NHSScotland Chief Executive’s Annual Report 2015/16

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Foreword

I’m very pleased to present this, my third NHSScotland Chief Executive’s Annual Report.

Once again, the achievements outlined in this year’s report are a tribute to the outstanding commitment of all NHSScotland staff, and to the dedication of colleagues in our partner organisations – including those in the voluntary and third sector, whose contribution I greatly value and appreciate.

I’m grateful for their continued focus on improving the quality of care for patients.

Our focus on quality continues to be at the heart of everything we do in the NHS. Indeed, the standards we have for the NHS in Scotland are world class and we should reflect on that point when we consider how our NHSScotland is performing.

We have made and sustained significant improvements in reducing Healthcare Associated Infections. We have seen reductions in Hospital Standardised Mortality Ratios within acute care which, in simple terms, means that our approach to safety and quality has reduced the number of deaths significantly. Our A&E performance this past year has been the best since 2011/12 – and Scotland can be proud of its international record. Importantly, patient satisfaction with NHSScotland remains high. Ninety per cent of hospital inpatients who took part in this year’s Scottish Inpatient Patient Experience Survey, rated their overall care and treatment as good or excellent – the highest rating since the survey began – and 87 per cent of those who responded to the Health and Care Experience Survey rated the overall care provided by their GP practice as good or excellent.

However, I very much recognise the challenges we face. Health budgets are going up, but pressures on recruitment, and the demands of an ageing population, are also very real. There is also still much to do in tackling inequalities and improving the health of the population, which NHSScotland cannot do on its own. And we do know that people have the best outcomes when they are treated and cared for at home, or in a homely setting. So our current models of care are changing to meet these demands, and to provide the most appropriate care and treatment for people, when they need it.

With that in mind, you’ll remember that the Cabinet Secretary for Health and Sport launched the ‘Creating a Healthier Scotland’ national conversation which ran from August 2015 to March this year. This gave people the chance to tell us what matters to them about their health and social care services.

Feedback told us that people want us to stay true to the founding principles and core values that led to the creation of the NHS nearly seventy years ago.

It also told us that people want to live happy, independent, healthy lives and that there is an appetite for change in a number of areas to ensure we’re well placed to meet the challenges we face.

So across the whole of our health and social care system, it’s important that we work together on our continued commitment to drive transformational change and to ensure that people have access to the best possible care when they need it, and that we manage our resources efficiently and sustainably in pursuit of that aim. That’s why the investment in the reform of Primary Care services is so important, both in terms of providing diagnosis, care and treatment, and in its contribution to improving the health of Scotland’s population. Our National Clinical Strategy, along with our work to maximise the benefits from health and social care integration, are key components of our response.

There’s still a long way to go but I hope this report gives us the opportunity to celebrate our success and reflect on the work still to do.

I’m grateful for the ongoing dedication of our committed NHSScotland workforce and our partner organisations, and hope you enjoy reading about their collective achievements.

Paul Gray

Chief Executive, NHSScotland
and Director-General Health and Social Care

Chapter 1 - Transforming Care and Delivering Improved Outcomes

High Quality Health and Care for Scotland

The Challenges

The demands for health and social care and the circumstances in which they are being delivered are radically different than a decade ago. NHSScotland and its partners across the public and voluntary sectors are having to collectively recognise and respond to the most immediate and significant challenges faced. These include Scotland’s public health record and level of inequalities, our ageing population, the increasing expectations arising from new drugs, treatments and technologies, and the specific impact of inflation on the health service.

Across Scotland, many people are living longer, healthier lives, thanks to better standards of living and advances in our health and social care services – achievements that can be rightly celebrated. NHSScotland and its partners across the public and voluntary sectors recognise, though, that there are challenges still to address. Progress on public health is not experienced equally across society. An ageing population means that we must adapt the way we work so that people living with multiple complex conditions are supported in their own homes and communities for as long as possible. At the same time, of course, we must continue to keep pace with new drugs, treatments and technologies, and maintain our focus on quality and improvement – people rightly expect access to the best possible standards of care, and services that are continually learning from evidence for improvement.

Our 2020 Vision

Our 2020 Vision for Health and Social Care is that by the year 2020, everyone is able to live longer, healthier lives at home, or in a homely setting.

We continue to focus on the priorities for action that will have the greatest impact on achieving our vision in three areas often referred to as the ‘Triple Aim’:

Improving the quality of the care we provide;

Improving the health of the population; and

Securing the value and financial sustainability of the health and care services we provide.

While we continue to build on existing work in each of these domains, it is important that we accelerate progress. We are seeing some of the biggest and most important changes to the way we care for and improve the health of the people of Scotland, in their communities, since the creation of the NHS. This work has been underway for a number of years. Now every part of Scotland has seen health service professionals and social care practitioners come together in partnership with those who design and commission services across the country to ensure that our changing needs are reflected by changing services, developing technologies and shared successes – all leading to better outcomes for people. We have made brave choices in order to bring about the change we are committed to delivering. Scotland is leading the UK in this and is admired for its vision and commitment.

Our Pursuit of Quality

Through our approach to quality healthcare improvement as described in the Healthcare Quality Strategy for Scotland¹ we continue to drive forward improvements in the care people receive. Our Quality Ambitions for person-centred, safe and effective care have continued to guide our work in improving quality, transforming care and delivering improved performance.

Transforming Care

The Wider Contribution of Health and Social Care

The role for health and social care in supporting people to live well, from pre-conception through childhood, adolescence, adulthood, old age and death, is fundamental to the Scottish Government’s Purpose of creating a more successful country through increasing sustainable economic growth and to its priorities for a fairer society, improved participation and localisation.

As we look beyond the year 2020, the need for a step change in how services are planned and delivered to take account of the challenges faced has never been greater. Shona Robison MSP, Cabinet Secretary for Health and Sport has confirmed her commitment to pursuing our health and social care agenda in the wider context of delivering better outcomes for the people of Scotland:

“I am committed to taking forward our health and social care agenda in the context of public sector improvement and against the four pillars of public sector reform in our response to the Christie report²: prevention; integration at a local level; workforce development; and a focus on performance, with outcomes-based targets. The key commitments in our manifesto underpin this Government’s future focus for health and social care so that, by 2020, we will have secured our vision of people living longer, healthier lives at home or in homely settings and, over the period to 2030, we will have in place policies, systems and services that support people to begin their lives well, live well, age well and die well.”

Shona Robison, Cabinet Secretary for Health and Sport, Scottish Parliament, 7 June 2016

Improving the health and wellbeing of the population, supported by high quality, compassionate, efficient and effective care when and where people need it is also essential to tackling inequalities, raising attainment for all, improving social justice, enhancing democratic renewal and contributing to the wider reform of public services.

Our NHSScotland is therefore central to Scotland’s prosperity. It is bigger than the sum of its parts and reaches across welfare, housing, taxation, employability, equalities and the third sector. That is why it remains as important as ever that quality should drive all that we do in developing policy and delivering innovative and integrated services and ways of working.

What Matters to People

We know that these aims continue to matter to people. The Creating a Healthier Scotland national conversation³ that ran from August last year to March 2016 directly reached over 9,000 people at 240 events across the length and breadth of the country, with over 360,000 inputs through digital and social media channels. It showed us that, while the people who use or deliver health and care services want to maintain the core values that drove the creation of the NHS nearly 70 years ago, there is a demand for real change in six broad areas to ensure that we have services fit for the 21st century and which are responsive to its challenges:

Supporting people to lead healthier lives – with more work on prevention, health education and promotion of individual life-style change;

Supporting wellbeing and better connected communities – with a focus on early intervention and parity between mental and physical health services;

Making even greater strides in person-centred care – with people more involved in decision-making and a greater focus on supported self-management;

Providing responsive and seamless journeys of care – with easier access to services and integration across Primary and Secondary Care as well as across health and social care;

More focus on social care and caring – better information about entitlement, more support at home, support for unpaid carers and better recognition for those working in social care; and

Addressing pressures and priorities in the system – getting better at workforce planning and development, looking at targets and outcomes and taking challenging decisions about funding.

Transforming Our Approaches

People want to live happy, independent, healthy lives and, in managing our health and social care system, it is important that we ensure people have access to the best possible care when they do need it, and that we manage our resources efficiently and sustainably in pursuit of that aim.

This will require a transformational change in our approaches which: shift from a fundamentally ‘fix and treat’ model of care to a model of prevention, anticipation and population health improvement; shift from ‘doing things to’ people to working with them and putting them at the centre of decisions about their care; and focus on shifting the balance of where care is provided from hospital to community care settings and people’s homes where that is best.

We are already making progress on this as we move towards securing our 2020 Vision, and we will make more progress, to 2020 and beyond, through the reform of Primary Care services while the continued deepening and embedding of health and social care integration is providing us with new teams formed from diverse fields of expertise and very different lived and worked experiences. This is allowing us to innovate at an enhanced level, improving the quality of care we provide locally and nationally by building on the shared vision of practitioners who are now free to facilitate change and create anew as never before.

We are delivering a future where early interventions and better models of holistic care built around communities and localities support people to live longer, healthier lives – and where our clinicians and health practitioners are able to work with others across health and social care to target interventions, and grow and develop new models of health improvement for the people who will see the greatest benefit and the most improved outcomes.

As we enhance our understanding and develop long-term strategies for meeting the needs of our people going forward, we realise that for older people and for people with complex needs home is almost always best: best for them and for their families and best for their health and wellbeing. In order to provide the best outcomes for people, we are committed to shifting the balance of care into communities and out of institutions in line with the best medical evidence.

Our National Clinical Strategy for Scotland⁴ sets out the direction of travel and transformational change necessary to deliver a safe, sustainable and person-centred NHSScotland for the people of Scotland over the next 10 to 15 years and provides the framework for the future of health and social care. It looks at the projected demographic challenges alongside potential innovations and their impact on the planning and delivery of healthcare services for our population as well as the already significant transformation arising from the integration of health and social care. A strand of this work will focus on the concept of Realistic Medicine, first proposed in the Chief Medical Officer’s Annual Report 2014-15: Realistic Medicine⁵, where the emphasis will be on improving the basis of clinical decision-making to ensure that there is a clearer focus on the provision of healthcare of greatest value to the individual in a way that has the least potential to harm, and is most in line with the patient’s wishes.

Digital technology is now a part of our everyday lives and evidence continues to build that health and wellbeing can be better supported through greater use of familiar everyday technology. We are working to transform services to provide fully person-centred care that fits seamlessly within an increasingly digital lifestyle to empower individuals to more actively manage their own care at home and in the community. Our challenge as a health service is how we can make the most of the technology that a significant majority of our population already own and use. At the same time, we should continue to improve our clinical IT infrastructure and make it increasingly easier for clinicians to make more informed decisions, together with colleagues and patients, by providing the right information at the right time through user-friendly digital tools.

In our Technology Enabled Care Programme⁶, we have enabled in excess of 20,000 Scottish citizens to benefit from technology enabled care, such as home and mobile health monitoring and telecare, thanks to funding made available during 2015/16.

You can read more about these and other transformational approaches later in this report.

We will continue to engage widely with the public, health and social care professionals, and other stakeholders as we take forward the themes from last year’s national conversation and the changes required, using the Our Voice framework (see chapter 2) to help shape policy and delivery options for the future.

The Scottish Government is committed to supporting people at all stages of their lives through a range of measures including:

Supporting people to start their lives well through the development of a 10-year child and adolescent health and wellbeing strategy, our new health visiting pathways, and the continued roll-out and extension of family nurse partnerships to provide support for young first-time mothers.

Supporting people to live well through the cancer strategy, supported by £100 million of investment, and through a range of commitments to expand Primary Care services by, for example, giving GP practices access to enhanced pharmacists and recruiting 250 community link workers. GP practices should become more of a community health service that involves teams of health professionals and others working together under the guidance of a GP, with people seeing the right professional at the right time, underpinned by the new GP contract in 2017; and through a 10-year plan to transform mental health care.

Supporting people to age well through the protection of free nursing and personal care for the elderly; a new three-year dementia strategy; and investing £200 million in five new elective centres and expanding the Golden Jubilee National Hospital so that we can meet the increased demands of an ageing population, are better prepared for winter pressures, and can reduce cancellations, delayed discharge and the use of the private sector.

Supporting people to die well by ensuring that everyone who needs it has access to palliative care that is designed with people and their families in mind, and with parity between public funding for children’s and adult hospices.

NHSScotland Performance in 2015/16

NHSScotland sees and treats hundreds of thousands of patients every year and it is vital that services are planned effectively. Performance measures are an important part of the planning process. There is no doubt that the way services are configured has changed markedly over recent years, including new acute hospitals in Glasgow and Forth Valley and major refurbishments in other hospitals including those in Ayrshire, Fife and Grampian. These new modern acute facilities, along with developments in eHealth systems, and new community hospitals and health centres around the country are important for the people who provide services and for those who use them. This report sets out a range of improvements that have been implemented across Scotland, recognising that the way services are delivered will change at an even faster rate over the next few years.

We have learned that improving and sustaining performance is dependent on investment in national clinically-led improvement programmes which support local teams to learn from international best practice, and from each other, with additional support where required. It is important that people understand why key performance measures are important and the positive impact that they have on outcomes. Clinical decision-making in the interest of patients is paramount and improvements in performance should be pursued in the right spirit and in a sustainable way. For example, we know that eliminating crowding in emergency departments has positive impacts on patient outcomes and for the staff working there and in the wider system; and being able to support suspected cancer patients along their whole diagnostic, treatment and care pathways is vital.

The official statistics show that Scotland’s A&E performance in 2015/16 was the best since 2011/12. Some 94.1 per cent of patients were seen and subsequently admitted, transferred or discharged within four hours⁷, reducing the risk of crowding and improving the quality of care. Scotland saw the best performance throughout the UK⁸, with the UK often seen as the best-performing system in the world. The number of bed days occupied by delayed patients reduced by 9 per cent⁹ which helped to reduce the risk that people lose their ability to live independently. The focus on planning and performance across the whole system for winter 2015/16 has helped to improve outcomes and performance in the last year – including the Six Essential Action national clinically-led improvement programme.

In 2015/16, 90.8 per cent of patients began cancer treatment within 62 days of their urgent referral with suspicion of cancer, while 95.7 per cent of all cancer patients commenced treatment within 31 days of a decision to treat¹⁰. Improving outcomes for cancer patients is a key priority as we implement the new cancer strategy Beating Cancer: Ambition and Action¹¹, which includes priority action on pathways and capacity in gastro and urology diagnostics.

Elective waiting times have been transformed over the last 10 years despite growth in demand. However we recognise that sustaining elective waiting times is a challenge. We expect that demand for elective treatment will increase over the coming years and the elective strategy will support the NHS in Scotland to establish the new elective centres which will transform elective services in Scotland. In 2015/16, diagnostic waiting times statistics showed that 94.6 per cent of elective patients had been waiting six weeks or less at the end of March 2016¹². Almost 300,000 or 94.4 per cent of elective inpatient and day case patients were treated within 12 weeks in 2015/16, while 88.0 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2016¹³.

During the quarter ending March 2016, 84.2 per cent of children and young people started treatment at Child and Adolescent Mental Health Services (CAMHS) in Scotland within 18 weeks¹⁴. In 2015/16, decisions were taken to fund a significant increase in capacity as well as work to redesign local services to be more efficient, effective and sustainable.

Most patients were positive about the care and treatment they received at GP practices. The overall positive rating of GP care has remained the same as last year at 87 per cent¹⁵. Innovative projects to improve GP recruitment and retention have been funded by the Scottish Government.

The Scottish Inpatient Patient Experience Survey 2016 found that 90 per cent of hospital inpatients who participated in the survey, rated their overall care and treatment as good or excellent, the highest rating since the survey began¹⁶.

Significant improvements have been made in reducing Healthcare Associated Infections in recent years. These improvements were sustained in 2015/16¹⁷.

The Scottish Government sets out its priorities in Local Delivery Plan (LDP) guidance. This requires NHS Boards to develop concise plans focused on new actions planned in a small number of strategic improvement priority areas to improve outcomes for patients and the people of Scotland. In order to ensure high quality, continuously improving health and social care in Scotland, it is important that we strike the right balance between improvement, performance management and scrutiny. The LDP also sets out standards that NHS Boards should pursue to improve services for patients. LDPs should address these with a focus on demand and capacity planning.

Information on LDP Standards is updated throughout the year on the Scotland Performs website¹⁸.

Review of Health and Social Care Targets and Indicators

Targets play an important role in our NHSScotland, and can be a useful tool to drive improvements in performance. As our new integrated arrangements for health and social care establish across Scotland, we must ensure that our approach to measuring progress is outcome-based, is focused on people and communities, and helps to ensure that people get the right care for their circumstances, at the right time and in the right place. With the support of our partners in local government, we are taking forward a review of the targets and indicators that underpin our understanding of the care people receive across health and social care in Scotland, focusing particularly on improving population health, promoting early intervention and enhancing community-based approaches to care. We also continue to invest in better data to support improvement in local systems.

Chapter 2 - Improving Quality of Care

Asking ‘what matters to you?’, rather than ‘what’s the matter with you?’ Read more about the approach pioneered at the Royal Hospital for Children in Glasgow at www.nhsscotannualreport.com

Our Quality Ambitions

Through our Healthcare Quality Strategy for Scotland (Quality Strategy) we have set ourselves three clearly articulated and widely accepted ambitions based on what people have told us they want from their NHS: care which is person-centred, safe and effective.

