with clinical and technical standards.

Not only will it be necessary to communicate between systems in NHSScotland, but a certain level of interoperability across the UK will also be necessary. This will limit freedom to procure and develop systems locally without reference to national requirements and strategy, and will be achieved through collaboration across Scotland and the UK and with the involvement of clinicians, including NMAHPs.

The current eHealth Programme in Scotland was set up following a commitment given in the White Paper on the NHS, Partnership for Care ( SEHD, 2003b). It emphasised the urgent need to establish an eHealth culture that would be driven by clinical leaders.

The eHealth Programme Board co-ordinates the diverse elements necessary for a successful programme, including:

• ensuring patients' needs and interests come first
• accessing appropriate technology closer to (or within) people's homes
• developing a strong eHealth culture
• encouraging engagement with clinical practitioners.

It is recognised that delivering the eHealth Programme will call for many changes in the way NMAHPs and other professionals work. Record-keeping standards will be more rigorous to ensure clinical information can be shared effectively in an electronic environment while ensuring data confidentiality, security and integrity. NMAHPs and others will be recording their interventions directly into EHRs as the norm, with only occasional reversion to handwritten records in particular circumstances.

This transformational change will have profound implications for NMAHPs working in Scotland. The changes, however, are likely to reduce, and not increase, the time and effort they make in recording data. Indeed, they will provide the opportunity for NMAHPs to adopt the culture of data collection and data recording, which will better help them to plan and deliver safe and effective care and evaluate the outcomes of their interventions in partnership with the multi-disciplinary team and patients, families and carers.

The revolution in data collection, analysis and use that Delivering for Health and the eHealth Programme sets in train will provide NMAHPs with the information they need to support decision making, benchmark practice against quality indicators and compare performance with peers. Significantly, it will also increase patient access to information, increasing their understanding of their conditions and progress and enhancing their capacity for self care.

NMAHPs' engagement with the eHealth Programme is therefore crucial to ensure workable solutions that support the NMAHP contribution required to deliver patient-centred care. Increasing amounts of health care activity at the point of access is being delivered by NMAHPs. They also tend to record different types of information from medical colleagues, with the focus very much on problem-solving and finding solutions. They must take a lead in developing new and better systems for integrating service delivery and ensuring the NMAHP perspective is central to all eHealth developments.

Data will become a core element of driving service and quality improvement, enabling NMAHPs and multi-disciplinary, multi-agency colleagues to highlight effective practice and identify areas where change is required. Creating, analysing and acting on data will become part of NMAHPs' everyday practice.

Key Message
NMAHPs must use information to highlight, maintain and develop practice to improve patients' experience of health services and health outcomes.

The Scottish Executive is committed to facilitating NMAHPs' involvement with the eHealth Programme through promoting leadership, addressing information needs and developing technical and information management competencies. In addition, the NHSScotland e-library, managed knowledge networks, communities of practice and other e-based networks offer a range of support for practitioners to support knowledge into practice.

Key Message
NMAHP leaders and clinicians must engage with the eHealth agenda.