NHSScotland Chief Executive’s Annual Report 2016/2017

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Foreword

I am very pleased to present my fourth annual report as NHSScotland's Chief Executive.

Our vision is for a Scotland where everyone lives longer, healthier lives at home or in a homely setting. This guides our priorities for a health and social care system that is integrated, focused on anticipation and prevention, and in which care is provided in the right setting.

The achievements in this report are a tribute to the outstanding commitment of all staff working across NHSScotland and our partners to deliver the best health and social care outcomes for the people of Scotland. Their dedication and hard work are what allow us to make such significant progress and I greatly value and appreciate all they do.

In my recent Annual Reports, I have focused on how NHSScotland has been driving greater improvements in the care provided for people and how it is addressing the challenges which are now well-understood. As a whole, people are living longer and increasingly need services that can support multiple health conditions - and parts of Scotland continue to experience significant health inequalities.

Against this background, NHSScotland and its partners across the public and voluntary sectors continue to make progress. Our focus on quality continues to be at the heart of everything we do. The standards we have for the NHS in Scotland are world-class and this should be the backdrop when we consider how NHSScotland is performing.

The internationally-acclaimed Scottish Patient Safety Programme continues to drive improvements across a number of key areas of healthcare. We have seen reductions in Hospital Standardised Mortality Ratios within acute care - meaning that our approach to safety has significantly reduced deaths, and we have made and sustained significant improvements in reducing Healthcare Associated Infections.

We have seen positive trends in people's experience of care, and 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 – 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. In other surveys, 92 per cent of women rated the overall care they received during pregnancy and birth as good or excellent and 94 per cent of patients rated their cancer care positively.

Scotland continues to deliver very good A&E performance, and we are seeing encouraging signs of improvement on delayed discharge and emergency bed day use.

But we are far from complacent. I recognise the challenges we face in meeting our standards for outpatient waits, mental health treatment and elective procedures. Pressures on recruitment continue in a number of specialisms, and we still have much to do to tackle the inequalities that exist across Scotland.

We are taking decisive action to reduce smoking rates and encourage people to live healthier, more active lives, and in a very recent development, the Judgment from the UK Supreme Court clears the way for minimum pricing for alcohol. This is a landmark ruling that allows a bold move which will save lives and protect public health across Scotland.

There is also no dispute that transformational change is needed in the way that we deliver health and social care in Scotland.

The publication of the Health and Social Care Delivery Plan in December 2016 signalled our determination to put in place a framework for transformational change that brings together our priorities for driving the further improvements we seek. It is important now that we work collectively across the whole of our health and social care system to deliver these priorities, ensuring 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.

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

I am grateful for the ongoing dedication of our committed NHSScotland workforce and colleagues in our partner organisations, and I hope that you enjoy finding out about their collective achievements.

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

Chapter 1
Transforming Care and Delivering Improved Outcomes

'At the heart of the
framework for improvement and change is the vision for a Scotland where everyone can live longer, healthier lives at home or in a homely setting'

Recent NHSScotland Chief Executive's Annual Reports have focused on how NHSScotland has been driving greater improvements and addressing the numerous challenges of developing a health and social care system that is fit for 21st century Scotland. The challenges have been well rehearsed. As a whole, people are living longer and increasingly need services that can support multiple health conditions, while parts of Scotland continue to experience health inequalities. While all public services are affected by financial challenges, these are being particularly felt in health and social care due to the increasing demand for services.

The key to meeting these challenges is transforming the care people receive from the NHS and delivering improved outcomes.

The Ambition

NHSScotland and its partners across Scotland have been responding to the challenges faced through innovative, sustained approaches to reform, many of which have gained recognition outside Scotland. In its recent report Learning from Scotland's NHS, the Nuffield Trust highlighted the Scottish approach to quality improvement – exemplified in the Scottish Patient Safety Programme, and set out in the Healthcare Quality Strategy for Scotland¹ – as one of the nation's outstanding strengths:

'In our judgement, the Scottish health system, with the high levels of trust leaders show in their colleagues and an emphasis on skills and autonomous testing at the front line, generally appears to be more flexible than the English and to some extent Welsh 'control' systems… There is a genuine orientation towards delivering better care to patients, and a willingness to test this against clear indicators'².

