1. Achievements and Progress During 2008/09
This chapter provides an overview of the delivery structure of NHSScotland and a summary of progress on our strategy, Better Health, Better Care * and towards our goal of developing a mutual NHS. In the next chapter we provide detailed statistical information of progress on the HEAT targets in 2008/09.
Delivering Healthcare in Scotland
NHSScotland consists of 14 Territorial NHS Boards and eight Special NHS Boards. They are accountable to Scottish Ministers, supported by the Health Directorates in the Scottish Government. The 14 Territorial NHS Boards are responsible for the protection and the improvement of their population's health and for the delivery of frontline healthcare services. The eight Special NHS Boards support the Territorial NHS Boards by providing a range of important services that are best provided by single national organisations. All NHS Boards work together for the benefit of the people of Scotland. They also work closely with partners in other parts of the public sector to fulfil the Scottish Government's Purpose and National Outcomes 1. Maintaining good health, social and economic participation is vital to sustainable economic growth.
A list of all Territorial and Special NHS Boards, along with links to each related website, is provided in Chapter 6.
Better Health, Better Care
The Scottish Government set out its plans for improving Scotland's health and healthcare in the document Better Health, Better Care * published in December 2007. It gave priority to measures to improve health and tackle health inequalities, and placed an emphasis on two healthcare objectives:
- developing a mutual NHS, offering all people in Scotland new rights, responsibilities and a stronger voice in the NHS; and
- improving the quality of healthcare.
The implementation of the action plan set out in Better Heath, Better Care, has led to impressive and internationally-recognised progress being made which has contributed to improvements in the quality of the healthcare services delivered in Scotland. As we move forward, we will build on these successes to meet our objective of raising and sustaining the quality of our healthcare services.
Our ambition for the highest quality healthcare services spans all NHS activity and complements our continuing focus on improved health and reduced health inequalities. Better health outcomes for the population require us to focus on health in early life and key risk factors, such as smoking and excessive alcohol consumption, as well as improving healthcare services. Our goal is to ensure that each individual person receives the information, help, care and support they need, when they need it. We want to achieve this by working with patients and carers, by listening to their experiences of the services we offer, and by taking action to make improvements. Through our dialogue with patients, staff and carers, we know that they want:
- caring and compassionate staff and services;
- clear communication and explanation about conditions and treatment;
- effective collaboration between clinicians, patients and others;
- a clean and safe care environment;
- continuity of care; and
- clinical excellence.
This report explains the progress we are making through our commitment to a mutual NHS, and through pioneering work such as the Patients' Rights Bill, * the Better Together * patient experience programme and the improvements in support for self management of long-term conditions. We will take this agenda forward in 2010 when we plan to set out our approach to quality across NHSScotland.
Summary of Achievements and Progress
NHSScotland has delivered a number of significant achievements in 2008/09 and made important progress towards a healthier Scotland. Progress has been made on key issues including Healthcare Associated Infection ( HAI), patient safety, dentistry, cancer care, Equally Well *, introduction of the first stage in the process of abolishing prescription charges and further improvements in access to treatment, while once again achieving financial balance.
Developing a Mutual NHSScotland
A new Patients' Bill of Rights
A public consultation on the Patients' Rights Bill * for users of the NHS in Scotland took place from September 2008 until January 2009. The Patients' Rights Bill aims to reinforce and strengthen our commitment to place patients at the very centre of the NHS whilst setting out the range of existing rights and responsibilities of patients in a clearer way. The overall aim is to improve patient outcomes.
Over 200 written responses were received to the consultation. More than 100 people attended national consultation events and 68 people took part in focus groups held with minority and disadvantaged communities. In addition, hundreds of people attended local consultation events organised by NHS Boards and Public Partnership Forums. The consultation responses and analysis have provided the Scottish Government with a breadth of opinion to inform the work on developing the Bill which will be introduced to Parliament in 2010.