Person-centred – Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

Safe – There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Effective – The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit and wasteful or harmful variation will be eradicated.

Person-centred Care

Person-centred care means real partnerships between the people using healthcare services, their families and carers, and the people delivering those services, which respect people’s individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. It means asking ‘what matters to you?’, rather than ‘what’s the matter with you?’, and listening deeply to the answers. It is an approach that has people in the driving seat of their care, with support from their professionals to achieve the outcomes that are important to them.

The Chief Medical Officer for Scotland (CMO), Dr Catherine Calderwood, used the publication of her first annual report in January 2016 to engage with clinicians as collaborative leaders, to influence and be a driver for change. In the Chief Medical Officer’s Annual Report 2014/15: Realistic Medicine¹⁹, she describes the need to ‘place collaborative, relational decision-making and planning at the heart of our system’ and the absolute imperative ‘to be focusing completely and relentlessly on what matters most to the people who look to us for care, support and treatment.’

While person-centred care is one of our quality ambitions for NHSScotland, the person-centred approach extends across health and social care, supporting people who use care and support services, their families and carers, to live well in communities across Scotland.

Third Sector Partnerships
Driving Change

NHSScotland continued to work with many third sector partners during 2015/16 – at national and local level – as part of the drive to improve care through active participation.

The Health and Social Care Alliance Scotland (ALLIANCE) continued to work with five adopter sites (NHS Tayside, NHS Greater Glasgow and Clyde, NHS Lothian, NHS Ayrshire & Arran, and NHS Lanarkshire) to take forward the House of Care²⁰ approach to collaborative care and support planning. This approach, which has an internationally-recognised evidence base, puts people and their families in the driving seat of their care.

Funded by the Scottish Government and delivered in partnership with The ALLIANCE, ALISS (A Local Information System for Scotland) continued to map assets across the community to enable people to more effectively self-manage by connecting them with local sources of support. ALISS has been rolled out across all Community Pharmacies in Scotland and can be accessed through Living it Up²¹ in a number of areas in Scotland. Work also continued to support people to have the knowledge, understanding, skills and confidence they need to use health information, to be active partners in their care, and to navigate health and social care systems. A demonstrator programme as part of the Making it Easy: a Health Literacy Action Plan for Scotland²² in NHS Tayside will start to report from autumn 2016, reflecting work undertaken throughout 2015/16. It is examining a range of tools and approaches to enable staff to recognise and cater for people’s health literacy needs.

In September 2015, the Cabinet Secretary for Health and Sport launched the next round of the Self Management Fund in Scotland. The Fund, which is managed by The ALLIANCE on the Scottish Government’s behalf, has been highlighted by Carnegie UK Trust²³ as a leading example of the way to drive the change described in the Christie Report. Over the past three years, the Self Management IMPACT Fund has provided grants, both large and small, to third sector groups to encourage the development of new approaches in supporting people to live well, on their own terms, with whatever health conditions they have.

Supporting People to Have Greater Choice and Control in Social Care

In 2014, the Scottish Government legislated to integrate health and social care services to ensure those who use services get the right care and support, whatever their needs, at any point in their care journey. Over the past year, the Scottish Government worked with strategic partners and people who use services to support people, their carers and families to make informed choices about what their social care support looks like and how it is delivered. This work is based on the understanding that having greater control of your life and decision-making leads to improved health and wellbeing.

Through the Social Care (Self-directed Support)(Scotland) Act 2013, Local Authority social work departments have a legal duty to offer people who are eligible for social care a range of informed choices over their care and support. Even if a person is not eligible for a formal public service or personal budget, any assessment process, contact with universal public services and engagement with voluntary organisations about care and support should follow the principles in the Act. This approach is called Self Directed Support²⁴.

Achievements in Self Directed Support

The Scottish Government has invested £50 million in making the transition to this new approach between 2011 and 2016. During 2015/16 this included £3.52 million to Local Authorities to support system and culture change with staff. The Social Care Survey 2015 shows that 35,000 people made a choice about their support during 2014/15²⁵.

In 2015/16, £2.8 million was invested in 34 third sector organisations through the Support in the Right Direction Fund. In the six months between October 2015 and March 2016: 3,200 people were supported to access their existing community resources; 2,400 individuals received training and development support; 1,000 people received brokerage support; 950 people were helped to set up and manage their care packages; and 800 people were helped to employ and manage personal assistants²⁶.

Just over £1 million was invested in 21 third and independent sector providers of care through the Innovation Fund. Projects built the capacity of social care providers and the social care workforce to deliver more flexible and creative support. Key outcomes achieved between October 2015 and March 2016 include: facilitated peer support and sharing of learning about Self Directed Support for practitioners and providers; Self Directed Support training and materials for practitioners and providers; and enabling people to use their social care budgets more creatively. As an example, ClickGo²⁷ is a digital tool that enables people to direct and manage their social care support. It won a commendation from The Herald Scottish Digital Business Awards 2015²⁸.

In the reporting year, £0.4 million was invested in workforce development with projects including action learning sets, collaborative work with the Care Inspectorate and the development of a risk resource. A further £0.8 million was invested in developing guidance, engagement, evaluation and independent living, including Self Directed Support Financial Guidance developed by the Chartered Institute of Public Finance and Accountancy (CIPFA)²⁹.

Supporting People in Their Caring Role

During the year, there was a strong emphasis on carers and the role they play in our communities. The Scottish Government worked with individuals and organisations across Scotland to deliver the Carers (Scotland) Act, which was passed in February 2016. The Act will make a meaningful difference to unpaid carers and will contribute towards the improvement of their health and wellbeing, ensuring that they can continue to care, if they so wish, and have a life alongside caring.

The package of provisions in the Act includes, amongst other things: a duty on Local Authorities to provide support to carers, based on the carer’s identified needs which meet the local eligibility criteria; a specific Adult Carer Support Plan and Young Carer Statement to identify carers’ needs and personal outcomes; a requirement for each Local Authority to have its own information and advice service for carers; and a duty on NHS Boards to ensure that carers are fully involved in the hospital discharge process of the person that they care for. The main provisions of the Act will be commenced on 1 April 2018.

In the meantime, funding of nearly £34 million has been provided between 2008 and 2016 to NHS Boards and the Scottish Ambulance Service for direct support to carers, of which £5 million was allocated in 2015/16. Over the year, NHS Board priorities included funding for carers’ centres that provide a range of services such as advocacy and advice; training for carers and the workforce; information on income maximisation; and projects that support black and minority ethnic and other hard to reach groups.

Listening to the voices of carers through initiatives such as the Carers Parliament and Young Carers Festival has allowed the development of legislation and policies, and the allocation of funds, based on what’s important to carers. The implementation of the Carers (Scotland) Act will be a high priority for the Scottish Government over the current and coming year.

Improving Palliative and End of Life Care

The Scottish Government published the Strategic Framework for Action on Palliative and End of Life Care³⁰ on 18 December 2015. It sets out the ambition of ensuring that by 2021 everyone in Scotland who needs palliative care will have access to it, supported by £3.5 million over the next four years. It also highlights the need to identify all those who need palliative care, and to ensure the professionals they encounter are appropriately skilled to support them with timely and focused conversations, to plan their care and support in line with their wishes.

The commissioning of palliative care and end of life care became the responsibility of Health and Social Care Partnerships in April 2016. One of the 10 commitments in the framework for action is to provide new commissioning guidance on this critical work. We expect this guidance to be available to Health and Social Care Partnerships in spring 2017. Other commitments being progressed with partners in health, independent hospice, academic, care and third sector partners include supporting the improvements in palliative care in at least five Health and Social Care Partnerships, the appointment of three training leads working across health and social care and the creation of a research forum, all of which are laying the groundwork for achieving the ambition.

Welcoming Feedback and Using it for Improvement

NHSScotland and the Scottish Government are jointly committed to supporting a culture of openness and transparency in NHSScotland, that welcomes feedback, comments, concerns and complaints, and uses them all as a valuable source of intelligence to drive continuous improvement.

In June 2015, the Cabinet Secretary for Health and Sport announced Our Voice³¹ at the NHSScotland Event. Our Voice is designed to create a voice with a purpose, that is representative and inclusive, informed, and focused on quality improvement. It has been developed through open engagement with citizens, led by a partnership involving the Scottish Health Council, Healthcare Improvement Scotland (HIS) public partners, COSLA, the Scottish Government, The ALLIANCE and other third sector organisations.

Our Voice will operate at individual, local and national level to support improvement and empower people to be equal partners in their care and will include: at national level, citizens’ panels and new models of deliberative engagement that will create opportunities for people to engage in national policy debate; at local level, peer networks to support people to engage purposefully in local planning processes; and at individual level, support for people to feed back about the care and services they receive, and for this feedback to be used to drive and inform continuous improvement to services.

Work started in 2015/16 to develop the infrastructure that will support the new framework, including the ourvoice.scot website, which launched at the end of 2015.

As part of its Person-centred Health and Care Programme³², Healthcare Improvement Scotland began work in 2015/16 with three NHS Boards across Scotland to test ‘real-time’ approaches to gathering feedback about people’s experience of using care, and using that feedback to identify and act on opportunities for service improvement. Two NHS Boards are also testing ‘right-time’ enquiry (two or three weeks after the experience of care), as there is some evidence that people feel able to provide more candid feedback on their experience of care within this time period.

Healthcare Improvement Scotland also supported the development and testing of Experience Based Co-design Methodology³³. This is a method for working with groups of people who access support or care and the staff that provide it, to co-design improvements to services. Experience-based co-design draws on knowledge and ideas from design sciences, where the aim of making products better is achieved by involving the people who use those products in the design process itself.

Work also started in 2015/16 to review the NHSScotland complaints procedure, to bring a sharper focus to the early, local resolution of complaints and support NHS Boards and their service providers to deliver a consistently person-centred service. A steering group chaired by the Complaints Standards Authority (CSA), and involving representatives from across NHSScotland as well as the Scottish Government, the independent Patient Advice and Support Service (PASS) and Healthcare Improvement Scotland public partners, met in September 2015 to begin the review, and has developed a revised procedure to be implemented from April 2017. This work has been taken forward in response to a recommendation in The Scottish Health Council’s Listening and Learning: how feedback, comments, concerns and complaints can improve NHS services in Scotland³⁴ report. It will help to address the current differences in the management of complaints across health and social care by bringing the NHS complaints procedure more closely into line with other public sector services.

The Patient Rights (Scotland) Act 2011³⁵ introduced the right for people to give feedback, make comments, and raise concerns and complaints about the services they receive from NHSScotland, and places a duty on the NHS to actively encourage, monitor, take action and share learning from the views they receive. In accordance with the regulations associated with the Act, NHS Boards once again published annual reports, showing where lessons have been learned and describing actions taken to improve services as a direct result of feedback, comments, concerns and complaints.

There were 21,456 complaints made about NHS services in Scotland in 2015/16 – a 4 per cent fall in the total number of complaints, compared to the previous year. This figure includes hospital visits and GP, dental and ophthalmic appointments, and represents the equivalent of 0.05 per cent of all NHSScotland activity³⁶. NHS Boards must listen to all of the complaints they receive, learn from them and take action where necessary in order to continuously improve services.

The Scottish Government has also supported NHSScotland to continue to engage with the independent website Patient Opinion³⁷, which provides an online route for people to share their experiences of care – whether good or bad – directly with NHS Boards and engage in constructive dialogue with them about how services can be improved. All of Scotland’s Territorial NHS Boards were reading and responding to stories posted on the Patient Opinion website in 2015/16. There were 1,779 stories shared about NHSScotland in 2015/16, which were viewed 600,000 times. Fifty-four per cent were positive, 81 per cent were responded to in five days or fewer, and 63 changes and improvements to services were made or planned as a direct result of a story shared in this way³⁸.

The Scottish Government has developed innovative approaches to supporting systematic analysis and learning from the care experiences being shared on Patient Opinion, and in 2015/16 it began a series of meetings with senior leaders in NHS Boards to promote this source of intelligence. With more than 5,000 experiences on the platform, it has become a rich source of knowledge about how people in Scotland are feeling about their NHS, what is working well and what could be improved. Work will continue to explore the potential of Patient Opinion to support quality improvement work and a series of follow-up visits will be undertaken in 2016/17.

Measuring and Improving Satisfaction with NHSScotland – National Surveys

Satisfaction with NHSScotland remains high, with 90 per cent of hospital inpatients who participated in the Scottish Inpatient Patient Experience Survey 2016³⁹ reporting overall care and treatment to be good or excellent and 87 per cent who responded to the Health and Care Experience Survey 2015/16⁴⁰ rating the overall care provided by their GP practice as good or excellent.

In autumn 2015, the first national Cancer Patient Experience Survey⁴¹ was launched to provide high quality national and local data on patients’ experiences of cancer care. This provides a measure of what matters to people with cancer and forms the basis for the learning to be able to improve the experience of cancer patients in Scotland.

The results published in June 2016 found that 94 per cent of patients rated their care positively (giving an overall rating of seven out of 10 or above). The cancer survey also found areas where improvements could be made, particularly around helping patients access support for their wider emotional, financial and practical needs.

These results will inform a range of actions being taken forward under the Scottish Government’s cancer strategy Beating Cancer: Ambition and Action which is supported by an investment of £100 million.

The second Maternity Care Experience Survey⁴² was conducted in 2015, which again showed a very positive picture of women’s experiences of maternity care overall. In most instances women said that they received excellent care from staff (92 per cent of women rated their care during labour and birth as either excellent or good), although postnatal care in hospital was rated less highly than other stages of care.

Achieving Better Outcomes for People with Dementia, Their Families and Carers

Workforce education, training and development is at the centre of national and local work to improve dementia services and support, and to implement the Standards of Care for Dementia in Scotland across the care pathway and in hospitals. The Scottish Government has an ongoing national commitment to fund this activity through the implementation of Promoting Excellence, backed by around £500,000 per year.

As part of this activity, there are 608 Dementia Champions, all trained to ‘Enhanced’ level on the Promoting Excellence Framework, with over 10 per cent in social services. A further 100 Dementia Champions are currently being trained. In social services, over 1,000 Dementia Ambassadors have been inducted, with around 850 currently active⁴³.

All Promoting Excellence initiatives, which are complemented by an ongoing and expanded national approach to improvement through Focus on Dementia⁴⁴, are contributing to better service responses and better outcomes for people with dementia and their families and carers. This includes implementation of the national post-diagnostic commitment, integrated support at home and national action specifically focused in general hospitals and NHS specialist dementia care.

Supporting People with Autism and Learning Disabilities to Live Healthier Lives

Scotland is at the mid-point of a 10-year Scottish Strategy for Autism⁴⁵, launched in November 2011. The recommendations of the strategy were reframed into an outcomes-based approach⁴⁶, which identified the priorities for 2015-2017. These outcomes focus on improving services so that people with autism can live healthier lives, have choice and control over the services they receive, and are supported to be independent active citizens with the same rights as all citizens to contribute to a fair, equal and prosperous Scotland. Work has started to develop a future outcomes approaches which will identify strategic priorities for delivery in 2017-2019.

The Keys to Life – Improving Quality of Life for People with Learning Disabilities⁴⁷ is a 10-year programme published in 2013 designed to meet the needs of people with learning disabilities. A refreshed delivery approach was developed which identified four strategic outcomes: a healthy life; choice and control; independence; and active citizenship. The delivery approach aims to address the wider socio-economic factors which contribute to the significant inequalities faced by this population. It is aligned to the United Nations Convention on the Rights of Persons with Disabilities and identifies key activities for 2015-2017. It places a greater emphasis on the cross-policy connections required to achieve the identified strategic outcomes. This approach will help us to prioritise and deliver the aims of the Keys to Life strategy in shorter periods over the 10-year lifetime of the strategy. The first of these shorter implementation plans has been developed for a two-year period 2015-2017⁴⁸ and will inform future plans throughout the duration of the strategy.

Supporting Survivors

Scotland is one of the few countries in the world that has dedicated funding for support services for survivors. In addition to the investment in the In Care Survivors Support Fund, the Scottish Government is committed to supporting all survivors of child abuse. Innovation and Development Funding of almost £1.8 million was allocated to a total of 21 organisations across 27 separate survivor services for 2015/16 to support the delivery of these strategic outcomes and priorities.

The strategic framework Survivor Scotland Strategic Outcomes and Priorities 2015-2017⁴⁹ was published on 1 October 2015. This delivery approach is grounded in what survivors tell us is important to them and has three identified outcomes:

A Healthy Life: Survivors are enabled and supported to enjoy an attainable standard of living, health and family life;

Choice and Control: Survivors are treated with dignity and respect and are empowered and enabled to access the right support; and

Safety and Security: Survivors have access to resources and services which are trauma informed and have the capacity and capability to recognise and respond to the signs of childhood abuse.

Through consultation during 2015/16, survivors expressed the need for services that are designed around their own individual circumstances, including specialised counselling, physical and mental healthcare, and support in terms of education, employment, benefits, legal advice, housing and practical matters. In response, the Scottish Government identified funding of £13.5 million over five years (2015-2020). This was announced in March 2016 by the Cabinet Secretary for Education and Lifelong Learning to develop a bespoke In Care Survivor Support Fund Service.