Our approach to maintaining the level and commitment to improvement has not altered. Indeed, what has changed over the last year has not been the scale of the challenges Scotland's health and social care system is facing, the actions needed to meet those challenges over the coming years, or the overarching vision for the health and social care of Scotland. What is new is the determination to put in place a framework that brings together the priority actions to drive improvement and adaptation in health and care, and sustains that change through the present Parliament and beyond.

Our Approach

At the heart of the framework for improvement and change is the vision for a Scotland where everyone can live longer, healthier lives at home or in a homely setting, and we have a health and social care system that:

is integrated;

focuses on prevention, anticipation and supported self-management;

will make day-case treatment the norm, where hospital treatment is required and cannot be provided in a community setting;

focuses on care being provided to the highest standards of quality and safety, whatever the setting, with the person at the centre of all decisions; and

ensures people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

To realise this vision, the Scottish Government published the Health and Social Care Delivery Plan³ in December 2016. The Delivery Plan provides the framework that brings together key change programmes and sets out the priority actions to be taken forward in this Parliament under the following 'pillars' of activity:

Health and social care integration;

The National Clinical Strategy;

Public health improvement; and

NHS Board reform.

As a whole, these pillars aim to have the greatest impact on delivery by focusing on three areas based on the 'triple aim':

Better care: we will improve the quality of care for people by targeting investment at improving services, which will be organised and delivered to provide the best, most effective support for all;

Better health: we will improve everyone's health and wellbeing by promoting and supporting healthier lives from the earliest years, reducing health inequalities and championing an approach based on anticipation, prevention and self-management; and

Better value: we will increase the value from and financial sustainability of care, by making the most effective use of the resources available to us, and the most efficient and consistent delivery of services, ensuring that resource is spent where it achieves the most, focusing on prevention and early intervention.

These priorities fit with what we know matters to people through the Creating a Healthier Scotland national conversation⁴, particularly in supporting: people to lead healthier lives; better connected communities; person-centred care; more seamless journeys of care; a focus on social care and caring; and dealing with the pressures on the system.

Better Care

We need to change our approach to medicine and how and where the services that support people's health are delivered. Services should not be 'doing things' to people but working with them on all aspects of their care and support. It is not always a question of 'more' medicine, but making sure that support fits with, and is informed by, individual needs and desires, so people can become equal partners with their clinicians, working with them to arrive at the right decisions about their care quickly. That requires changes to how medical professionals work with people – especially through Realistic Medicine⁵ – and how that support can be provided more quickly within primary/community and secondary/acute services.

Realistic Medicine

Scotland's Chief Medical Officer (CMO) has continued to pursue a public debate over how the principles of Realistic Medicine can drive improvement in how professionals can better support members of the public. Through the CMO's annual reports and a programme of widespread engagement, Realistic Medicine has resonated across numerous health and social care professions. It has been critical in building a shared understanding of what it means across different health and social care contexts, and throughout 2016, Chief Professional Officers in health and social care discussed what Realistic Medicine meant in their professions, and how professionals and services could work together to achieve its aims.

Following publication of the first CMO annual report focusing on Realistic Medicine, people felt energised by the potential inherent in Realistic Medicine through greater shared decision-making and stepping up our efforts to reduce harm, waste and variation. A number of national initiatives are supporting this by creating the conditions for Realistic Medicine to flourish:

The Scottish Health Council and The Health and Social Care Alliance Scotland (the ALLIANCE) have been exploring with people what Realistic Medicine means to them during 2017, and how best it can be co-produced;

The national health literacy plan Making it Easy:⁶ a Health Literacy Action Plan for Scotland will support Realistic Medicine by helping everyone in Scotland to have the confidence, knowledge, understanding and skills to live well with any condition they have;

The consent process for people we care for and support in Scotland will be reviewed by the Scottish Government, General Medical Council and the Academy of Medical Royal Colleges to update advice to clinicians following the Montgomery Supreme Court judgement⁷;

The Professionalism and Excellence in Medicine Action Plan⁸ will be refreshed aligning and prioritising high impact actions that will support clinicians with Realistic Medicine;

A Scottish atlas of variation will be published and a collaborative training programme for clinicians initiated to create better understanding and aid identification of unwarranted variation and promote high-value care;

A single national formulary will be developed to help achieve more equitable, greater value-based care so that the potential population benefit from medicines use can be maximised; and

The principles of Realistic Medicine will be incorporated as a core component of lifelong learning in medical education, through undergraduate and specialty training programmes as well as continuing professional development.