Direct elections to NHS Boards
The Scottish Government launched a consultation exercise in January 2008 on direct elections to NHS Boards in Scotland. As a result of this consultation, the Health Board (Membership and Elections) Scotland Bill * was introduced to the Scottish Parliament and was unanimously passed prior to receiving Royal Assent on 22 April 2009. The resulting Act provides powers to enhance public involvement and increased participation in the design and delivery of local health services. On 16 June 2009, it was announced that pilot NHS Board elections would take place in NHS Dumfries and Galloway and NHS Fife in spring 2010. Two alternate non statutory pilots will run concurrently in NHS Grampian and NHS Lothian which aim to enhance the current public appointment processes and increase the diversity of candidates applying to become members of NHS Boards without direct elections.
A new patient experience programme
Better Together, the patient experience programme, has continued to work with NHS Boards and key stakeholders to develop national surveys for three key areas: inpatients, users of GP services, and those living with long-term conditions. The National Improvement Partnership has been established with NHS Boards and stakeholders to examine how to use this information as it becomes available. The results of related research projects have been published. The programme is also considering how to engage people irrespective of their race, disability, gender, sexual orientation, age or religion/faith.
Health of the Population and Reducing Inequalities
Government proposals to tackle Scotland's most significant and widening health inequalities
Equally Well*, the report of the Ministerial Task Force on Health Inequalities, was published in June 2008. The report addresses underlying causes of health inequalities such as poverty, a lack of employment and exposure to physical and social environments that perpetuate poor health. It makes 78 recommendations for change in policy, practice and delivery across a range of topics and sectors, requiring action from national and local government, the NHS, schools, employers and the third sector. The publication of Equally Well has been well received both nationally and internationally and has demonstrated the Scottish Government's commitment to tackling health inequalities.
The Equally Well Implementation Plan * was published in December 2008. It identified lead agencies for each of the 78 recommendations, as well as setting out activity - both underway and planned - to give effect to those recommendations. The plan will serve as a baseline for the Task Force, when it reconvenes in 2010, to review progress in implementing Equally Well.
Development of a long-term early years strategy
The Early Years Framework * was published by the Scottish Government and the Convention of Scottish Local Authorities ( CoSLA). The framework identifies the changes needed to give children the best start in life. Its themes are building parenting and family capacity, creating communities that provide a supportive environment for children and families, delivering integrated services that meet the needs of children and families, and developing a suitable workforce to support the framework.
A national statement and action plan on race equality
In December 2008, the Minister for Communities and Sport set out the Scottish Government's priorities on race equality up to March 2011. The Government's commitment to race equality extends across NHSScotland and will ensure that health services continue to meet the needs of minority ethnic communities by involving them in the design, development and delivery of services. In particular, the Better Together patient experience programme will seek the views of minority ethnic communities using services to ensure that we continue to improve in meeting their needs.
A new Smoking Prevention Action Plan
Efforts to reduce tobacco-related harm continued to have high priority in 2008/09. In May 2008, we published Scotland's Future is Smoke-free: A Smoking Prevention Action Plan *, setting out an ambitious programme of measures to discourage smoking among children and young people by reducing the attractiveness, affordability and availability of cigarettes and other tobacco products. Key actions included the introduction, in February 2009, of the Tobacco and Primary Medical Services (Scotland) Bill * proposing, among other things, a ban on cigarette vending machines and tobacco displays in shops and improved access to NHS smoking cessation services via the Public Health Service ( PHS) element of the community pharmacy contract.
A new strategy for tackling alcohol misuse
In June 2008, Changing our Relationship with Alcohol: a discussion paper on our strategic approach * was published. This made clear our commitment to tackling alcohol misuse as a major public health challenge and a significant contributor to health inequalities. This resulted in the publication of a framework for action on changing Scotland's relationship with alcohol in March 2009. The framework for action outlines a comprehensive approach to tackling alcohol misuse in Scotland, including legislative action on matters such as minimum pricing of alcohol; measures designed to support families and communities; actions to promote positive choices and attitudes around alcohol; and improvements to treatment and support.