The Support Fund will offer a person-centred, outcomes-based approach that identifies what matters to survivors. This approach places people at the centre of their own support and is not restricted to health and social care needs, but rather encompasses a much wider range of support.

Safe Care

We have set ourselves clear aims to ensure that there will be no avoidable injury or harm to people from the healthcare they receive, and that an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times. The internationally-acclaimed Scottish Patient Safety Programme (SPSP) continues to drive improvements across a number of key areas of healthcare. Significant new work has been done to draw together improvement support resources across health and social care with the Improvement Hub based at Healthcare Improvement Scotland (HIS) going live on 1 April 2016. Work has also been undertaken to provide assurance across health and social care with the development of a clinical and care assurance framework. Work is also continuing to ensure our hospitals are safer and cleaner with support from the Healthcare Environment Inspectorate.

Making Healthcare Safer

The Scottish Patient Safety Programme is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered. From an initial focus on acute hospitals, work now includes safety improvement programmes for the following areas:

Acute adult;

Healthcare Associated Infection;

Maternity and children;

Medicines;

Mental health;

Primary Care; and

Dentistry.

Building on the successes achieved to date, the Scottish Patient Safety Programme has been developing the key priorities for safety going forward, identifying three core themes to support achieving National Health and Wellbeing Outcome 7: People using health and social care services are safe from harm⁵⁰.

The three core themes are: prevention, recognition and response to deterioration; medicines; and system enablers for safety.

The Scottish Patient Safety Programme is led and coordinated nationally by Healthcare Improvement Scotland, supporting implementation within NHS Boards through local teams within hospitals, GP practices, mental health inpatient units and community pharmacies. The programme is delivered through a collaborative approach based on the Breakthrough Series Collaborative Model⁵¹, using national learning sessions to bring NHS Boards together to share and learn from each other. This is interspersed with action periods where local teams test and implement changes using improvement methodology – The Model for Improvement – to bring about improvements in care provision. The programme is supported by a range of stakeholders including NHS Education for Scotland.

In response to the integration of health and social care across Scotland, during 2015/16 Healthcare Improvement Scotland worked with a range of partners including the Joint Improvement Team and the Quality and Efficiency Support Team (QuEST) to develop a new improvement resource called the Improvement Hub (iHub)⁵². This resource came into effect on 1 April 2016 and will support Health and Social Care Partnerships and NHS Boards to improve the quality of health and social care services by: supporting the development of cultures of continuous quality improvement so that every person working in health and social care is engaged in the work of improving their day-to-day practice; and supporting the work to design systems, services and processes which enable people to receive the right support and care, in the right place, at the right time whilst also reducing harm, waste, duplication, fragmentation and inappropriate variation.

Examples of key achievements of the quality improvement work across NHSScotland are set out here.

Making Acute Care Safer

Mortality Rates

Within acute care there has been an overall reduction in Hospital Standardised Mortality Ratios (HSMR) of 16.5 per cent between October-December 2007 and October-December 2015. The methodology used by ISD was updated in August 2016 and progress towards the new aim to reduce hospital mortality by a further 10 per cent by December 2018 is measured from the end of a new baseline period (January 2011 to December 2013 to the latest quarter). The HSMR for Scotland has decreased by 4.5 per cent since January to March 2014 (first quarter after the new baseline) and January to March 2016⁵³.

Figures from the Scottish Patient Safety Programme, show that during the period January 2011 to January 2016, there has been a 21 per cent reduction in mortality from sepsis⁵⁴ and that there has been a 19 per cent reduction in cardiac arrest rate⁵⁵ for 11 of 25 hospitals that have reported consistently from February 2012 to December 2015.

Reducing Falls and Pressure Ulcers

The Scottish Patient Safety Programme acute adult programme has been working with clinical and improvement teams to reduce falls by 20 per cent and harm from falls by 25 per cent within acute hospitals. This is being done through supporting a variety of process improvements including risk assessment, falls bundles and post falls reviews to identify opportunities for learning and improvement. Following the transition of pressure ulcer improvement work from Leading Better Care in 2013, we have committed to reducing pressure ulcers in acute hospitals by 50 per cent. Current improvement work suggests development and implementation of more robust systems and processes for pressure ulcer recording have led to an increased confidence in the data of pressure ulcers reported. This increasing confidence in the quality of outcome data is supporting focused improvement work.

Reducing Healthcare Associated Infections and Tackling Antimicrobial Resistance

Reducing Healthcare Associated Infections (HAIs) and containing Antimicrobial Resistance (AMR) remains a priority for the Scottish Government and NHSScotland. Patients and the public must have complete confidence in the cleanliness and safety of Scottish hospitals and the quality of NHS services. We will continue to support and work closely across NHSScotland and with key stakeholders to reduce HAIs and tackle AMR to deliver further improvements for the safety of patients.

Significant progress has been made to reduce Healthcare Associated Infections across Scotland. From January-March 2007 to January-March 2016, cases of Methicillin-resistant Staphylococcus aureus (MRSA) and cases of Clostridium difficile Infection (CDI) in patients aged 65 years and older have reduced by 88 per cent and 87 per cent respectively⁵⁶.

The Healthcare Environment Inspectorate (HEI) carries out inspections of Scotland’s hospitals and has played a vital role in supporting hospitals to reduce incidents of infection. This year, the HEI started inspecting NHS Boards against new Healthcare Associated Infection (HAI) standards, published by Healthcare Improvement Scotland in February 2015⁵⁷. These standards are more expansive than the 2008 standards they supersede, and provide more detail and clarity to care providers about what is expected of them and how they can provide evidence to show how they prevent and control infections. In 2015/16 the HEI carried out 31 inspections of which 27 (87 per cent) were unannounced⁵⁸.

In 2015/16, £11.5 million was provided to support projects to help reduce HAI and AMR and funding of £4.2 million was granted to the Scottish Infection Research Network to set up a Scottish Healthcare Associated Infection Prevention Institute (SHAIPI). This five-year project, which commenced in April 2015, is the largest single investment into research into Healthcare Associated Infections in Scotland ever.

In 2015, the Controlling Antimicrobial Resistance In Scotland (CARS) Group was established to oversee Scotland’s contribution to the UK AMR Strategy 2013-18⁵⁹. CARS has taken forward a number of significant work streams to improve knowledge and understanding of antimicrobial resistance through the capture and use of better information on prescribing and antibiotic resistance.

Improving Child and Maternal Health Safety

In paediatrics, work has focused on reducing harm from ventilator associated pneumonia, central venous catheter bloodstream infection, unplanned admission to intensive care, medicines harm and child protection harm. One example of improvement can be seen in NHS Greater Glasgow and Clyde, where staff in the NHS Board have achieved a reduction of 78 per cent in the ventilator associated pneumonia rate. Work is ongoing to spread this success.

Making Medicines Safer

The Scottish Patient Safety Programme medicines programme brings together improvement activity related to medicines across acute, Primary Care, maternity and children’s services and mental health. It has a focus on: reducing medicines harm across transitions (medicines reconciliation); and high risk medicines with a whole systems approach to these two priority areas.

Improving Patient Safety in Mental Health Services

Mental health is a major public health challenge in Scotland. It is estimated that around one in four people are affected by mental illness in any one year. The Mental Health Safety Programme has worked with mental health clinicians and service users. An increasing number of wards and units are showing improvements in rates of violence and restraint, seclusion and percentage of individuals self harming. There are examples of reductions in restraint of up to 64 per cent, reduction in the percentage of patients who self harm of up to 75 per cent and reduction in the rates of violence of up to 80 per cent⁶⁰.

Reducing Harm in Primary Care

The Primary Care strand of the Scottish Patient Safety Programme aims to reduce the number of events which could cause avoidable harm from healthcare delivered across the wide range of Primary Care settings. Launched with an initial focus on General Practice, a range of tools and resources has been developed to support those working within Primary Care to improve the quality of care to patients, developing the patient safety culture within their teams and making higher-risk processes reliable.

Within Community Pharmacy, in four NHS Boards (Fife, Grampian, Greater Glasgow and Clyde and Highland), tools and interventions were piloted over two years in 27 pharmacies. Pharmacy teams tested care bundles for two high risk medicines: warfarin in NHS Fife and NHS Grampian; and non-steroidal anti-inflammatory drugs (NSAIDs) in NHS Greater Glasgow and Clyde and NHS Highland. They also piloted a pharmacy safety climate survey to improve the ‘safety culture’ in their pharmacies and nearly all of them identified areas for team improvement. In year two, participating pharmacies and dispensing practices have begun to test a medicines reconciliation care bundle by collecting data on a small sample of patients recently discharged from an acute hospital. The learning from this pilot will inform Quality Improvement in Community Pharmacy.

Within General Practice, the current GMS contract supports two principal pieces of work: reflective review of case notes by trigger tool; and a practice Safety Climate Survey. The trigger tool review, using the NHS Education for Scotland Primary Care Trigger Tool, allows GP practices to analyse a sample of case notes to determine whether any safety events, or near misses, have taken place. The resultant reflective report is discussed within the practice before being shared with the NHS Board so that themes may be developed and further improvement activity undertaken if appropriate.

The Safety Climate Survey is a validated tool for all practice staff, clinical and non-clinical, to express their views in six key areas of safety climate. This data can then be used by practices to determine strengths and areas for development through the formation of a reflective report which is shared with the NHS Board where learning across the system may again be aggregated. The number of GP practices participating in the safety climate survey has increased by 3 per cent since 2013, now totalling 93 per cent of all practices⁶¹. In addition to each of these areas, NHS Boards have commissioned a range of local enhanced services to improve areas of care that are recognised as being of higher risk to individuals.

Making Dentistry Safer

NHS Ayrshire & Arran, NHS Dumfries & Galloway and NHS Fife were recruited following a national recruitment process to allow testing to take place in a wider range of dentistry settings in Primary Care. The collaborative will run initially until December 2016. Dental practice teams will learn more about improvement methodology, pilot the use of tools and interventions to deliver safer, more reliable care, begin to explore their safety climate by undertaking a safety climate survey and share learning within their teams, their NHS Board and with other NHS Boards.

This is a ground-breaking project to test interventions and tools, further expanding the scope and reach of Scottish Patient Safety Programme. Each participating NHS Boards has recruited a dentistry clinical lead, and five dental practice teams, to work together on testing the tools and interventions. The learning from this project will support further work across Scotland and ultimately, it will improve patient safety in dentistry.

Supporting Improvement with Continuous Learning

Learning is central to all of these achievements and Healthcare Improvement Scotland has been supporting this work in a number of ways. Support to NHS Boards to improve their processes for managing and learning from adverse events continues. Implementation of Learning from adverse events through reporting and review: A national framework for Scotland⁶², coupled with the development of Board-level learning and improvement summary reports, has enabled improved outcomes at a local and national level.

Healthcare Improvement Scotland has been supporting two Boards – NHS Tayside and NHS Borders – to test a framework for the measurement and monitoring of safety in Scotland. The framework encourages a shift from a focus on past harm to thinking about safety today and in the future at its core is integration and learning. Healthcare Improvement Scotland is now seeking to embed the framework and its principles into existing national programmes and policy to encourage a new view of safety and quality more broadly.

Ensuring Safety Across Health and Social Care

The integration of health and social care will enable people to get the right care at the right time, in the right place. These arrangements are intended to provide safe care which best meets the needs and wishes of people, their families and carers. As part of ensuring safety, a Clinical and Care Governance Framework⁶³ was developed by an expert group. This framework covers those services which, from 1 April 2016, will be the responsibility of Health and Social Care Partnerships and builds on the existing governance frameworks within Local Authorities and NHS Boards.

Effective Care

Many of the areas for improvement that have been prioritised during 2015/16 make a direct contribution to our Quality Ambition for more effective healthcare services. A focus of this activity has been to identify those improvements where there is clear and agreed evidence of clinical and cost-effectiveness, and to support the spread of these practices where appropriate to ensure that unexplained and potentially wasteful or harmful variation is reduced.

Setting Out a Framework for the Development of Health Services

A National Clinical Strategy for Scotland⁶⁴ was launched by the Cabinet Secretary for Health and Sport in February 2016. It sets out the direction of travel and transformational change necessary to deliver a person-centred, safe and sustainable NHS for the people of Scotland over the next 10 to 15 years. It was developed through wide-ranging engagement with clinicians and staff across NHSScotland, third sector and professional bodies and provides the framework for the future of health and social care.

The Strategy is evidence-based, looking at the projected demographic challenges alongside potential innovations and their impact on the planning and delivery of healthcare services for our population as well as the already significant transformation arising from the integration of health and social care. It provides a platform for the continuous quality improvement of healthcare, social and voluntary services across Scotland to improve outcomes.

Improving Unscheduled Care Planning and Delivery

Scotland’s unscheduled care performance was the best performance we have seen since 2011/12. Some 94.1 per cent of patients were seen and subsequently admitted, transferred or discharged within four hours. In 2015/16 Scotland saw the best performance throughout the UK for the first time since records began. Scotland’s core A&E Departments have been the best performing in the UK since March 2015.

The launch of the new improvement focused approach in May 2015, based on six fundamental actions developed in partnership with the Academy of Royal Colleges, has supported the progress seen in Scotland. The Six Essential Actions⁶⁵ are:

Clinically-focused and empowered hospital management;

Realignment of hospital capacity and patient flow;

Patient rather than bed management – operational performance;

Medical and surgical processes arranged to take patients from A&E through the acute system;

Seven-day services targeted to increase weekend and earlier-in-the-day discharges; and

Ensuring patients are cared for in their own homes or a homely setting.

Over the last year, the implementation of the Six Essential Actions has primarily focused on what was required in the acute sector, sharing good practice and embedding changes and focusing on those sites with the biggest challenges. While work will continue to build upon this success, it is recognised that to maintain progress, there is a need to increase the focus on the whole system, and engagement and alignment of primary, secondary, voluntary and third sector organisations. This is vital if the system is to change to one that allows each organisation to link seamlessly together and support our ambition of person-centred, safe and effective care for generations to come.

Nearly £10 million has been invested this year to progress this approach. It is multi-disciplinary in nature and has commitment from partners across every part of the health and social care system. A number of key actions have been put in place to ensure progress. The national team, which consists of a number of experts with a range of professional expertise, has been enhanced, and with central funding, local teams are now dedicated to implementing the Six Essential Actions. This has allowed the Scottish Government and NHS Boards to work closely to make steady and significant improvements, particularly in the case of sites experiencing the biggest challenges.

Improving Delayed Discharge Performance

The impact on delayed discharge performance of new integrated ways of working is starting to be seen already. Bed days associated with delayed discharges have been on an overall downward trend throughout the year, running at 9 per cent below the level in 2014/15⁶⁶. Many local Health and Social Care Partnerships have now almost eradicated delays from the system. Others are making substantial progress. Health and Social Care Partnerships are adopting reablement approaches to help older people regain their independence, allowing them to live in their own homes for longer, as well as investing in new technology enabled care. These actions should help prevent avoidable admission to hospital as well as facilitating timely discharge where treatment in hospital has been necessary.

Transforming Outpatients

The Delivering Outpatient Integration Together Programme (DOIT) was launched on 10 August 2015 by the Cabinet Secretary for Health and Sport. Demand in Outpatients is increasing and new ways of managing patients and improving their experience is core to the ambitions of the DOIT Programme. Four key improvement elements have been found to have most success in ensuring the patient is seen by the right clinician first time, whilst ensuring greater efficiency in outpatient services. Each NHS Board is expected to implement the ‘Improvement Bundle’.

Enhancing Elective Capacity

Some £200 million is being invested to create five new elective centres across Scotland as well as a further expansion of the Golden Jubilee National Hospital. This investment is intended to enhance elective capacity to meet the needs of a growing – and ageing – population. The new capacity will be part of a wider programme to put in place a comprehensive national elective strategy for Scotland, which will deliver diagnostic and treatment facilities which meet the aims of the National Clinical Strategy for Scotland⁶⁷ and the principles of Realistic Medicine, as set out in the Chief Medical Officer’s Annual Report 2014-15: Realistic Medicine⁶⁸.

This programme will also enable creative redesign of services to ensure that all elective capacity is operating at optimum efficiency, reflecting ‘best in class’ practices from across the world and ensuring timely access for all patients across Scotland. In June this year, the programme was launched at a national event at the Golden Jubilee National Hospital and NHS Boards are now working with their partners to plan the size, role and scope of the new centres – with initial business cases due for submission to the Scottish Government at the end of the 2016/17 financial year.

The Golden Jubilee is also working to bring forward part of the expansion of its elective centre from 2018/19 to this year. The investment in MRI scanners will enable delivery of an additional 10,000 scans per annum on a recurring basis from Quarter 4 2016/17 and help build resilience. It also plans to move its ophthalmology suite into a state-of-the-art modular theatre and to create additional theatre capacity that will provide capacity for 2,100 routine general surgery procedures per annum when operating at full capacity, which will take around 12 months.

Elective waiting times have been transformed over the last 10 years despite growth in demand, however we recognise that sustaining elective waiting times is a challenge. In 2015/16, diagnostic waiting times statistics showed that 94.6 per cent of elective patients had been waiting six weeks or less at the end of March 2016⁶⁹. Almost 300,000 or 94.4 per cent of elective inpatient and day case patients were treated within 12 weeks in 2015/16, while 88.0 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2016⁷⁰.