Primary and Community Care

Our vision of health and social care envisages more care being provided locally to avoid the need to go into hospital where a better alternative can be provided in the community. People should benefit from community care with a wider range of available support, and practices would typically consist of complementary teams of professionals, bringing together clusters of health support and expertise. Communities would have access to quicker and joined-up treatment – this might be the GP, but supported by a team including highly-trained nurses, physiotherapists, pharmacists, mental health workers and social care workers. Through this multi-disciplinary approach, local practices will be able to provide more information and better advice to people locally without the need to attend hospitals to get specialist consultancy.

To achieve this, community and hospital-based care needs to be integrated and rebalanced to ensure that local health services are more responsive and supportive to the needs of people, not least those with chronic conditions who would be better supported in primary and community care. Spending on primary care and GP services will increase by £500 million by the end of the current Parliament so that it represents 11 per cent of the frontline budget. Moreover, action has been taken to:

Support people, families and their carers to understand fully and manage their health and wellbeing, with a sharper focus on prevention, rehabilitation and independence;

Expand the multi-disciplinary community care team with extended roles for a range of professionals and a clearer leadership role for GPs;

Design and implement changes to the Scottish General Medical Services (GMS) contractual arrangements for 2017 (the terms and conditions of work which apply to GPs in Scotland) in agreement with the British Medical Association, with the aim of focusing the contract on person-centred, sustainable healthcare;

Develop and roll out new models of care that are person- and relationship-centred and not focused on conditions alone through investment from the Primary Care Transformation Fund;

Enable those waiting for routine check-up or test results to be seen closer to home by a team of community healthcare professionals;

Ensure the problems of multiple longer-term conditions are addressed by social rather than medical responses, where that support is more appropriate; and

Reduce the risk of admission to hospital through evidence-based interventions, particularly for older people and those with longer-term conditions.

At the same time, we need to address the current workload pressures and recruitment challenges facing many GP practices and cannot simply result in a crude redistribution of pressures between different parts of the health service. Through the Health and Social Care Delivery Plan, this will include:

Continuing the investment in the expansion of the primary care workforce so that, by 2022, there will be more GPs, every GP practice will have access to a pharmacist with advanced clinical skills and 1,000 new paramedics will be in post;

Increasing health visitor numbers so that every family will be offered a minimum of 11 home visits, including three child health reviews;

Refreshing the role of district nurses;

Training an additional 500 advanced nurse practitioners by the end of the Parliament; and

Creating an additional 1,000 training places for nurses and midwives.

Secondary and Acute Care

People should only be in hospital when they cannot be treated in the community and should not stay in hospital any longer than necessary for their care. This will mean reducing inappropriate referral, attendance and admission to hospital; better signposting to ensure the right treatment in a timely fashion; and reducing unnecessary delay in people leaving hospital. All partners will need to work together to reduce the levels of delayed discharges and ensure services are in place to facilitate early discharge and avoid preventable admissions in the first place.

At the same time, hospitals need to make more-effective use of resources. There is increasing evidence that better outcomes are achieved for people when complex operations are undertaken by specialist teams and some services are planned and delivered on a population basis. This might mean some services currently delivered at local level would produce better outcomes for people if delivered on a wider basis. This kind of service change needs to be accompanied by investment in new, dedicated facilities to ensure that the capacity for high-quality, sustainable services can be delivered at the appropriate level.