NHS Boards also put in place improved programmes for their alcohol treatment and support services. This included the development of a programme of alcohol brief interventions which aims to deliver some 150,000 interventions by March 2011. This represents one of the world's largest early intervention programmes on alcohol, designed to capture and address misuse problems before they become acute.
A new Public Health Act
The Public Health etc. (Scotland) Act * was passed by Parliament in June 2008. The Act aims to provide a modern statutory framework that will enable public and environmental health practitioners to respond effectively to current and future public health challenges. It clarifies roles and responsibilities in health protection work; introduces a new statutory system of notifiable diseases, organisms and health risk states; and provides a broad range of investigatory and regulatory powers for NHS Boards and local authorities to protect public health. The Act also leads the way in the UK in the regulation of sunbed use.
A new immunisation programme to combat cervical cancer
This NHS-led programme will vaccinate all girls aged 12-13 (in Secondary 2) against the two main cervical cancer causing types of Human Papilloma Virus ( HPV). This is vitally important in the battle against cancer. The first year of the programme went very well, with NHS Boards working in collaboration with Health Protection Scotland and NHS Health Scotland to ensure widespread awareness of the vaccination programme and its aims and objectives. Initial uptake figures, published in February 2009, showed that amongst girls in second, fifth and sixth year of secondary school, uptake of the HPV vaccine was 93.5 per cent for the first dose, 92.4 per cent for the second dose and 87.7 per cent for the third dose.
A new framework for adult rehabilitation
Access to rehabilitation can be a key determinant of an independent life. Significant progress has been made in the implementation of the Rehabilitation Framework across health and social care, working in partnership with patients and service users. This includes the introduction of rehabilitation co-ordinators and falls leads within NHS Boards. Work has been undertaken to improve access and introduce patient-centred services such as a physiotherapy advice and triage pilot with NHS 24. An online portal for self management and rehabilitation has been launched for service users, carers and staff.
Reintroduction of the school-based preventive dental service
The Childsmile School targets dental support to children in the most deprived areas. It forms part of the Childsmile programme which provides additional preventive care including twice yearly fluoride varnish applications. To date, over 400 nursery and primary schools have been visited. Over 30,000 fluoride varnish interventions have been provided in Ayrshire and Arran, Borders, Fife, Forth Valley, Highland, Lothian, Shetland and Tayside NHS Boards - over 10,000 of these for primary school children. The programme will be rolled out across Scotland to all NHS Board areas by the end of 2010/11.
The results of the National Dental Inspection Programme ( NDIP) show that considerable progress has been made in tackling inequalities in dental care, particularly amongst the most deprived children. It found that, across Scotland, 57.7 per cent of Primary 1 children had no obvious dental decay in their permanent teeth. This is a further improvement on the 54.1 per cent seen in the same age group in 2006 and 50.7 per cent in 2004.
Efficiency and Productivity, Resources and Workforce
A new programme for efficiency and productivity in NHSScotland
The NHSScotland Efficiency and Productivity Programme was launched in April 2008 to help NHS Boards identify and share further opportunities for improvement, and deliver efficiency savings to ensure optimal deployment of resources to the delivery of frontline patient care. The Programme also integrates much of the improvement work already happening across NHSScotland and complements the significant progress made across the 2008/09 HEAT efficiency targets. The Efficiency and Productivity Steering Group also developed a delivery framework (published in 2009/10) which sets out the first phase of the programme proposed by the NHS. NHSScotland exceeded its efficiency delivery plan target in 2008/09 with total savings of £297 million.
Staff experience survey
The results of the 2008 NHSScotland staff survey showed an increase in the number of staff who feel that NHSScotland is a good place to work compared with the previous survey in 2006, and indicated that there had been a number of improvements in areas such as equality of opportunity. The Working Well Challenge Fund * has been established to support projects that have a positive impact on the health and wellbeing of the workforce.