Improving Cancer Outcomes

New Cancer Strategy

In March 2016, a new cancer strategy Beating Cancer: Ambition and Action⁷¹ was published. It sets out a direction of travel for cancer and related services for the next five to ten years, including prevention, early detection, diagnosis, treatment, care after treatment, quality, workforce and research.

The Strategy supports a new and significant initiative. Established in May 2015, the Innovative Healthcare Delivery Programme⁷² is focusing on new and innovative ways of both accessing and using cancer data to improve services and patient outcomes. Up to £2 million is being invested as part of the Cancer Strategy to develop a Scottish Cancer Intelligence Framework, with the programme based at the Farr Institute in Edinburgh. Performance of NHS Boards is monitored against Quality Performance Indicators (QPIs) by the National Cancer Quality Steering Group with reviews undertaken by Healthcare Improvement Scotland. A process of regular revision is in place to ensure that the QPIs keep pace with changes in the international evidence base and clinical practice.

Detect Cancer Early

The Scottish Government launched the Detect Cancer Early (DCE) Programme⁷³ in February 2012 to address the poor quality of life and poor survival rates resulting from late diagnosis. Early detection offers people the best chance of cure and possibly an opportunity to join clinical trials. Even in cases of advanced or incurable disease, early detection increases the chances of being able to offer treatment that prolongs life or allows more time to manage symptoms better and improve quality of life.

In the combined calendar years of 2014 and 2015, 25.1 per cent of lung, breast and colorectal cancers were diagnosed at the earliest stage, an increase of 8.0 per cent on the baseline combined calendar years of 2010 and 2011. The largest increase in Stage I diagnoses was in the most deprived (SIMD 1) which was a 16.3 per cent increase from baseline. There has also been particular improvements in the proportion of lung cancers being diagnosed at stage I (35.6 per cent increase from baseline)⁷⁴.

During 2015/16, the DCE Programme has successfully carried out social marketing campaigns on bowel cancer screening, lung cancer and breast screening. A new strand of activity was introduced into the DCE programme in 2015 called the wee c⁷⁵. In partnership with Cancer Research UK, the wee c aims to change perceptions and attitudes to cancer in Scotland in a bid to reduce fear around the disease and encourage earlier presentation. This was accompanied by a generic awareness raising campaign #getchecked.

To support GPs to refer patients with suspected cancer as early as possible, a mobile app was launched in February 2016 for the Scottish Referral Guidelines for Suspected Cancer⁷⁶.

DCE has funded a pilot study in NHS Tayside looking at the use of faecal immunochemical testing (qFIT) in Primary Care for symptomatic patients who may or may not have bowel cancer. This pilot enables GPs to identify those patients who warrant urgent ‘straight to test’ referral, and to reassure those for whom a policy of watch and wait would be the optimal choice.

If this pilot is successful, it could transform the management of patients with colorectal symptoms so that many would be spared unnecessary invasive investigation and those who need it would have appropriate further tests more promptly. As a consequence of the use of qFIT in routine use in Primary Care, this may also lead to reduced waiting times. This pilot will be evaluated on completion.

Cancer Waiting Times

For the financial year 2015/16, 90.8 per cent of patients began cancer treatment within 62 days of urgent referral with suspicion of cancer. The 31-day standard was met overall in the 2015/16 financial year at 95.7 per cent⁷⁷.

These standards have been set to encourage NHS Boards, where clinically appropriate, to adopt efficient cancer pathways and reduce avoidable delays between appointments.

Beating Cancer: Ambition and Action highlights the challenging position for NHS Boards and their ability to achieve these cancer waiting times standards. Specifically, the strategy highlights six actions which will support improvement in cancer waiting times performance:

Invest an additional £2 million per annum in a new Diagnostics Fund to support swift access to diagnostics for people with a suspected cancer diagnosis;

Invest an additional £1 million per annum in additional scope capacity, which will see an additional 2,000 scopes per annum on a sustainable basis;

Invest £7.5 million over the next five years to support improvements in surgical treatments, including urological cancer surgery;

Invest a further £2 million of capital to support our nationwide programme which will see two further robots for prostate cancer surgery in place – one in Glasgow and one in Edinburgh;

Invest a further £39 million in radiotherapy equipment over five years. This includes an £8 million investment in 2016/17; and

Examine whether additional targets for treatment or diagnosis would improve outcomes for people with cancer.

Improving Outcomes Through Whole System Orthopaedic Service Redesign

Whole system redesign of orthopaedic services, using clinical evidence and a focus on improved patient outcomes, is helping to ensure that patients get on the right pathway – starting in the community. A model that uses NHS 24 and NHS inform for early advice and self-management support with end-to-end pathways from community to secondary care is now being implemented across all NHS Boards. A further focus on ensuring that patients are seen by the most appropriate professional the first time they are seen, along with standardised decision-making to ensure they receive the most appropriate treatment, is leading to significant benefits to patients, while reducing the demand for Orthopaedic outpatient assessments and procedures. Where hospital treatment is required, work is focused on achieving efficient throughput in theatres, ensuring that this important resource is fully utilised.

Significant improvements have been seen in the quality of care for hip fracture patients with more people returning home quickly. There has been an increase from 50 per cent to 59 per cent of people returning home or to their original place of residence between 2013 and 2016⁷⁸. This has been achieved through a focus on a pathway of evidence-based interventions, with input from occupational therapy, physiotherapy and geriatrics speciality, so that patients recover quickly and are able to leave hospital without delay. Further improvements in the pathway for patients will be pursued through an enhanced multi-disciplinary focus and social care integration.

An intensive focus on the Enhanced Recovery Pathway⁷⁹ is also leading to improved outcomes for patients following hip and knee replacement surgery, with patients spending significantly less time in hospital (14,000 fewer post-operative bed days per annum than in 2010⁸⁰). Variation exists, however, in the benefits being realised from this approach and further work is being undertaken to ensure best practice is embedded to achieve improved patient recovery, reduce length of stay and release capacity in the acute system.

Enhancing the Role of Primary Care

General Practice

In December 2015, the Cabinet Secretary for Health and Sport announced that the Scottish Government had reached agreement with the BMA Scotland, to remove all remaining Quality Outcome Framework (QOF) points from the Scottish GP contract from April 2016. This means that Scotland is the first in the UK to abolish this bureaucratic system of GP payments. All funding associated with the QOF system will transfer to the core payment, ensuring no reduction in the amount of money GP practices receive. This will significantly reduce the bureaucratic burden on GPs – reducing workload and freeing up GP time to spend with patients.

There will also be transitional arrangements for quality assurance, ahead of a new Scottish GP contract coming into force in 2017. These transitional arrangements include the introduction of ‘cluster working’ which will allow practices to work more closely together to the benefit of patients. This is a move towards a system of values-driven governance that reflects, and is sensitive to, the needs of different communities across Scotland, and will focus on closer working with other parts of the wider primary, secondary and social care systems.

A £20 million package for GPs was announced in March 2015 by the Cabinet Secretary to ease pressures on the workforce over the next year, while negotiations towards putting General Practice on a long-term, sustainable footing continue. The package includes:

£11 million to uplift GP pay by 1 per cent and uplift GP expenses by 1.5 per cent, and funding to cover the costs of population growth in 2015/16;

£5 million to fund a GP from every practice in Scotland to take part in fortnightly sessions on cluster working;

£2 million funding to improve or upgrade IT infrastructure in GP practices; and

£2 million on specific measures called for by the BMA‘s Scottish General Practitioners’ Committee: funding a new rate for backfill cover for GPs taking maternity, paternity or adoption leave; developing occupational health services for Primary Care staff; and supplying GP practices with oxygen cylinders for emergency use.

During 2015/16, the Scottish Government announced an £85 million Primary Care fund. Over three years, this investment will enable work to progress to address immediate workload and recruitment issues, as well as putting in place long-term, sustainable change within Primary Care.

Of this investment, £2.5 million has been allocated towards a GP Recruitment and Retention Fund. This fund is exploring with key stakeholders, the issues surrounding GP recruitment and retention. It will examine and take forward proposals that promote Scottish General Practice as a positive career choice, support medical students to actively choose General Practice, inspire doctors in training to select speciality training in General Practice, and encourage our alumni to stay in or return to Scotland and encourage those wanting to work in rural and economically deprived areas. All NHS Boards and Health and Social Care Partnerships were invited to apply. A number of proposals will be selected for development and will be reported on during 2016/17.

Primary Care Transformation Fund

The creation of the Primary Care Transformation Fund (PCTF) was announced by the Cabinet Secretary in July 2015. With funding of £20.5 million to be allocated over the next three years, this will support the redesign of Primary Care services across Scotland, building towards a future where Primary Care is delivered by multi-disciplinary community teams in localities. NHS Boards and Health and Social Care Partnerships were invited to submit proposals on how they proposed to use their PCTF allocation. Proposals were received from every NHS Board. The assessment and stakeholder engagement meetings are complete and the majority of NHS Boards have now received their allocations.

Review of Primary Care Out of Hours Services

The National Review of Primary Care Out of Hours Services Report, Pulling together: transforming urgent care for the people of Scotland⁸¹, led by Professor Sir Lewis Ritchie, was published on 30 November 2015. The Review, announced by the Cabinet Secretary for Health and Sport in January 2015, reviewed the current landscape and recommended actions to ensure person-centred, sustainable, high-quality out of hours services for the people of Scotland. By visiting NHS Boards across Scotland, the purpose of the National Engagement Programme 2015 was to provide an opportunity for the range of people involved in delivering health and social care during the out of hours period to their communities to contribute their views on what worked well and what did not.

The Chair advocated that the following guiding principles are adopted in the design and implementation of future urgent care services: person-centred; intelligence led; asset optimised; and outcomes focused. Work is now ongoing on behalf of the Scottish Government to take forward the implementation of the report’s recommendations.

Optometry

Glaucoma is a progressive disease, affecting around 50,000 patients in Scotland, and is the second most common cause of blindness in the UK. While it is a difficult disease to diagnose as there are no symptoms in the initial stages, early diagnosis and treatment is the best chance of preventing blindness. On publication of the Scottish Intercollegiate Guidelines Network (SIGN) Guidelines on Glaucoma Referral and Safe Discharge⁸² in March 2015, the Scottish Government provided every optometry practice in Scotland with a pachymeter, a handheld device which measures the central corneal thickness of a patient’s eye. This measurement needs to be considered when assessing the pressure within a patient’s eye, a sign of glaucoma. The pachymeters were provided to every practice in Scotland by March 2016, a first in the UK and helping to deliver the Scottish Government’s ambition of shifting more resources into Primary Care.

Pharmacy – Building Clinical Capacity

Work has continued to deliver the three-year programme to invest £16.2 million from the Primary Care Fund to recruit up to 140 whole time equivalent (WTE) additional pharmacists with advanced clinical skills training to work in Primary Care settings. In the first two years of the funding, NHS Boards have made plans to recruit a total of 121.8 WTE pharmacists and 10.9 WTE pharmacy technicians. In year 1, Boards planned to recruit a total of 40.7 WTE pharmacists, providing support to 141 GP practices. For year 2, plans are in place to recruit a further 81.1 WTE pharmacists and 10.9 WTE technicians. These will provide support to around 283 practices across Scotland. To date, there are 47.8 WTE pharmacists in post. By the end of this Parliament all GP practices will have access to a pharmacist with advanced clinical skills⁸³.

Dentistry

A pilot commenced in four Territorial NHS Boards on 1 April 2015 to use existing data and quality indicators to identify at an early stage practices or dentists that are experiencing difficulties. Ten indicators are being used to ensure that NHS Boards are able to offer support as early as possible to avoid the practice or dentist getting into further difficulty. The 10 indicators are: practice inspection; out of hours arrangements; patient complaints; drug prescribing pattern; Childsmile fluoride varnish applications; clinical quality; clinical audit; probity; patient view; and NHS Board concerns.

Improving Motor Neurone Disease Care

Significant progress has been made towards achieving the Ministerial commitment to improve support for people with Motor Neurone Disease (MND) by doubling the number of Motor Neurone Disease Clinical Nurse Specialists and increasing the number of specialist nurses across Scotland. Over £2.4 million has been invested by the Scottish Government on a recurring basis to improve access to specialist Motor Neurone Disease (MND) nursing and care. Patients in NHS Fife, NHS Forth Valley, NHS Orkney and NHS Shetland now have specialist nursing support available in their local areas – made possible through cross NHS Board collaboration. This is just one area of specialist nursing that has benefited from NHS Board investment. Other specialist nursing services to have benefited from investment include cancer, epilepsy, Parkinson’s disease, multiple sclerosis and learning disability – increasing the number of nurses in all parts of Scotland.

Saving Lives at Risk from Cardiac Arrest

Scotland’s Out-of-Hospital Cardiac Arrest (OHCA) Strategy⁸⁴ is being implemented by a wide range of stakeholders. This is pivotal to its success which is now starting to be evidenced through increased survival from cardiac arrest, innovative ways of delivering emergency response to cardiac arrest to the public, and effective collaboration between organisations. Collaboration is already making a difference. This includes: third sector and emergency services working together to provide cardiopulmonary resuscitation (CPR) training for school children; Scottish Fire and Rescue Service and the British Heart Foundation making CPR training kits available for community use across all fire stations; and a co-responding trial between Scottish Fire and Rescue and the Scottish Ambulance Service in several parts of Scotland.

The Save a Life for Scotland⁸⁵ campaign was launched in October 2015 aimed at increasing numbers with CPR skills. Over 1,400 people learned basic life-saving CPR skills on that day alone⁸⁶. In November 2015, Out-of-Hospital Cardiac Arrest: A Strategy for Scotland won the policy development award at the Scottish Public Service Awards.

Improving Mental Health Services

A New Mental Health Strategy for Scotland

In late 2015 and early 2016, a first round of engagement was carried out to help shape and develop the new Mental Health Strategy. Following that first round of engagement, views were sought in a paper Mental Health in Scotland – a 10 Year Vision⁸⁷ on: our priorities for transforming mental health in Scotland; the early actions proposed to deliver this transformation; and how success should be measured over the 10-year period. The engagement closed on 16 September. The analysis of the consultation and the new Mental Health Strategy will be published in late 2016.

Mental Health Primary Care Transformation

In February 2016, the Cabinet Secretary for Health and Sport launched the Mental Health Primary Care Transformation Fund, totalling £10 million over two years. This is part of the wider Primary Care Transformation Fund. This money will support innovative tests of change which will result in the redesign of mental health services and support at primary and community care level so that people receive the most appropriate support, as fast as possible, in the most appropriate setting. NHS Boards and Health and Social Care Partnerships submitted proposals on how they proposed to use their funding. Proposals were received from all Boards. Assessment and stakeholder engagement meetings are now complete and funding has been allocated so the tests of change can begin.

Psychological Therapies and Child and Adolescent Mental Health Services

Waiting times for access to Psychological Therapies and to Child and Adolescent Mental Health Services (CAMHS) and performance on the mental health access standards continues to show a considerable rise in the number of people starting treatment⁸⁸. The total number of people starting treatment for Psychological Therapies in the first quarter of 2016 has increased 2.5 per cent on the last quarter of 2015, and 15 per cent on the same period last year, with over 1,700 more people starting treatment. It is welcome to see the increase in the number of children and young people seen within the target time has increased on the previous quarter, with 84.2 per cent of people being seen within 18 weeks during the first quarter of 2016 (see Table 1). In addition, a total of eight NHS Boards are meeting the standard in the first quarter of 2016, up from five at the end of 2015.

Table 1: Starting treatment with Psychological Therapies and child and adolescent mental health services, 2015/16

| Psychological Therapies⁸⁹ | Child and Adolescent Mental Health Services⁹⁰
March 2015 | 11,659 | 4,269
March 2016 | 13,451 | 4,436
Difference | +1,792 | +167
As a percentage of March 2015 | 15 per cent (15.4 per cent) | 4 per cent (3.9 per cent)

The Scottish Government is committed to supporting NHS Boards to meet their access targets and an improvement programme was included in the comprehensive package of support for mental health services announced by the First Minister in January 2016.

The Improvement Programme will take a phased approach, working intensively in collaboration with NHS Boards to deliver sustained improvements in access. The programme will be delivered by Healthcare Improvement Scotland and will work in partnership with NHS Boards.

Distress Brief Intervention

Distress Brief Intervention (DBI) is a time-limited, supportive and problem-solving contact with an individual in distress. The intended outcome of the DBI is to better engage and equip people to manage their own health and to offer a systematic and structured approach for staff to use that promotes a medium to long-term reduction in distress in service users. A better response by services to individuals in distress – including by NHSScotland, emergency services, social services and the third sector – is seen as a key component in supporting people at risk of non-fatal self-harm, and of future suicide prevention⁹¹.

Health and Social Care North Lanarkshire and South Lanarkshire Health and Social Care Partnership will host the DBI central team and participate as one of five test sites, with partners Penumbra in Aberdeen, Support in Mind in Inverness, NHS Greater Glasgow and Clyde and its constituent Health and Social Care Partnerships, and NHS Borders Joint Mental Health Service hosting local pilots.