To take forward the work begun by the National Clinical Strategy for Scotland⁹, the Health and Social Care Delivery Plan sets out a number of areas where this will be pursued:

Addressing unscheduled care, particularly through national roll out of the Six Essential Actions¹⁰ which will improve the time-of-day of discharge, increase weekend emergency discharges and establish a more effective use of electronic information in hospitals;

Enhancing scheduled care, through the roll out of the Patient Flow Programme (reducing cancellations and private care spend), £200 million investment in elective care capacity and the expansion of the Golden Jubilee Hospital, and investment of £100 million in cancer care; and

Improving primary care, by reducing unnecessary attendances and referrals to outpatient services through the Modern Outpatient Programme.

Shifting the Balance of Care

Good quality community care should mean less unscheduled care in hospitals, and people staying in hospitals only for as long as they need specific treatment. Integration of health and social care has been introduced to change the way key services are delivered, with greater emphasis on supporting people in their own homes and communities and less inappropriate use of hospitals and care homes. As the population ages, the demand for care and support grows and the nature, complexity and acuteness of that demand grows as well. These changes mean that delivering even the current levels of service in the same way as has been done in the past is not sustainable. The integration of health and social care is one of the most significant reforms since the establishment of the NHS. It is about ensuring that those who use services get the right care and support whatever their needs, at any point in their care journey.

Health and Social Care Partnerships (sometimes referred to as Integration Authorities) – which bring together NHS Boards, Local Authorities and others to ensure the delivery of efficient, integrated services – have real power to drive change. They are managing more than £8 billion of resources that NHS Boards and Local Authorities previously managed separately, representing more than 50 per cent of territorial NHS Board expenditure, and more than 80 per cent of Local Authority social care expenditure. They are being provided with a range of recurring funding to support integration, including an Integrated Care Fund of £100 million to support delivery of improved outcomes from health and social care integration, and £30 million a year to support Health and Social Care Partnerships to reduce delayed discharges, including the development of a range of community-based services like intermediate care beds, re-ablement at home and other preventative services.

Better Health

To improve the health of the people of Scotland, the traditional 'fix and treat' approach to our health and social care needs to change to one based on anticipation, prevention and self-management. The key causes of preventable ill-health should be tackled at an early stage, and there should be a more comprehensive, cross-sector approach to ensuring healthy behaviours are the norm, starting from the earliest years and lasting throughout people's lives. This can only be achieved by all public services working together systematically to be sensitive to individual health and social care needs, with a clear focus on early intervention. They need to be designed around how best to support people, families and their communities and promote and maintain health and healthy living. You can read more about what is being achieved in Chapter 3.

Better Value

NHS Boards need to work together differently to ensure their services deliver better outcomes for people and better value. Collaboration and joint working need to become increasingly the norm, not only between NHS Boards but also with Health and Social Care Partnerships, Local Authorities and other partners across disciplines and boundaries to plan and deliver services over the next 15 to 20 years.

To drive forward the changes required, regional delivery plans are being developed by NHS Boards and partners for three regions across Scotland (North, East and West). These regional delivery plans will set out the services which can best be planned and delivered at regional level and support the services that can best be delivered closer to home. In doing so, they will focus on the safest and most effective way to provide specialist services unconstrained by bureaucratic boundaries. Through close working with partners, the plans will also fit seamlessly with the planning of local services through existing NHS Boards and Health and Social Care Partnerships, and provide a comprehensive vision for service development over the coming years.

Outline plans are due to be produced for wide public and stakeholder discussion commencing in autumn 2017, with the aim to produce detailed documents by the end of March 2018.

At the same time, a single national delivery plan is being produced jointly by the national NHS Boards to set out their collaborative contribution to the Health and Social Care Delivery Plan and the regional delivery plans including, where appropriate, taking a 'Once for Scotland' approach in areas such as radiology, digital services, clinical demand management and support services.

Progress Against Measures of Health and Social Care in 2016/17

What Independent Reports Say About Progress

In 2016/17, the Scottish Government commissioned Sir Harry Burns to review health and social care targets and indicators in Scotland to improve outcomes¹¹. This was a demanding ask as it covered the whole of health and social care and inevitably covered the use of data in quality improvement collaboration, policy-making, performance management and planning. One of the key messages that the Scottish Government took from the review is the need to take a rounded view when considering health and social care systems – not simply focusing on one or two dimensions or a handful of indicators.