A new dental school in Aberdeen
The creation of a new dental school in Aberdeen has been a major priority for the Scottish Government. This has been combined with NHS Grampian's plans to develop stage two of the Aberdeen Dental Institute to provide modern facilities for restorative dentistry, orthodontics and special needs/community dentistry. The school officially opened in October 2008 and will eventually accommodate 80 graduate entrant students (15 in 2008 in its first year of establishment). In due course it will also make use of outreach facilities across the north of Scotland.
Modernising Medical Careers
Changes to how junior doctors are trained have been delivered by the Modernising Medical Careers ( MMC) programme. This has represented a major reform of postgraduate medical training with the aim of ensuring that service is delivered by trained doctors instead of doctors in training. From 2008/09 postgraduate medical training in Scotland is known as Scottish Medical Training ( SMT). SMT delivers a modern training scheme and career structure that allows clinical professionals to support the healthcare needs of patients. It also offers doctors the chance to gain insight into possible career options or to build a wider appreciation of medicine before embarking on specialist training.
Implementing Agenda for Change
Agenda for Change ( AfC) is being implemented across the whole of NHSScotland. AfC introduces new pay bands and harmonises terms and conditions for NHS workers. It aims to ensure that staff receive equal pay for work of equal value and in doing so deliver more effective patient-centred care and better value for money. Virtually all staff have now been assimilated into the new system.
Access to Services and Waiting Times
Reduced waiting times for diagnosis and treatment
NHSScotland made significant progress in reducing waiting times during 2008/09. NHS Boards effectively delivered a maximum 12 week waiting time for outpatient, inpatient and day case treatment one year early, by 31 March 2009. NHS Boards also delivered the six weeks maximum waiting time for the eight key diagnostic tests on 31 March 2009. The 62-day cancer waiting times target was also met, with the best ever performance recorded by the NHS in Scotland for this target.
Faster response time for ambulances
In March 2009, the Scottish Ambulance Service met and exceeded, for the first time, its response target for Category A (life threatening) calls by reaching 77.4 per cent of calls within eight minutes across mainland Scotland against a target of 75 per cent.
Treatment and Quality of Services
A new eHealth strategy
The eHealth strategy focuses on improving patient safety and clinical effectiveness through better use of information. New information technology systems for NHS Boards have either been implemented or are being procured. These include a digital x-ray system, new IT systems to support general practice and chemotherapy prescribing, and a new hospital patient management system. A computerised clinical portal is also being developed as a way of assembling the various elements of the patient's record that can be electronically and securely accessed at the point of care.
A new national plan for specialist children's services
The National Delivery Plan for Specialist Children's Services * was published in January 2009. Key actions include the establishment of four new national managed clinical networks and the appointment of staff to boost service provision, resulting in more local care, reduced travelling for patients, reduced waiting times and enhanced skills for staff in district general hospitals. The plan has also led to the installation of nine new telemedicine systems, enabling clinicians to discuss cases remotely, access distance education and improve overall quality and consistency of care.
Further reductions in Healthcare Associated Infection
Rates of C. difficile fell by 17 per cent in 2008/09 compared with 2007/08 while the numbers of methicillin-resistant Staphylococcus aureus ( MRSA) cases fell by 20 per cent. The level of national hand hygiene compliance improved from 88 per cent in 2007/08 to 93 per cent in 2008/09.
An HAI Task Force has overseen the introduction of a number of improvement measures including a pilot MRSA screening programme in three pathfinder NHS Boards which will pave the way for a national MRSA screening programme from 2009/10 and a zero tolerance approach to non-hand hygiene compliance. Following events at the Vale of Leven Hospital in 2008 which led to an increased focus on the need to reduce the risk of HAI, a National HAI Action Plan was implemented to drive improvements in the key areas of governance, leadership and surveillance across NHSScotland. Action also included the creation of a new Healthcare Environment Inspectorate that will inspect every acute hospital at least once in any three-year period on both an announced and unannounced basis (more details are provided in Chapter 5 in the section describing the activities of the Special NHS Board, NHS Quality Improvement Scotland). Hospital-level reporting of infection rates on a bi-monthly basis has been implemented and there has been significant investment in key infection control staff and local surveillance systems to track the progress being made.