Mental Health and Learning Disability Inpatient Bed Census

The Mental Health Strategy: 2012-2015⁹² had a commitment to undertake an audit of who was in hospital on a given date and the reason for their stay, to provide a better understanding of how the inpatient estate was being used. This was carried out in October 2014 and the results provided a range of valuable data on usage of inpatient beds and those patients who were in beds outwith, but paid for by, NHSScotland⁹³. The outputs proved valuable and it was agreed that this would be repeated on an annual basis. A further census was carried out on 30 March 2016 and the results were published in September 2016⁹⁴. It showed that the trend of shifting resources from hospitals into the community is continuing and that bed occupancy levels met best practice guidelines. For the first time it included data about the physical health of patients which will allow the measurement of progress in improving the physical health of people with mental health problems or learning disabilities.

Reducing Suicide Risk Discussion Framework Tool

Learning from suicide reviews and from national reports on suicide incidence were used to identify key evidence-based, organisational features that reduce suicide. These were pulled together into a discussion framework for mental health teams to use episodically in internal discussions about reducing risk⁹⁵.

Ensuring Children Get the Best Start

Prevention and early intervention is fundamental to ensuring the long-term health and wellbeing of our children and making sure they get the best start in life. It is key to achieving our ambition to address inequalities, raise attainment and create equitable economic growth. The Scottish Government is committed to delivering improved outcomes for children, young people and their families. This begins before birth and continues throughout the child’s journey to adulthood.

Maternity and Neonatal Services

We launched a review of maternity and neonatal services in 2015 that will report in early 2017. The Review will make recommendations for a Scottish model of care, with a focus on choice, quality and safety of services. It is based on evidence and extensive engagement with staff and service users in every NHS Board area in Scotland across all of the professions involved in delivery of maternity and neonatal services; and also with a wide range of third sector organisations, and professional groups.

Stillbirth

Stillbirth is a dreadful experience for women and their families. Working through the Maternity and Children Quality Improvement Collaborative and a number of initiatives, NHSScotland continues to drive down the rate of stillbirths in Scotland, with preliminary figures showing the lowest ever rate in 2015 of 3.8 stillbirths per 1,000 births⁹⁶.

Health Visiting

Health professionals, particularly Health Visitors, have a vital role to play in supporting children and families in the early years of a child’s life. NHSScotland has been developing the Health Visiting Services over the last year to introduce a consistent enhanced service to all families and grow the workforce. In October 2015, the Scottish Government, in conjunction with Territorial NHS Boards, published the new Universal Health Visiting Pathway in Scotland – Pre Birth to Pre School⁹⁷. This outlines a core home visiting programme to be offered to families with pre-school children. It consists of 11 contact points including formal health reviews of the child at 13-15 months, 27-30 months and prior to starting school to assess development and report on any issues or concerns. This provides an opportunity for Health Visitors, children and their parents and carers to review development and act as a gateway to other services when needed.

Early Years Collaborative

NHSScotland is actively involved in the improvements being delivered through the Early Years Collaborative (EYC)⁹⁸. This is strengthening services for children and families and contributing towards the shift to prevention and early intervention in line with Getting It Right For Every Child (GIRFEC)⁹⁹ and public sector reform. For example, Health Visitor teams are using the quality improvement methodology adopted through the EYC to improve family uptake of the 27-30 Month Child Health Review and speed up responses for those children who need extra support. Some NHS Boards have utilised the EYC to ensure pregnant mums on low incomes are signposted towards the benefits they are entitled to, with families increasing their income by up to £5,000. This work is closely affiliated to the Maternity and Children Quality Improvement Collaborative¹⁰⁰ – an integral part of the Scottish Patient Safety Programme.

In Vitro Fertilisation

Scotland leads the way on In Vitro Fertilisation (IVF) access in the UK. Eligible couples are provided with two full cycles of IVF treatment, with treatment provided within twelve months of referral for 99.9 per cent of patients in 2015/16¹⁰¹. Over the last four years, around £18 million has been invested to reduce waiting times and to improve the outcomes for patients undergoing IVF treatment.

Investing in Cutting-edge Medical Research

Developing precision medicine – the practice of tailoring treatment to individual patients based on knowledge about their genetics and other biology and information from their health records – is being supported through investments by the Scottish Government announced in 2015/16. An investment of £4 million will support the establishment of a Scottish Precision Medicine Ecosystem that will bring together resources across Scotland, coordinated by the Stratified Medicine Scotland Innovation Centre, with an initial focus on precision medicine approaches for pancreatic cancer and multiple sclerosis.

Further investment of £4 million plus £2 million from the Medical Research Council is supporting the Scottish Genomes Partnership¹⁰² – a collaboration between the Universities of Edinburgh and Glasgow, NHSScotland and NHS England – to use whole genome sequencing technology for research on rare diseases, cancers, Scottish populations and to work with Genomics England on the diagnosis of patients in Scotland with rare diseases.

Empowering People and Improving Care Through Digital Health

Digital technology has an important role to play in helping to transform services, and to ensure person-centred care is provided in a way that fits with people’s lives, particularly in an increasingly digital age. Empowering people to more actively manage their own health is key to our 2020 vision for health and social care that everyone is able to live longer, healthier lives at home, or in a homely setting.

Patient Portal

NHSScotland is working to provide everyone in Scotland with on-line access to an integrated summary of their Electronic Patient Record by 2020, which is an important step in self-management and co-production. Working on behalf of NHSScotland as a whole, a consortium of West of Scotland NHS Boards has defined the content and services that will be available through the national patient portal. Work is now underway to develop a business case to take this forward for development.

‘My Diabetes My Way’ Patient Portal

The ‘My Diabetes My Way’ patient portal¹⁰³ delivers tailored support and information to patients, including access to their own records and two-way secure communication with their care providers. The portal consists of an interactive website which includes electronic Personal Health Record (ePHR) allowing anyone with diabetes in Scotland access to their records. The website contains a variety of multimedia resources aimed at improving self-management and patients can manually enter home-recorded information (weight, blood pressure, etc.), or automatically upload blood glucose results.

Patients can correspond with their healthcare team using secure messaging, delivering remote guidance between routine appointments. These features enhance the service’s value and allow patients to contribute to a genuinely ‘shared’ record. As at April 2016, ‘My Diabetes My Way’ had 19,098 registrants (an increase of 6,146 since 2015) who had an interest in participating and 8,358 (44.6 per cent) who were fully enrolled and active on the site. The proportion of registrants transferring to active users has increased by 6.1 per cent in the last year¹⁰⁴.

Information Governance

NHSScotland takes privacy of an individual extremely seriously. Securing people’s trust in the safety of their personal data and how it will be used is vital to maximise the opportunities that technology has to offer in supporting the delivery of seamless care and support to people. In July 2015, the NHSScotland Information Security Policy Framework¹⁰⁵ was published which sets out the measures that NHS Boards need to put in place. This policy framework includes a number of commitments such as the appointment, for the first time, of Senior Information Risk Owners at NHS Board-level, as well as a 114 different controls that need to be in place in each NHS Board. All NHS Boards are being asked to provide evidence of progress against this standard each year.

Sharing Information to Improve Care

The Scottish Wide Area Network (SWAN)¹⁰⁶ is a single public services network for the use of all public service organisations within Scotland. As the major partner, NHSScotland led the procurement for SWAN. During 2015/16, the SWAN transition to improve broadband services continued apace. With over 3,300 NHS sites in Scotland, this is a major project that directly supports the aims of health and social care integration, making it easier to share information appropriately and securely between NHSScotland and other accredited public sector partners – improving the care that is offered while at the same time increasing efficiency. Work is also underway to upgrade the NHSScotland mail system which also assists in effective information sharing and working practices.

Clinical Decision Support

Clinical Decision Support (CDS) is a key enabler of healthcare improvement and safe care. NHSScotland has increased its focus on the appropriate use of CDS tools across a range of settings and services. During 2015/16, the CDS programme, part of the implementation of the eHealth Strategy, delivered several successful outcomes.

For example, we know that individuals with diabetes are more likely to develop complications associated with their illness, and appropriate clinical decision support has been shown to lead to earlier identification of potential issues leading to earlier screening and intervention. In a pilot project on context-sensitive decision support¹⁰⁷ linked to Scottish Care Information (SCI) Diabetes in NHS Tayside and NHS Lothian, it was shown that patients provided with evidence-based prompts, alerts and reminders to support lifestyle interventions, prevention and treatment were three to four times more likely to be referred to screening; and patients with decision support also showed a small but significant improvement in glycaemic control¹⁰⁸. The SCI Diabetes team is now exploring options for extending this decision support more widely.

Technology Enabled Care

There is no doubt that technology is increasingly present in people’s daily lives. The challenge for health systems is to determine how to make the most of the technology people already own and use. Through the Technology Enabled Care (TEC) Programme, self-reported outcomes from local areas show we have enabled in excess of 20,000 people to benefit from technology enabled care thanks to funding made available during 2015/16, and laid firm foundations for the further expansion of Technology Enabled Care. This has enabled more people to be supported at home, with fewer admissions to care homes and hospitals and an increased feeling of safety and independence.

Computerised Cognitive Behavioural Therapy

The NHS 24 Scottish Centre for Telehealth and Telecare has compiled significant evidence that computerised cognitive behaviour therapy (cCBT) works. As part of the three-year MasterMind programme involving a consortium of nine European Union members, the MasterMind team in Scotland has spent its first full year developing, implementing and evaluating its cCBT services across NHS Lanarkshire, NHS Grampian, NHS Fife and NHS Shetland. MasterMind is targeted at people with low to moderate levels of depression and/or anxiety. The service currently utilises the digital software package Beating the Blues, and builds on services originally established in NHS Forth Valley and NHS Tayside in 2005 and 2007 respectively, which continue to offer cCBT as one of their core, mainstream psychological therapies. In 2015/16, there were over 4,000 referrals to the MasterMind cCBT service, with 2,889 patients commencing treatment. Of all referrals made to the service, 80 per cent were made by GPs, with the remaining 20 per cent coming from clinical psychology and other mental health services. Funding has now been made available from the TEC Programme to roll this approach out nationally.

Developing Healthcare Science

The Healthcare Science National Delivery Plan¹⁰⁹ has set out service improvement programmes that focus on improving health outcomes for people by reducing inappropriate referrals to Secondary Care and preventing unplanned admissions to hospital or long-term settings. Ongoing work on a national approach to demand optimisation will significantly improve patient outcomes, with each diagnostic test optimised to improve clinical care and ensure efficient use of resources.

Chapter 3 - Improving the Health of the Population

Marie, who has the support of a Links Worker. You can read more about Marie’s story and hear from her directly at www.nhsscotannualreport.com

Scotland has effective and mature public health systems which are the match, and in some aspects superior, to those across the developed world. Health protection arrangements have been tested in recent times through the outbreak of Legionella in Edinburgh in 2012, a patient with Crimean Congo Haemorrhagic Fever in Glasgow in 2013 and Ebola at the end of 2015. On all three occasions, the systems worked well and limited the risk to the public’s health. Equally effective are our vaccination programmes (in childhood, for elderly people and for at risk groups). Uptake rates in most cases are higher than in other comparable countries and our programmes achieve and often exceed the level of immunity amongst the general population which means the unvaccinated population has a degree of protection (often referred to as herd immunity).

But, in common with all developed societies, the greater recent challenges to our public health have come from non-communicable diseases. These are largely created through lifestyle behaviours, changing societal expectations and a new urban and suburban environment which reduces individuals’ opportunities to be physically active.

Tackling Inequalities and Strengthening Community Participation

One way of addressing the challenges that our urban and suburban environment place on us, whether as communities or individuals, is through use of the newly developed Place Standard.

The Place Standard derives from a commitment made in Scotland’s architecture policy Creating Places¹¹⁰, and a recommendation arising from Good Places, Better Health¹¹¹, the Scottish Government’s strategy on health and the environment. Delivery of the Place Standard is integral to the Government’s agenda on tackling inequalities and strengthening community participation. Launched in December 2015, the aim of the Place Standard is to support the delivery of high quality places in Scotland and to maximise the potential of the physical and social environment in supporting health, wellbeing and a high quality of life. Research shows that the quality of a place can have a direct impact on a community’s quality of life, particularly in relation to health and wellbeing outcomes.

The Place Standard is an easy-to-use tool, framed around a set of 14 key questions that are central to the delivery of successful, sustainable places. Each question has been informed by the evidence base on the impacts of the physical and social environment on quality of life, and in particular, health outcomes.

Theme | Question: In my place…
Moving around | can I easily walk and cycle around using good quality routes?
Public transport | does public transport meet my needs?
Facilities and amenities | do facilities and amenities meet my needs?
Natural space | can I regularly experience good quality natural space?
Play and recreation | do I have access to a range of spaces and opportunities for play and recreation?
Housing and community | does housing support the needs of the community and contribute to a positive environment?
Traffic and parking | do traffic and parking arrangements allow people to move around safely and also meet the community’s needs?
Streets and spaces | do buildings, streets and public spaces create at attractive place that is easy to get around?
Identity and belonging | does this place have a positive identity and do I feel I belong?
Social interaction | is there a range of spaces and opportunities to meet people?
Influence and sense of control | do I feel able to participate in decisions and help change things for the better?
Care and maintenance | are buildings and spaces well cared for?
Feeling safe | do I feel safe?
Work and local economy | is there an active local economy and the opportunity to access good quality work?

The tool does not deliver a numerical outcome or overall ‘score’. Instead the results are represented in a radar diagram format or ‘place compass’, as shown in Chart 1.

Chart 1: Sample Place Compass

Chart 1: Sample Place Compass

This represents an assets map of the assessment area, as identified by those carrying out the evaluation. Space within the tool is provided for comments, priorities and potential actions to be included. It has been designed so that communities and individuals can easily use the tool, but it is also useful to professional audiences.

The Place Standard produces visual outputs in diagram and text format. Its purpose is to instigate structured conversations on issues that are linked to improving quality of life and reducing inequalities. These conversations can generate positive and collaborative relationships, potentially leading to more informed decision-making, co-production projects and participative processes.

As an example, in East Dunbartonshire, a joint project led by the Community Planning Partnership with support from NHS Health Scotland and Keep Scotland Beautiful is implementing the Place Standard tool as part of planning for local improvement. Surveys, participatory workshops and one-to-one sessions will all use the tool as a central method to gather the views of communities about their local places, with a focus on localities within the council area that have a relatively high percentage of the population living in income deprivation. This approach is already having an impact in preparing for the production of the Local Outcome Improvement Plan.

There are several other parts of the country such as within Fife, Inverclyde, Shetland and South Queensferry (within the City of Edinburgh Council area) where the place standard tool has already been used, or is being used, to collect and collate local knowledge about a specific place in a consistent format; with the resultant data informing plans for action, change or development. The Place Standard Implementation Group is supporting work to build on early experiences and share good practice across all Local Authorities in Scotland.

As we develop measures to help communities come together and help shape their living spaces we also continue to focus our efforts on the individuals and families living in those communities to help them make healthier choices.

Chart 2: European Age-standardised Mortality Rates per 100,000 for People Aged Under 75 in Scotland

Source: National Records of Scotland. Rates are based on the 2013 European Standard Population

Reducing Premature Mortality

As a result of improved treatments and a greater focus on prevention, premature mortality (deaths among those aged under 75 years) has reduced substantially, down 17 per cent since 2005 to a death rate of 440.5 deaths per 100,000 population in 2015 (see Chart 2). Early deaths due to cancer – the leading cause of death – have reduced by 13 per cent over the last decade. Deaths due to heart disease and cerebrovascular disease are down by 41 per cent and 37 per cent respectively, while deaths due to diseases of the respiratory system have reduced by 11 per cent¹¹². The increase by 4 per cent in premature mortality between 2014 and 2015 is likely to be due to the impact of the specific flu strain prevalent over the winter period. Older people were particularly affected by the flu strain, which also ran for a longer period of time than usual. Similar patterns were seen in a number of other European countries.

Tackling Alcohol-related Harm

Scotland is also seen as a world-leader in addressing alcohol-related harm. It was recognised several years ago that Scotland’s relationship with alcohol had become unbalanced, and bold action has been taken to tackle alcohol misuse.

A whole-population approach is at the heart of Scotland’s alcohol strategy, Changing Scotland’s Relationship with Alcohol: A Framework for Action¹¹³, which includes a package of over 40 measures to reduce alcohol-related harm by helping to prevent problems arising in the first place. It also addresses improving support and treatment for those who are already experiencing problems.

Alcohol-related harm has an impact not only on individuals, but also on families and communities. Alcohol Brief Interventions (ABIs) play an important preventative role in tackling this as part of a wider strategic approach to addressing problem alcohol use. The ABI Programme has focused delivery on three priority settings: Primary Care, A&E and antenatal services. In 2015/16, 97,245 ABIs were carried out, exceeding the target of 61,081 by 59 per cent¹¹⁴. The target has continued into 2016/17 to support the long-term aim of embedding ABI delivery into routine practice, with broadened delivery opportunities in wider community settings to increase coverage of harder-to-reach groups. If people feel better supported to live well within their community and to self-manage, they are more likely to avoid reaching crisis point, which can mean ending up in hospital.

Reducing Smoking and Tackling its Harmful Effects

Tobacco remains the primary preventable cause of ill health and premature death. It is associated with 127,000 hospital admissions and over 10,000 deaths each year in Scotland – around a fifth of all annual deaths. Annual costs to NHSScotland associated with tobacco-related illness are estimated to exceed £500 million per year¹¹⁵.