The recent analysis by the Commonwealth Fund looked at healthcare system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States¹². It considered 72 indicators in five domains: care process; access; administrative efficiency; equity; and healthcare outcomes. It found that the UK achieves superior performance compared to those other countries; however, no country ranks first consistently across all domains or measures, suggesting that all countries have room to improve.

The already-referenced Nuffield Trust report Learning from Scotland's NHS¹³ looked at what it described as Scotland's unique healthcare system, and explored how other parts of the UK might be able to learn from it. It found that Scotland has a unique system of improving the quality of healthcare that focuses on engaging the altruistic professional motivations of frontline staff to do better, and building their skills to improve. It also found that the Scottish NHS has benefited from a continuous focus on quality improvement over many years using a consistent, coherent method where better ways of working are tested on a small scale, quickly changed, and then rolled out.

Current Measures of Health and Social Care in Scotland

In Scotland, there are currently three suites of high-level measures: (i) the direct health and social care indicators within the National Performance Framework (NPF)¹⁴, which primarily focus on high-level outcomes such as improving self-assessed general health, improving mental wellbeing and reducing premature mortality; (ii) the Local Delivery Plan (LDP) Standards¹⁵, which primarily focus on waiting times for scheduled, unscheduled, cancer and mental health services, and volumes of intervention activity to support behaviour change such as smoking cessation and Alcohol Brief Interventions, and Healthcare Associated Infections; and (iii) Integration Indicators¹⁶, which focus on two broad areas – people's experience of care and high-level indicators of how care is being delivered, for example in emergency admissions, delayed discharge, and where the last six months of life is being spent. Data is widely available through the website Scotland Performs¹⁷, official statistics¹⁸, and local system annual reports¹⁹.

The majority of the direct health and social care measures within the NPF remained steady in 2016/17, however we want to see more improvement and this Annual Report highlights some of the actions that were taken this year to support improvements in population health. We are also clear that the health and social care system has to do all it can to help tackle poverty.

In the case of LDP Standards, last year's Annual Report noted the on-going challenges in meeting the elective, cancer and mental health waiting times standards. These challenges continued in 2016/17 and in August 2017 the Cabinet Secretary for Health and Sport announced the establishment of an Elective Access Collaborative Programme to provide support to NHS Boards to improve the way elective services are configured²⁰. In 2016/17, diagnostic waiting times statistics showed that 86.7 per cent of elective patients had been waiting six weeks or less at the end of March 2017²¹. Just over 260,000 or 87.4 per cent of patients received their treatment within the 12 week legal treatment time guarantee in 2016/17, while 80.7 per cent of new outpatients had been waiting 12 weeks or less at the end of March 2017²². During the quarter ending March 2017, 88.1 per cent of patients started treatment for cancer within the 62 day standard and 94.9 per cent of patients started treatment for cancer within the 31 day standard²³. During the quarter ending March 2017, 83.6 per cent of children and young people started treatment at Child and Adolescent Mental Health Services (CAMHS) in Scotland within 18 weeks of being referred²⁴. Unscheduled care waiting times in Scotland are the best in the UK²⁵, and Healthcare Associated Infection measures in Scotland remain steady after years of improvement²⁶.

We are seeing improvements in some of the high-level indicators within the Integration Indicators²⁷, including encouraging signs on delayed discharge²⁸ and emergency bed days²⁹. Data on individuals' experience of social care support is developing and so limited trend data is available in relation to this aspect of care in Scotland³⁰. There is, however, a range of data about experiences of care in both primary and secondary care which shows that people's experiences of care in these sectors remain high³¹. There is an upward trend in positive experiences of care in Scotland shared online at Care Opinion (previously Patient Opinion)³² and this is covered later in the report.

This Annual Report

The following chapters in this report concentrate on the key areas that are about how we are transforming care and delivering improved outcomes for people based on the triple aim: Chapter 2 - Improving Quality of Care; Chapter 3 - Improving the Health of the Population; and Chapter 4 - Securing Value and Financial Sustainability. Chapter 5 focuses on the important role that our workforce play in making change happen.