Implementation of the Scottish Patient Safety Programme
The Scottish Patient Safety Programme ( SPSP) is being implemented in every NHS Board and is designed to improve the safety of care through a number of evidence-based interventions. There is now good evidence of sustainable improvements across each of the main strands of activity which aim to reduce Healthcare Associated Infection, adverse surgical incidents and adverse drug events as well as improving critical care outcomes and the organisational and leadership culture on safety.
A new strategy for cancer
Better Cancer Care, An Action Plan* was launched in October 2008. It aims to further improve the quality of services for: the prevention, screening and detection of cancer; referral, diagnosis and treatment; and to provide improved support for people living with cancer. The Scottish Cancer Taskforce ( SCT) was established in January 2009 to oversee the delivery of the commitments made in the Action Plan. The Long Term Conditions Collaborative ( LTCC) was established in April 2008 to provide a new opportunity for NHSScotland to work with local authority and voluntary sector partners to develop and deliver sustainable improvements in the quality of care for people with long-term conditions, including cancer. This will result in better support for people to manage their own conditions, where appropriate, and will identify those people with more complex needs who require additional support.
A new Mental Health Collaborative
The Mental Health Collaborative was launched in April 2008. This is a three-year programme that supports NHS Boards and their key partners, to deliver improvements in the quality of care for people with mental health problems. All NHS Boards across Scotland are now involved in supporting frontline staff to apply new approaches to improving services. The collaborative is also promoting the sharing of good practice across NHS Boards. The first year has focused on appointing additional service improvement staff, developing their skills and identifying key improvement activities.
Dementia becomes a new national clinical priority
The Scottish Government established dementia as a national clinical priority in 2007. Work has focused on increasing the number of people identified on GP dementia registers, which give access to carer assessments and physical health checks. From the review visits carried out in 2008/09, it is clear that NHS Boards are responding positively. The Mental Health Collaborative published a toolkit at the end of 2008 to help NHS Boards analyse their dementia services from the perspective of people using them in order to improve the quality and responsiveness of services. Work is also being undertaken by Alzheimer Scotland and the Dementia Services Development Centre to pilot improved post-diagnostic care through structured interventions, support and information services. The Scottish Government has made a commitment to produce a dementia strategy during 2009/10.
Shifting the balance of care
A shift in the balance of care is required to address the projected increase in the numbers of older people and the need to improve health and social care outcomes. The intention is to provide services which promote independence and are quicker, more personal and are delivered closer to home. In particular, NHSScotland is working with its partners to: maximise flexible and responsive care at home with support for carers; improve capacity and flow for scheduled care; and integrate health and social care and support for people in need and at risk. NHS Boards are also seeking to reduce avoidable unscheduled emergency attendances and admissions to acute hospitals and extend the range of services provided by non-medical practitioners outside acute hospitals. Progress is also being made towards improving access to care for remote and rural populations and improving palliative and end of life care.
Services in remote and rural areas
Following the publication of Delivering for Remote and Rural Healthcare *, the Remote and Rural Implementation Group ( RRIG) has made considerable progress in the implementation of regional, inter-regional and national recommendations. Achievements include: the development of the Obligate Network for Mental Health and Learning Disability between NHS Grampian, Orkney and Shetland; the development of a Strategic Options Framework for emergency response; and the introduction of telestroke care in NHS Western Isles which allows quicker diagnosis and treatment. Improvement of local A&E services within the Galloway Community Hospital has significantly reduced the number of patients transferred to Dumfries Royal infirmary, and the establishment of a multi-professional emergency assessment unit in the Belford Hospital has reduced unnecessary admission to hospital and has improved waiting times. RRIG also undertook work to assess the effectiveness of differing medical workforce models.