Reducing the number of people who take up smoking, supporting those who do smoke to quit and protecting people from second-hand smoke have long been clear public health priorities. The Scottish Government’s Tobacco Control Strategy – Creating a Tobacco-free Generation¹¹⁶ was published in 2013. This sets a bold and ambitious target to reduce smoking rates to 5 per cent or lower by 2034. The Scottish Health Survey for 2015 published in September 2016 reveals encouraging progress towards achieving this goal. It shows that 21 per cent of adults now smoke – one in five adults in Scotland. There was also a significant decrease from 2014 to 2015 in the proportion of children who were exposed to second-hand smoke in the home (11 per cent to 6 per cent)¹¹⁷.

NHSScotland continues to play a key role in tobacco control efforts. NHSScotland succeeded in achieving the Scottish Government’s target of supporting at least 7,279 people to quit for at least three months in the most deprived areas between April 2015 and March 2016. Recently-published figures show that NHSScotland achieved 109 per cent of the target (7,047 successful three-month quits). This is despite the fact that the number of quit attempts made through NHS smoking cessation services in Scotland has fallen by 47 per cent since 2011/12¹¹⁸.

This is likely to be due to a number of factors, including the rise in the popularity of e-cigarettes as a means of stopping smoking. Supporting people in deprived communities to stop smoking, particularly given the high smoking prevalence in this group, remains a challenge but will continue to be a priority for tobacco control activity.

It is not just people who smoke who are affected by the health impact of tobacco. Second-hand smoke also affects children who are exposed to it. Recent Scottish research shows that harmful chemicals from tobacco can linger in a room for up to five hours¹¹⁹. NHSScotland rolled out a nation-wide smoke-free policy for all its outdoor grounds as of April 2015. This built on the range of policies already in place across NHS Boards to deliver one Scotland-wide approach, and was supported by a national campaign that recognised the efforts of people who smoke in trying to comply with the policy. The Scottish Government included powers for Ministers to set perimeters around hospital buildings in legislation passed in April 2016. This will make it an offence to smoke within defined perimeters in hospital grounds. This will support implementation of smoke-free grounds.

In addition, the Scottish Government’s Take it Right Outside campaign, launched in 2014, was developed with the support of NHS Boards to raise awareness of the risks of smoking indoors and supports people to not smoke in the homes of children. Help continues to be provided for those who want to quit. GPs provide expert advice and will direct people to a range of local services on their doorstep. Pharmacists have become a convenient frontline smoking cessation service for many people, providing smoking cessation products to help people quit with ongoing advice and follow-up support. Further information and advice is also provided through services such as Smokeline (0800 84 84 84) and the Take it Right Outside campaign.

Tackling Overweight and Obesity

Obesity rates in Scotland are among the highest in the developed world, with current projections suggesting obesity rates could be over 40 per cent by 2030¹²⁰. The Scottish Health Survey Results 2015 showed almost two-thirds of adults (65 per cent) in Scotland are overweight or obese, with 29 per cent classified as obese.

The proportion of boys of healthy weight (73 per cent in 2015) has increased year on year since 2011 (63 per cent) and is comparable to the level seen in 1998 (70 per cent). The proportion of girls who were a healthy weight in 2015 was 70 per cent, a level that has remained relatively steady since 1998. Just over one in four (28 per cent) children were at risk of being overweight in 2015, with no significant difference existing between boys and girls (26 per cent of boys and 29 per cent of girls). In 2015, 15 per cent of boys and 14 per cent of girls were at risk of obesity, figures which were identical to those in 1998. Compared with a child with parents of a healthy weight, a child with an obese parent was significantly more likely to be at risk of being overweight, including obesity (40 per cent compared with 22 per cent), or at risk of obesity (23 per cent compared with 11 per cent)¹²¹.

The Scottish Government’s strategy, Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight¹²², focuses on prevention. The Route Map sets out both national and local governments’ respective long-term commitment to tackling overweight and obesity. It focuses on reducing energy consumption, increasing energy expenditure with a particular focus on those in early years and with people of a working age. Work continues to support a series of healthy weight interventions, including supporting adult and child healthy weight interventions in NHS Boards.

Football Fans In Training

Losing weight is difficult but keeping it off is even harder. Most people who lose weight are back at their original weight three to five years later. One promising programme in Scotland is Football Fans In Training (FFIT), run by the Scottish Professional Football League (SPFL) Trust. Developed by a Scottish research team led by the University of Glasgow, a randomised controlled trial in 2011/12 found that 12 months after starting FFIT, men who took part in the programme lost 5.56 kg, or 4.96 per cent of their baseline weight¹²³.

The programme was also cost-effective. With funding from Scottish Government, the SPFL Trust has continued to deliver the programme in 32 football clubs across Scotland: now almost 3,000 men have taken part in FFIT¹²⁴. The research team has now followed up the original participants in the trial to see if they managed to keep the weight they lost off three-and-a-half years after starting the programme. The research will be published in early 2017. Football Fans In Training is now internationally-recognised. It has been transferred to the English Leagues with clubs such as Southampton, Middlesbrough and Blackburn Rovers and lower league clubs such as Torquay actively involved. Work is also in place to start to transfer the programme to the German Bundesliga.

Supporting Wellbeing in Pregnancy and Parenthood in Young People

March 2016 saw the publication of the Pregnancy and Parenthood in Young People Strategy¹²⁵. The strategy supports Scotland’s young people and young parents, and aims to drive actions that will address the cycle of deprivation associated with pregnancy in young people aged under 18.

Whilst rates of pregnancy in young people have fallen in recent years, the gap in inequality is increasing. Young women aged under 20 living in Scotland’s most deprived areas are five times more likely to experience a pregnancy as someone living in the least deprived. In order to address this gap in equality, the Strategy aims to increase the opportunities available to young people to support their wellbeing and prosperity across the life course. Multiple agencies have been tasked with working toward achieving the aims of the strategy, working together across NHSScotland, Local Authorities and the third sector with the support of a national lead.

Promoting Healthier Behaviours

NHSScotland has a key responsibility for promoting health and wellbeing in the population it serves, but it has recognised in recent years that it should also be seen as an organisation that values and promotes health among its workforce and those that engage with the service. This is being realised through the Health Promoting Health Service.

Health Promoting Health Service is about promoting healthier behaviours and discouraging detrimental ones in NHSScotland, and is aimed at staff and anyone visiting NHS premises in Scotland. It seeks to achieve this by ensuring that healthier choices are readily available and that appropriate support and encouragement is in place to help people make better choices. With its person-centred approach, Health Promoting Health Service goes further, seeking to connect people with sources of support for non-medical issues that may be impacting on their health – such as money worries and housing issues – so that those at risk of poverty and inequality achieve the best possible health outcomes.

Improvements in the hospital environment have been particularly evident over the last year, with healthier food choices on offer in staff canteens and visitor cafés, an increase in the number of sites with well-designed, usable green spaces for therapy and to encourage physical activity, and the ban on smoking in NHSScotland grounds.

NHS Boards achieved the Healthyliving Award Plus¹²⁶ in all 123 NHS-operated sites, with a further 60 in the third and private sector. The Healthyliving Award rewards caterers from across the length and breadth of Scotland for making it easier to eat healthily when eating out. Now retailers are required also to adopt healthier practice through the Healthcare Retail Standard¹²⁷. Both sets of criteria are based on the general principles of a healthy balanced diet. They have been developed to reflect Scottish dietary targets, and so aim to ensure that healthier ingredients and cooking methods are used to keep fat, salt and sugar to a minimum, and options such as water, low-fat dairy products and fruit and vegetables are always available. NHS Boards are asked to ensure that all caterers (such as tea bars, restaurants and cafés) which sell food or drinks in healthcare premises work to maintain the Healthyliving Award Plus. To ensure a consistent approach among food service providers across NHSScotland, by 31 March 2017, 70 per cent of all food provision must meet Healthyliving criteria and have implemented the Healthcare Retail Standard.

Improving Oral Health

NHS Boards and their delivery of the Childsmile Programme have ensured that continued progress is made in improving the oral health of children. This is a crucial area, as dental decay is almost always entirely preventable, and by ensuring good oral health in children, we help safeguard the oral health of the future adult population. The latest results from the National Dental Inspection Programme (NDIP) showed that 75 per cent of children in Scotland at Primary 7 had ‘no obvious decay experience’, compared with 59 per cent in 2007¹²⁸.

Despite the national success of the Childsmile Programme, health inequalities in oral health persist in Scotland. For example, 64 per cent of Primary 7 children in the most deprived areas have ‘no obvious decay’; the equivalent figure for the least deprived areas is 85 per cent. This gap between least and most deprived needs to be further addressed and the Scottish Government’s consultation on Scotland’s Oral Health Plan is intended to achieve this¹²⁹.

Protecting the Public Against Serious Diseases

After clean water, vaccines have had the greatest impact on people’s health around the world. Vaccination programmes are one of the most effective ways of protecting the public against serious diseases and of reducing the spread of disease. Scotland has a number of well-established vaccination programmes for people across all ages and at various stages in their lives. Indeed, the Scottish routine childhood vaccination programme is one of the cornerstones of Scotland’s efforts to protect public health, and the importance of this programme is clearly recognised by the public, as uptake rates in Scotland are enviably high. During 2015, two new meningitis vaccines were added to the routine childhood vaccination programme in order to help protect against particular strains of meningococcal disease (Men ACWY and Men B).

In August 2015, Scotland introduced an accelerated catch-up programme to vaccinate all 14-18 year olds with Men ACWY vaccine within one year to respond to an increase in cases of meningococcal group W (Men W) in the UK. The vaccine was also offered to students under the age of 25 attending university for the first time in autumn 2015. The Men ACWY vaccine now replaces the Men C vaccine given at around age 14 under the routine childhood vaccination schedule. While uptake figures for the Men ACWY catch up programme have not yet been published, it is almost certain that the uptake is likely to be very high, in line with other teenage booster vaccinations. Additionally, indications are that there has been a steady decline in cases of Men ACWY in the vaccinated age group, potentially suggesting early effectiveness of the programme.

In September 2015, Scotland became one of the first countries in the world to introduce a Men B vaccine. It is given alongside other routine immunisations at two and four months of age, with a booster dose at 12-13 months. Provisional vaccine uptake for the first routine cohort eligible for infant Men B vaccination is 95.7 per cent for one dose and 82.4 per cent for two doses by six months of age¹³⁰. Such high uptake six months after introducing the vaccine demonstrates that the programme is working well and that inclusion of the Men B vaccine is acceptable to parents and guardians. Final uptake figures for Men B vaccination of children reaching 12 months of age between July to September 2016 will be published in December 2016. It is expected that the full impact of the Men B vaccine will become more apparent over time.

Chapter 4 - Securing Value and Financial Sustainability

Financial Overview

In 2015/16, health spending in Scotland exceeded £12 billion for the first time and amounted to 40 per cent of total Scottish Government spending. In line with the Scottish Government commitment to protect the NHSScotland resource budget, the 14 Territorial NHS Boards received an above inflation baseline increase of 3.4 per cent, which was directed towards the provision of frontline healthcare services for patients and their families.

For the eighth year in a row, all NHS Boards achieved their financial targets. Once again, this demonstrates the commitment of all those involved across NHSScotland in managing resources, often within very challenging circumstances, and delivering high quality services underpinned by financial strength.

In 2016/17, health spending in Scotland is rising to a record level of almost £13 billion. NHS Boards have received a 5.5 per cent resource increase over 2015/16 budget levels, including investment of a further £250 million from NHSScotland to Health and Social Care Partnerships to protect and grow social care services and deliver our shared priorities.

The Scottish Government will continue to ensure that NHSScotland is equipped for the challenges it faces and will increase the revenue budget by £500 million more than inflation by the end of this parliament. As part of this, a key priority will be shifting the balance of care from an acute to community setting by increasing the share of the budget dedicated to mental health and to primary, community, and social care.

As the most significant reform of our health and social care services since the creation of NHSScotland, over the course of 2015/16 work progressed towards integration with the new Health and Social Care Partnerships becoming fully operational by 1 April 2016. Additional investment of £1.3 billion over five years in our Health and Social Care Partnerships will help to build up our social care capacity, helping people to maintain their independence for as long as possible, in their own homes and communities and meaning that fewer people need to go to hospital to receive care.

How the Health Budget was Spent in 2015/16

The Scottish Government allocated £10.4 billion directly to the 14 Territorial NHS Boards. The seven Special NHS Boards and Healthcare Improvement Scotland received £1.3 billion, and £0.5 billion was used to fund a variety of other support programmes, research and improving access to services.

Capital Investment

In terms of capital investment, 2015/16 saw the Queen Elizabeth University Hospital and Royal Hospital for Children open to patients. This £842 million investment, completed on time and on budget, provides patients of all ages with access to services on a single site and ensures better continuity of care.

The Scottish Government has continued its programme of investment in health infrastructure, with other major investments in the NHSScotland estate. In Dumfries, good progress is being made with the £275 million replacement of the Dumfries and Galloway Royal Infirmary, while in Edinburgh, construction is ongoing on the £230 million new Royal Hospital for Sick Children. The Woodland View Hospital in Ayr opened in the summer of 2016. Part of a £55 million project, the new hospital provides a 206-bed integrated mental health facility and community hospital.

The Scottish Government has committed over £500 million in funding to deliver new community health infrastructure through the hub programme. This funding has delivered projects such as the Eastwood and Maryhill Health and Care Centres (£25 million) and three new health centres in Lanarkshire, serving East Kilbride, Wishaw and Kilsyth (£50 million). Projects in the pipeline include a bundle of new health centres in Lothian to serve Blackburn, Firrhill and north-west Edinburgh (£35 million) and the Stirling Care Village (£35 million).

In major acute infrastructure, the Scottish Government has committed £200 million to deliver new diagnostic and treatment centres across Scotland, as well as further investment in excess of £40 million in NHS Grampian’s Baird Family Hospital and ANCHOR Centre projects on the Foresterhill Campus in Aberdeen.

Chart 3: Planned and Actual Efficiency Savings 2015/16 by NHS Board

Chart 3: Planned and Actual Efficiency Savings 2015/16 by NHS Board
Source: NHS Boards’ Financial Performance Returns

Efficiency Savings

NHS Boards were required to deliver at a corporate level efficiency savings of £293 million for NHSScotland for 2015/16. This equates to 3.0 per cent of their baseline funding. Savings requirements ranged from 0.4 per cent (NHS Education for Scotland) to 7.1 per cent (Golden Jubilee Foundation Board). Almost all Boards achieved this level of efficiency and a number over-delivered, bringing the final total for 2015/16 to just over £290 million (see Chart 3).

NHS Boards delivered these savings while maintaining the quality of services through a range of initiatives. These included:

Service transformation activity, such as improving elective flow;

Drugs and prescribing, including implementing medicines reviews in Primary Care;

Procurement – a focus on ensuring best value when purchasing goods and services;

Workforce – reducing the use of locums and agency staff in NHSScotland;

Estates and facilities – improving energy efficiency and reducing waste; and

Support services – reducing spend on non-clinical staff.

Chart 4: Glasgow Royal Infirmary – Improvements to Reduce the Time Taken to get Patients to Operating Theatres for Emergency Surgery

Chart 4: Glasgow Royal Infirmary – Improvements to Reduce the Time Taken to get Patients to Operating Theatres for Emergency Surgery
Source: Glasgow Royal Infirmary

An example of the innovative way in which NHSScotland is improving the quality of care for patients, whilst also being more efficient is shown here.

Glasgow Royal Infirmary – Optimising Patient Flow

Glasgow Royal Infirmary has been implementing the Institute of Healthcare Optimization’s (IHO) Variability Methodology since April 2015 and as a result has achieved impressive improvements in the safety and quality of patient care. A standardised approach to classify the urgency of each individual patient has been implemented across all specialties accessing emergency theatres, with more than 95 per cent of all patients now consistently getting to theatre without delay. Post-operative length of stay has also been improved by almost one day for all patients who have reached theatre within their urgency waiting time. As the cost of an inpatient stay is usually estimated at around £350 on average, and evidence shows that reducing the length of time patients spend in hospital unnecessarily is beneficial, this is both an improvement in outcomes and a cost saving¹³¹.

Chart 4 shows the impact of specific improvements to reduce the time taken to get patients to operating theatres for emergency surgery within clinically appropriate times. Chart 5 shows the reduction in the length of stay for those patients.

Chart 5: Glasgow Royal Infirmary – Reduction in Length of Stay
Chart 5: Glasgow Royal Infirmary – Reduction in Length of Stay

Source: Glasgow Royal Infirmary

Focusing on the Future

Recognising that NHSScotland will face financial pressures in future, despite the commitment to maintain funding levels, there will continue to be a focus on innovative ways of both improving the quality of care and making our services more sustainable. A continued focus on reducing unnecessary prescribing, making patient ‘flow’ through our acute hospitals better, using technological advances to improve outcomes and ensuring that all of our infrastructure and support functions are as efficient as possible will be a major area of activity across health, social care and government during 2016/17 and beyond.

Chapter 5 - Our Workforce

Our NHSScotland workforce is vital in responding to the many challenges we continue to face and it is down to the extraordinary commitment and dedication of our health and social care staff across Scotland that we have the world-class NHS that we have today.

We know from evidence that staff who are valued, treated well and supported to give their best, deliver better patient care and overall outcomes. Everyone Matters: 2020 Workforce Vision¹³² is our commitment to valuing our workforce and changing the workforce things that need to change or be done better to ensure that we can continue to deliver the high quality services that the people in Scotland deserve.

Our 2020 Workforce Vision is:

We will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations. We will continue to modernise the way we work and embrace technology. We will do this in a way that lives up to our core values.

Together we will create a great place to work and deliver a high quality healthcare service which is among the best in the world.

Our values that are shared across NHSScotland are:

Care and compassion;

Dignity and respect;

Openness, honesty and responsibility; and

Quality and teamwork.

Our five priorities to deliver our 2020 Workforce Vision are:

Healthy Organisational Culture – creating a healthy organisational culture in which our NHSScotland values are embedded in everything we do, enabling a healthy, engaged and empowered workforce;

Sustainable Workforce – ensuring that the right people are available to deliver the right care, in the right place, at the right time;

Capable Workforce – ensuring that everyone has the skills needed to deliver safe, effective, person-centred care;

Working to Deliver Integrated Services – health and social care workforce across NHS Boards, Local Authorities and third party providers; and

Effective Leadership and Management – leaders and managers lead by example and empower teams and individuals to deliver the 2020 Vision.

A huge amount of work has been carried out by NHS Boards and key partners in 2015/16 across these priorities. In September 2015, the Scottish Government published a Review of Progress which highlighted work by all NHS Boards to deliver our priorities and embed our shared values in everything we do.

The progress being made in Scotland was also highlighted by the Organisation for Economic Co-operation and Development (OECD) in their review of the four healthcare systems in the UK¹³³, which described our work to deliver our 2020 Workforce Vision as ‘clear and impressive’. But we are not complacent and, while we are making progress towards our 2020 Workforce Vision, we are doing more to support our staff who are low paid, ensure that we have a true culture where staff are encouraged and supported to speak up when they see practice or behaviours that don’t meet our shared values – without repercussion.

To drive forward the transformational agenda, work across boundaries and harness the talents of all those working in our organisations, we are doing more to support the continuing development of our current and future leaders. This is building on many of the well-established programmes already being offered at local and national level, with a fresh approach now being developed for our top leadership cohort at NHS Board-level. The key dimensions of our approach spans leadership development, talent management and succession planning, performance review and appraisal and moving towards values-based approaches in areas such as recruitment. These approaches will draw on existing good practice in Scotland, learning from elsewhere and the most up-to-date evidence of how organisations best serve and work with their stakeholders.

Key developments in 2015/16 include:

Improving Staff Experience

The implementation of iMatter, the continuous improvement model to improve staff experience across NHSScotland continues to be a particular achievement. All NHS Boards are engaged in rolling out the model across their organisations and are on track to complete this by the end of 2017. IMatter response rates are currently at much higher levels than those achieved by the NHSScotland staff survey with Employee Engagement Index scores for NHSScotland returning values which place them in the top percentile within the range of scoring on a world stage. This would suggest that the model is making a significant impact in involving staff in the decisions that affect them and making real changes for the benefit of patients and staff. In addition, some Health and Social Care Partnerships are now also using the model to measure and improve their staff experience.

Enabling a Healthy, Engaged and Empowered Workforce

NHS Boards must ensure that it is safe and acceptable for staff to speak up about wrongdoing or malpractice within their organisation, and much has been done in 2015/16 to further support this. Following a full public consultation on detailed proposals, work is underway to establish an Independent National Whistleblowing Officer. This will complement existing policies and provide independent and external review on the handling of whistleblowing cases in NHSScotland. Non-executive Whistleblowing Champions were introduced in each NHS Board in November 2015, providing a critical oversight and assurance role at local level. The contract for the National Confidential Alert Line has been extended for a further year to ensure that staff have access to additional independent support should they feel unsure about how or whether to whistleblow. NHSScotland has also responded to concerns and stopped the standard practice of using confidentiality clauses in settlement agreements. This was in response to a perception that they were used to ‘gag’ staff, and they are now only used with the explicit consent of staff.

Right Staff, Right Time, Doing the Right Things

The Scottish Government is committed to introducing national and regional workforce planning, with preparations underway to take proposals forward and publish a first iteration of a national healthcare Workforce Plan in spring 2017. In 2015/16, numbers of NHSScotland staff continued to rise to over 138,000 whole time equivalent (WTE)¹³⁴. However, the proposals are not exclusively about numbers. They will involve close consideration, with partnership stakeholders, of the many influences on workforce planning. That will not only mean ensuring sufficient numbers of NHSScotland staff, but that they are in the right place, at the right time, and doing the right things in pursuit of safe, high quality patient care. The proposals are expected to help bring about practical solutions to capacity issues which are experienced by NHS Boards.

Additional manifesto commitments were made to maintain, increase and improve staffing capacity, including specific plans to increase numbers of GPs, Nurses, Advanced Nurse Practitioners, Health Visitors, medical school places, community link workers and paramedics. This was designed not only to increase staffing levels throughout NHSScotland but to continue to attract and retain the best talent in the healthcare profession.

Providing Timely Access to High Quality Care

The aim of the Sustainability and Seven Day Services Programme¹³⁵ is to ensure that people who require healthcare have timely access to high quality care whenever they need it, on a basis that is sustainable in the long-term. Activity this year has focused on taking forward the next steps detailed in last year’s interim report¹³⁶. The Sustainability and Seven Day Services Taskforce accepted the service model proposed by the Scottish Clinical Imaging Network for reviewing and reporting diagnostic imaging and the provision of interventional radiology. Plans are now progressing for the implementation of this with NHSScotland Shared Services.

The Programme for Government 2015/16¹³⁷ announced two innovative community health hubs would be tested in NHS Forth Valley and NHS Fife. A number of GPs have been recruited and are currently undergoing an additional year of training to provide them with the skills to work across Primary and acute care and to staff the hubs as part of a wider multidisciplinary team. The pilot NHS Boards are making good progress with their delivery models. Two distinct models are emerging in response to local needs, albeit both are centred around issues of frailty. The hubs are on course to go live in early 2017. A review of acute general surgery across NHSScotland is progressing well and a large amount of data has been gathered. The review is on track to be completed this year.

Supporting Nurses and Midwives to Return to Practice

During the reporting year, some parts of Scotland continued to experience challenges in recruiting to the nursing and midwifery professions because of their geographical location. In February 2015, the Scottish Government announced assistance to former nurses and midwives who wished to return to practice. The aim originally was to provide support for 75 nurses and midwives a year by providing funding for their university fees and for other support. The programme has been much more successful than originally planned, with many more applicants applying to return to practice. This has allowed a total of 150 nurses and midwives in the first year of the scheme to receive funding to re-join the nursing and midwifery workforce, alongside an additional 14 non-funded applicants also beginning the Return to Practice programmes¹³⁸.

Supporting Decisions on Staffing

A ground-breaking, multi-disciplinary tool has been available since May 2015 for use in Emergency Departments/Emergency Medicine (EDEM) settings. This tool is part of a suite of workload and workforce planning tools available to NHS Boards in Scotland which cover the majority of service areas helping to plan for the number of nurses and midwives they require to provide the best possible care for patients. The EDEM tool is unique because it not only informs the number of nurses required but also the numbers of medical staff needed. Scotland has led the way in developing these tools, looking at factors such as the number of patients, the complexity of the care required, local factors, shift patterns and also time for tasks such as administration. Feedback from NHS Boards demonstrates that use of the tools, including the EDEM tool, is encouraging an evidence-based approach to decisions on staffing.

NHS Pay and Conditions

NHS Pay Review Bodies’ recommendations for salaries in 2016/17 have been implemented in full, leading to all NHSScotland staff on salaries over £22,000 receiving a 1 per cent pay increase from 1 April 2016. Staff earning under £22,000 received an increase of at least £400, underpinned by an uprated Living Wage. In addition, a review of use of the lowest pay band available within NHSScotland was instigated which would ultimately offer those currently on band 1 of the Agenda for Change system the chance to move to band 2 with an expanded job description. This initiative was taken forward in partnership between employers and staff with a view to creating a higher skilled and more flexible workforce on the one hand and allowing staff to access higher pay on the other.

A new NHS pension scheme was successfully introduced from 1 April 2015 following communication with all staff. The new scheme includes a later pension age. Work to consider the implications of this and to develop support for staff and employers has been taken forward through the UK NHS Working Longer Group and a Scottish Working Longer Group.

Meeting Recruitment Challenges

Scotland’s needs are different to those in the rest of the UK due to Scotland’s distinctive demographic structure and migrant workers remain an important labour source. Whilst the UK Government remains committed to reducing dependence on migrant workers and tightening the rules around entry to the country, Scotland has some power through the Shortage Occupation List (Scotland only) to facilitate entry routes for certain skilled migrant workers.

Although recruitment of staff remains the responsibility of individual NHS Boards, the Scottish Government has been able to help their recruitment challenges. For example, following a review of the Shortage Occupation List (UK and Scotland only), the Scottish Government worked with NHS Boards to gather evidence of shortages across medical specialties and submitted this to the Migration Advisory Committee (MAC) in December 2014. This evidence successfully met the strict criterion set down by the MAC which recommended the UK Government increase the number of medical specialist roles on the Scotland only Shortage Occupation List. The UK Government accepted the MAC recommendations and a revised list was published in April 2015¹³⁹. NHS Boards seeking to recruit international specialists from this list should find it quicker and less expensive to do so.

When recruiting internationally, NHS Boards must adhere to The Code of Practice for the International Recruitment of Healthcare Professionals in Scotland¹⁴⁰. The code highlights the ethics that should be considered in international medical recruitment, including seeking the agreement of the government of the country being targeted. In May 2015, the Scottish Government worked with NHSScotland and the Government of the Netherlands through the European Recruitment Services (EURES), to promote NHSScotland as a good place to work and Scotland as an attractive place to live. As a direct result of this work, over 50 firm expressions of interest in working in NHSScotland were received and shared with NHS Boards. The Scottish Government, working with NHSScotland, will continue to build on this work as it continues to support NHS Boards to recruit the staff they need.

Developing the Young Workforce

NHS Boards continue to implement the Developing the Young Workforce: Scotland’s Youth Employment Strategy¹⁴¹ and in particular the commitment to reduce youth unemployment by 40 per cent by 2021. Over the reporting year 2015/16, 14 NHS Boards provided new Modern Apprentice opportunities. A total of 144 Modern Apprentices utilising differing frameworks were appointed and contribute to the ministerial target of 500. Combined with 96 last year, there is evidence that a total of 240 MAs have been appointed by NHS Boards since the introduction of this target. This is 72 per cent of the target for all NHS Boards to recruit from August 2014 – March 2016 and 48 per cent of the overall target. Over the reporting year 2015/16, NHS Boards have delivered 4,187 new employment opportunities for young people (aged 16 to 24). This figure includes Modern Apprentice opportunities. This is an increase of 37 per cent over the same period last year when 3,050 were appointed. Evidence suggests that a total of 10,699 employability opportunities for young people have been offered by NHS Boards over the past three years¹⁴².

Working to Deliver Integrated Services

As the integration of health and social care progresses, consideration continues to be given to the associated workforce aspects. The Human Resources Working Group on Integration¹⁴³ continues its work to address strategic-level workforce issues and to identify issues which may require national co-ordination. In addition, a further two events in the Strengthening the Links series were held over the year. These events successfully brought together those with an interest in workforce issues to share learning and experience of integration both within and across sectors and to facilitate peer support and networking around common workforce challenges and opportunities.

Appendix

Territorial NHS Boards

NHS Ayrshire & Arran | www.nhsaaa.net
NHS Borders | www.nhsborders.org.uk
NHS Dumfries & Galloway | www.nhsdg.scot.nhs.uk
NHS Fife | www.nhsfife.scot.nhs.uk
NHS Forth Valley | www.nhsforthvalley.com
NHS Grampian | www.nhsgrampian.org
NHS Greater Glasgow and Clyde | www.nhsggc.org.uk
NHS Highland | www.nhshighland.scot.nhs.uk
NHS Lanarkshire | www.nhslanarkshire.co.uk
NHS Lothian | www.nhslothian.scot.nhs.uk
NHS Orkney | www.ohb.scot.nhs.uk
NHS Shetland | www.shb.scot.nhs.uk
NHS Tayside | www.nhstayside.scot.nhs.uk
NHS Western Isles | www.wihb.scot.nhs.uk

Special NHS Boards

NHS Education for Scotland (NES) | www.nes.scot.nhs.uk
NHS Health Scotland | www.healthscotland.com
NHS National Services Scotland (NSS) | www.nhsnss.org
NHS 24 | www.nhs24.com
Scottish Ambulance Service | www.scottishambulance.com
The State Hospital Board | www.tsh.scot.nhs.uk
Golden Jubilee Foundation Board | www.nhsgoldenjubilee.co.uk

Healthcare Improvement Scotland

Healthcare Improvement Scotland
www.healthcareimprovementscotland.org

Footnotes

1. Healthcare Quality Strategy for Scotland, Scottish Government, May 2010. Access at: www.gov.scot/Resource/Doc/311667/0098354.pdf

2. Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie, Public Services Commission, 29 June 2011. Access at: www.gov.scot/Publications/2011/06/27154527/0

3. Creating a Healthier Scotland, Scottish Government, March 2016. Access at: www.gov.scot/Resource/0049/00497965.pdf

4. A National Clinical Strategy for Scotland, The Scottish Government, February 2016. Access at: www.gov.scot/Publications/2016/02/8699

5. Chief Medical Officer’s Annual Report 2015: Realistic Medicine, The Scottish Government, January 2016. Access at: www.gov.scot/Publications/2016/01/3745

6. Further information on the Technology Enabled Care Programme can be found at: www.jitscotland.org.uk/action-areas/telehealth-and-telecare/technology-enabled-care-programme

7. Source: ISD Scotland: Emergency Department Activity & Waiting Times. Access at: www.isdscotland.org/Health-Topics/Emergency-Care/Publications/index.asp

8. England: NHS England, A&E Attendances and Emergency Admissions Monthly. Access at:

www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/statistical-work-areasae-waiting-times-and-activityae-attendances-and-emergency-admissions-2016-17, Northern Ireland: NHS Northern Ireland, Statistics on Emergency Care Waiting Times by Department and Month. Access at: www.health-ni.gov.uk/articles/emergency-care-waiting-times, Wales: Time Spent in NHS Wales Accident and Emergency Departments: Monthly Management Information. Access at: www.infoandstats.wales.nhs.uk/page.cfm?org

9. ISD Scotland: Delayed Discharges in NHSScotland. Access at: www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care

10. ISD Scotland: Cancer Waiting Times. Access at: www.isdscotland.org/Health-Topics/Waiting-Times/Cancer

11. Beating Cancer: Ambition and Action, The Scottish Government, March 2016. Access at: www.gov.scot/Publications/2016/03/9784

12. ISD Scotland: Diagnostics Waiting Times. Access at: www.isdscotland.org/Health-Topics/Waiting-Times/Diagnostics

13. Source: ISD Scotland: Inpatient, Day Case & Outpatient stage of treatment waiting times. Access at: www.isdscotland.org/Health-Topics/Waiting-Times/Inpatient-Day-Cases-and-Outpatients

14. Source: ISD Scotland: Child and Adolescent Mental Health Waiting times. Access at: www.isdscotland.org/Health-Topics/Waiting-Times/Child-and-Adolescent-Mental-Health

15. Health and Care Experience Survey 2015/16, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey/HACE2015-16

16. Scottish Inpatient Patient Experience Survey 2016, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/InpatientSurvey

17. Health Protection Scotland: Quarterly Epidemiological Commentaries. Access at: www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx

18. Scotland Performs. Access at: www.gov.scot/About/Performance/scotPerforms/NHSScotlandperformance

19. Chief Medical Officer’s Annual Report 2015: Realistic Medicine, The Scottish Government, January 2016. Access at: www.gov.scot/Publications/2016/01/3745

20. Further information on the House of Care approach to collaborative care and support-planning can be found at: www.gov.scot/Publications/2016/02/8618/7

21. Living it Up is a health, wellbeing and self-management website for the over 50s, run by NHS 24. Access at: www.livingitup.scot

22. Making it Easy: a Health Literacy Action Plan for Scotland, The Scottish Government, May 2014. Access at: www.gov.scot/Publications/2014/06/9850

23. The Enabling State: From Rhetoric to Reality, Carnegie UK Trust, November 2013. Access at: http://www.carnegieuktrust.org.uk/publications/the-enabling-statefrom-rhetoric-to-reality/

24. Further information can be found at:

www.selfdirectedsupportscotland.org.uk

25. Social Care Services, Scotland, 2015, The Scottish Government, November 2015. Access at: www.gov.scot/Topics/Statistics/Browse/Health/Data/HomeCare

26. You can read the full progress report at www.inspiringscotland.org.uk/our-funds/self-directed-support/project-progress-and-sds-resources

27. Further information on ClickGo can be found at:
www.clickgo2.com

28. The full progress report can be accessed at:
www.inspiringscotland.org.uk/our-funds/self-directed-support/project-progress-and-sds-resources

29. Further information on Self Directed Support Financial Guidance can be found at: www.selfdirectedsupportscotland.org.uk/whats-new/25-cipfa-self-directed-support-guidance-launched

30. Strategic Framework for Action on Palliative and End of Life Care, The Scottish Government, December 2015. Access at:
www.gov.scot/Publications/2015/12/4053

31. Further information and the Our Voice website can be found at: www.ourvoice.scot

32. Further information on the Healthcare Improvement Scotland Person-Centred Health and Care Programme can be found at: www.healthcareimprovementscotland.org/our_work/person-centred_care/person-centred_collaborative.aspx

33. Experience Based Co-design Methodology, The Kings Fund. Access at: www.kingsfund.org.uk/projects/ebcd/experience-based-co-design-description

34. Listening and Learning: how feedback, comments, concerns and complaints can improve NHS services in Scotland, The Scottish Health Council, April 2014. Access at:

www.scottishhealthcouncil.org/publications/research/listening_and_learning.aspx

35. Further information on The Patient Rights (Scotland) Act 2011 can be found at: www.legislation.gov.uk/asp/2011/5/contents

36. ISD Scotland: NHS Complaints Statistics. Access at:

www.isdscotland.org/Health-Topics/Quality-Indicators/NHS-Complaints-Statistics/

37. The Patient Opinion website can be accessed at:
www.patientopinion.org.uk

38. Patient Opinion Annual Review. Access at: www.patientopinion.org.uk/resources/patient-opinion-annual-summary-2015-2016.pdf

39. Scottish Inpatient Patient Experience Survey 2016, The Scottish Government, August 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/InpatientSurvey/Inpatient2016

40. Health and Care Experience Survey 2015/16, The Scottish Government, May 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey

41. Cancer Patient Experience Survey, The Scottish Government, October 2015. Access at: www.gov.scot/Topics/Statistics/Browse/Health/cancersurvey

42. Having a baby in Scotland 2015: listening to mothers, Maternity Care Experience Survey, December 2015. Access at:
www.gov.scot/Topics/Statistics/Browse/Health/maternitysurvey

43. Source: Management Data, NHS Education for Scotland

44. Focus on Dementia is a partnership improvement programme which brings together and maximises the skills, expertise and knowledge of improvement professionals, policy practitioners and the third sector. Further information can be found at: www.qihub.scot.nhs.uk/quality-and-efficiency/focus-on-dementia.aspx

45. The Scottish Strategy for Autism. Access at:
www.autismstrategyscotland.org.uk

46. Scottish Strategy for Autism. Access at:
www.autismstrategyscotland.org.uk/news/outcomes-framework-aligns-strategy-with-national-priorities.html

47. The Keys to Life – Improving Quality of Life for People with Learning Disabilities, The Scottish Government, June 2013, www.gov.scot/Publications/2013/06/1123

48. The Keys to Life Implementation Framework and Priorities, 2015-17. Access at: www.keystolife.info/updates/the-keys-to-life-implementation-framework-and-priorities-2015-17

49. Survivor Scotland Strategic Outcomes and Priorities 2015 – 2017, The Scottish Government, October 2015. Access at: www.gov.scot/Publications/2015/10/3487

50. Further information on the National Health and Wellbeing Outcomes can be found at: www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Outcomes

51. The Breakthrough Series: IHI‘s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. Access at: www.IHI.org

52. The Improvement Hub (iHub) is hosted by Healthcare Improvement Scotland and can be found at: www.ihub.scot

53. Quarterly Hospital Standardised Mortality Ratios (HSMR), ISD Scotland. Access at: www.isdscotland.org/Health-Topics/Quality-Indicators/HSMR

54. Scottish Patient Safety Programme Acute Adult: End of phase report August 2016, Healthcare Improvement Scotland. Access at: www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Acute%20Adult%20Care/201609%20SPSP%20AA%20EOPR%201.1.pdf

55. Scottish Patient Safety Programme Acute Adult: End of phase report August 2016, Healthcare Improvement Scotland. Access at: www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Acute%20Adult%20Care/201609%20SPSP%20AA%20EOPR%201.1.pdf

56. Health Protection Scotland: Quarterly Epidemiological Commentaries. Access at: www.hps.scot.nhs.uk/haiic/sshaip/quarterlyepidemiologicalcommentaries.aspx

57. Healthcare Associated Infection (HAI) standards. Access at: www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_policies_and_procedures/hai_standards_2015.aspx

58. Further information on HEI Inspections can be found at:

www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/nhs_hospitals_and_services/hei_inspections/all_hei_reports.aspx

59. UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018, Department of Health, September 2013. Access at:

www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018

60. The Scottish Patient Safety Mental Health Programme. Access at: www.scottishpatientsafetyprogramme.scot.nhs.uk/programmes/mental-health

61. SPSP Primary Care: End of Phase Report August 2016, Healthcare Improvement Scotland, August 2016. Access at: www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Primary%20Care/SPSP%20PC%20EOPR.PDF

62. Learning from adverse events through reporting and review: A national framework for Scotland: Second edition, Healthcare Improvement Scotland, April 2015. Access at:
www.healthcareimprovementscotland.org/our_work/governance_and_assurance/management_of_adverse_events/national_framework.aspx

63. Clinical and Care Governance Framework, The Scottish Government, October 2015. Access at: www.gov.scot/Resource/0049/00491266.pdf

64. A National Clinical Strategy for Scotland, The Scottish Government, February 2016. Access at: www.gov.scot/Publications/2016/02/8699

65. Further information on the Six Essential Actions can be found at: www.gov.scot/Topics/Health/Quality-Improvement-Performance/UnscheduledCare/6-Essential-Actions-To-Improving-Unscheduled-Care

66. ISD Scotland: Delayed Discharges. Access at: www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges

67. A National Clinical Strategy for Scotland, The Scottish Government, February 2016. Access at: www.gov.scot/Resource/0049/00494144.pdf

68. Chief Medical Officer’s Annual Report 2014/15: Realistic Medicine, The Scottish Government, January 2016. Access at: www.gov.scot/Resource/0049/00492520.pdf

69. ISD Scotland: Diagnostics Waiting Times. Access at:

www.isdscotland.org/Health-Topics/Waiting-Times/Diagnostics

70. ISD Scotland: Inpatient, Day Case & Outpatient stage of treatment waiting times. Access at: www.isdscotland.org/Health-Topics/Waiting-Times/Inpatient-Day-Cases-and-Outpatients

71. Beating Cancer: Ambition and Action, The Scottish Government, March 2016. Access at: www.gov.scot/Publications/2016/03/9784

72. Further information on the Innovative Healthcare Delivery Programme can be found at: www.farrinstitute.org/partnerships/ihdp

73. Further information on the Detect Cancer Early Programme can be found at: www.gov.scot/Topics/Health/Services/Cancer/Detect-Cancer-Early

74. ISD Scotland: Detect Cancer Early staging data year 4 July 2016

75. The wee c website can be accessed at: www.theweec.org

76. Scottish Referral Guidelines for Suspected Cancer, Healthcare Improvement Scotland, August 2014. Access at:
www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/programme_resources/scottish_referral_guidelines.aspx

77. ISD Scotland: Cancer Waiting Times Access at:

www.isdscotland.org/Health-Topics/Waiting-Times/Cancer

78. ISD Scotland: Hip Fracture Audit – www.isdscotland.org/Health-Topics/Scottish-Healthcare-Audits/Publications/index.asp?#1698

79. Enhanced Recovery Pathway – Optimising patient recovery after joint replacement. Access at: www.qihub.scot.nhs.uk/quality-and-efficiency/msk-and-orthopaedics-quality-drive/enhanced-recovery.aspx

80. ISD Scotland: The Musculoskeletal Audit. Access at: www.msk.scot.nhs.uk

81. Pulling together: transforming urgent care for the people of Scotland, The Report of the Independent Review of Primary Care Out of Hours Services. The Scottish Government, December 2015. Access at: www.gov.scot/Resource/0048/00489938.pdf

82. Glaucoma referral and safe discharge, The Scottish Intercollegiate Guidelines Network (SIGN). Access at: www.sign.ac.uk/guidelines/fulltext/144/index.html

83. Management data, Pharmacy and Medicines Division, The Scottish Government

84. Out-of-Hospital Cardiac Arrest: A Strategy for Scotland, The Scottish Government, March 2015. Access at: www.gov.scot/Publications/2015/03/7484

85. Further information on the Save a Life for Scotland campaign can be found at: www.savealife.scot

86. Save a Life for Scotland – External Report, SALFS Launch, Friday 16th October 2015. Access at: www.savealife.scot/resources/The%20Launch%20Report%2016th%20October%202015.pdf

87. Mental Health in Scotland – a 10 year vision, The Scottish Government, July 2016. Access at: www.gov.scot/Publications/2016/07/7151

88. Child and Adolescent Mental Health Services Waiting Times in NHSScotland and Psychological Therapies Waiting Times in NHSScotland. Both published reports published quarterly by ISD Scotland are available online at: www.isdscotland.org/Publications

89. ISD Scotland: Psychological Therapies Waiting Times. Access at: www.isdscotland.org/Publications

90. ISD Scotland: Child and Adolescent Mental Health Services Source: ISD Scotland Waiting Times in NHSScotland. Access at: www.isdscotland.org/Publications

91. Further information on the Suicide Prevention Strategy can be found at: www.gov.scot/Topics/Health/Services/Mental-Health/Suicide-Self-Harm/SPS-IMG/SPSCommitments

92. Mental Health Strategy for Scotland: 2012-2015, The Scottish Government, August 2012. Access at: www.gov.scot/Publications/2012/08/9714

93. Mental Health & Learning Disability Inpatient Bed Census, 2014, The Scottish Government, October 2014. Access at:

www.gov.scot/Publications/2015/06/7555/4

94. Inpatient Census, 2016 – Part 1: Mental Health & Learning Disability Inpatient Bed Census – Part 2: Out of Scotland NHS Placements, The Scottish Government, September 2016. Access at: www.gov.scot/Publications/2016/09/9885

95. The discussion framework can be found at: www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4062767/Reducing%20suicide%20risk%20-%20discussion%20framework%20v0.18%20final.pdf

96. National Records of Scotland: 2015 Births, Deaths and Other Vital Events – Preliminary Annual Figures. Access at:
www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/general-publications/births-deaths-and-other-vital-events-preliminary-annual-figures/2015

97. Universal Health Visiting Pathway in Scotland – Pre Birth to Pre School, The Scottish Government, October 2015

98. Further information on the Early Years Collaborative can be found at: www.gov.scot/Topics/People/Young-People/early-years/early-years-collaborative. The Early Years Collaborative and the Raising Attainment for All Programme are joining up to become the Children and Young People Improvement Collaborative to deliver quality improvement throughout a child’s journey.

99. Further information on Getting It Right For Every Child can be found at: www.gov.scot/Topics/People/Young-People/gettingitright

100. Further information on the Maternity and Children Quality Improvement Collaborative can be found at:
www.scottishpatientsafetyprogramme.scot.nhs.uk/programmes/mcqic

101. ISD Scotland: IVF Waiting Times in Scotland. Access at:

www.isdscotland.org/Health-Topics/Waiting-Times/IVF-Waiting-Times/Publications/2016-05-31

102. Further information on the Scottish Genomes Partnership can be found at: www.scottishgenomespartnership.org

103. The ‘My Diabetes My Way’ Interactive Website can be found at: www.mydiabetesmyway.scot.nhs.uk

104. Management Information provided by the ‘My Diabetes My Way’ Project Team at the University of Dundee. The My Diabetes My Way website can be found at: www.mydiabetesmyway.scot.nhs.uk

105. NHSScotland Information Security Policy Framework, July 2015. Access at: www.informationgovernance.scot.nhs.uk/wp-content/uploads/2016/03/IS-Policy-Framework.pdf

106. Further information on the Scottish Wide Area Network can be found at: www.scottishwan.com

107. Context-sensitive decision support is decision support that is adaptable to different contexts and evolving technical and work environments.

108. Information on clinical decision support (CDS) for diabetes in NHS Tayside and NHS Lothian is available on the eHealth website at: www.ehealth.nhs.scot/case-studies

109. Healthcare Science National Delivery Plan for Healthcare Science Professionals in Scotland 2014-2017, The Scottish Government, June 2014. Access at: www.gov.scot/Resource/0045/00453441.pdf

110. Creating Places – A policy statement on architecture and place for Scotland, The Scottish Government, June 2013. Access at: www.gov.scot/Publications/2013/06/9811

111. Further information on Good Places, Better Health can be found at: www.gov.scot/Topics/Health/Healthy-Living/Good-Places-Better-Health

112. National Records of Scotland: Age-standardised Death Rates Calculated Using the European Standard Population. Access at: www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/age-standardised-death-rates-calculated-using-the-esp

113. Changing Scotland’s Relationship with Alcohol: A Framework for Action, The Scottish Government, March 2009. Access at:
www.gov.scot/Publications/2009/03/04144703/0

114. Alcohol Brief Interventions 2015/16, ISD Scotland, June 2015. Access at: www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2016-06-14/2016-06-14-ABI2015-16-Summary.pdf

115. ScotPHO Smoking Ready Reckoner – 2011 Edition, Scottish Public Health Observatory (ScotPHO), January 2012. Access at: www.scotpho.org.uk/downloads/scotphoreports/scotpho120626_smokingreadyreckoner.pdf

116. Tobacco Control Strategy – Creating a Tobacco-free Generation, The Scottish Government, March 2013. Access at:
www.gov.scot/Publications/2013/03/3766

117. Scottish Health Survey 2015, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

118. ISD Scotland: NHS Smoking Cessation Service Statistics (Scotland) 2015-16. Access at: www.isdscotland.org/Health-Topics/Public-Health/Publications/index.asp#1752

119. Semple S, Latif N (2014). How Long Does Secondhand Smoke Remain in Household Air: Analysis of PM2.5 Data From Smokers’ Homes. Nicotine Tob Res. 16(10):1365-70. Access at: www.ncbi.nlm.nih.gov/pubmed/24904023

120. Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight, The Scottish Government, February 2010. Access at: www.gov.scot/Publications/2010/02/17140721/0

121. Scottish Health Survey, The Scottish Government, September 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

122. Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight, The Scottish Government, February 2010. Access at: www.gov.scot/Publications/2010/02/17140721/0

123. The Lancet, Volume 383, No. 9924, p1211-1221, 5 April 2014 A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Access at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62420-4/abstract

124. Source: www.gla.ac.uk/myglasgow/news/headline_485287_en.html

125. Pregnancy and Parenthood in Young People Strategy, The Scottish Government, March 2016. Access at: www.gov.scot/Publications/2016/03/5858

126. Further information on the Health Living Award Plus can be found at: www.healthylivingaward.co.uk/caterers/the-plus-award

127. Criteria for the Healthcare Retail Standard, The Scottish Government, July 2016. Access at: www.gov.scot/Publications/2016/07/2024

128. Latest National Dental Inspection Programme (NDIP) results can be found at: www.ndip.scottishdental.org/ndip-reports

129. Scotland’s Oral Health Plan: A Scottish Government Consultation Exercise on the Future of Oral Health, The Scottish Government, September 2016. Access at: www.gov.scot/Publications/2016/09/7679

130. Health Protection Scotland: Provisional vaccine uptake for the new meningococcal B (MenB) immunisation programme in Scotland, March 2016. Access at: www.hps.scot.nhs.uk/immvax/wrdetail.aspx?id=67129&wrtype=9

131. Source: Glasgow Royal Infirmary

132. Everyone Matters: 2020 Workforce Vision. Access at:
www.workforcevision.scot.nhs.uk

133. Reported at: www.news.scotland.gov.uk/News/Report-recognises-quality-of-Scottish-healthcare-228d.aspx. The OECD Quality Review is available at: www.oecd.org/unitedkingdom/oecd-reviews-of-health-care-quality-united-kingdom-2016-9789264239487-en.htm

134. ISD Scotland Workforce Statistics. Access at: www.isdscotland.org/Health-Topics/Workforce

135. Further information on the Sustainability and Seven Day Services Programme can be found at: www.gov.scot/Topics/Health/NHS-Workforce/Policy/SustainSevenDayServ

136. Sustainability and Seven Day Services Taskforce Interim Report, The Scottish Government, March 2015. Access at:
www.gov.scot/Publications/2015/03/7764

137. Programme for Government 2015-16, The Scottish Government, September 2015. Access at: www.gov.scot/Publications/2015/09/7685

138. NHS Education Scotland: Return to Practice management information based on numbers enrolled and receiving funding

139. Tier 2 Shortage Occupation List: Government-approved version valid from 6 April 2015. Access at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/423800/shortage_occupation_list_april_2015.pdf

140. The Code of Practice for the International Recruitment of Healthcare Professionals in Scotland, The Scottish Executive, 2006. Access at: www.gov.scot/Resource/0041/00412480.pdf

141. Developing the Young Workforce: Scotland’s Youth Employment Strategy, The Scottish Government, December 2014. Access at: www.gov.scot/Publications/2014/12/7750

142. Source: Management data collated on behalf of NHSScotland by Employee Experience Team, Health Workforce and Strategic Change Directorate, Scottish Government

143. Further information on the Human Resources Working Group on Integration can be found at: www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Implementation/working_Groups/HRWG