The report is complemented and supported by an interactive website that includes a video introduction, real-life examples of people's experiences of care and improved outcomes, and key information presented in graphic form. The website can be accessed at: www.nhsscotannualreport.com.

Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.

Chapter 2
Improving Quality of Care

'...people in the driving seat, with support from professionals to achieve the outcomes that are important to them'

Philip who receives specialist Motor Neurone Disease (MND) nursing care to help him live comfortably at home. Hear about Philip's story at www.nhsscotannualreport.com

You will see in this chapter how measures taken across a wide range of areas are having a positive impact on the care people receive and the outcomes they experience. Key to improving the quality of care are our Quality Ambitions.

Our Quality Ambitions

Through our Healthcare Quality Strategy for Scotland³³ 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 has people in the driving seat, with support from professionals to achieve the outcomes that are important to them. It is an approach that extends across health and social care, enabling people to live well, with appropriate care and support, in communities across Scotland. For care and support to be reliably person-centred, there needs to be collaboration and equal partnerships between the people accessing services, their families and carers, and the people delivering those services. It also requires a person-centred system that supports the people who work within it to deliver care that is based on compassion, continuity, clear communication and shared decision-making.

Promoting the What Matters To You? Approach

The 'What Matters To You?'³⁴ approach is at the heart of delivering high-quality care and support that is person-centred, safe and effective. By talking to people about what is important to them, listening deeply to the answers and taking action on what they hear, our staff can provide the care and support that people really need and want.

Scotland is at the forefront of a growing international movement working to improve health and social care by gaining a better understanding of what really matters. Healthcare Improvement Scotland and the Scottish Government formed a partnership with people working in health and social care to hold Scotland's first 'What Matters To You?' day on 6 June 2016. Staff working across health and social care were invited to 'ask what matters, listen to what matters, do what matters.' Over 500 teams took part, with teams joining from other sectors and from countries around the world. The impact of the day has been captured in the 'What Matters To You?' Day Report 2016³⁵ and the lessons learned were used to deliver an even more successful 'What Matters to You?" Day in June 2017, with more than 2,000 teams taking part in 30 countries around the world. 'What Matters To You?' Day has proved to be a great way to encourage a collective focus on hearing from the people across Scotland who use health and social care services. The aim is for this to become an on-going conversation, taking place every day in health and social care settings across Scotland.

Driving Change through Third Sector Partnerships

Third sector partners continued to work with us to drive change and improvement at national and local level in 2016/17.

The House of Care³⁶ approach supports and enables people with long term conditions to articulate their needs and decide on their own priorities through a process of joint decision-making, goal setting and action planning. In 2016/17, the Health and Social Care Alliance Scotland (the ALLIANCE) continued to work with Year of Care Partnerships, the British Heart Foundation, NHS Boards, the Scottish Government and other partners to support the development of this approach in Scotland, publishing Scotland's House of Care Learning Report³⁷ in December 2016.

The ALLIANCE is funded by the Scottish Government to deliver A Local Information System for Scotland (ALISS)³⁸. This continues to map community assets and to connect people with local sources of support that will enable them to manage their own health conditions more effectively. In 2016/17, the team at ALISS developed a new version of the site, which makes it easier to keep information content up to date. The team worked with disabled people, people living with long term conditions, unpaid carers, health and social care professionals and technology professionals to co-produce this digital service.

The Transforming Self Management in Scotland Fund³⁹ provides grants, both large and small, to community and voluntary organisations and partnerships to encourage the development of new approaches to supporting people to live well, on their own terms, with whatever health condition they have. The Scottish Government has committed £2 million annually from April 2016 to March 2019 to the Fund, which is administered by the ALLIANCE.

The ALLIANCE announced 15 new projects to be funded through the Transforming Self Management in Scotland Fund at the Self Management Awards⁴⁰ in October 2016. The awards highlighted a range of initiatives which are already leading the way in self-management.

Improving Health Literacy

The growing demands and expectations that modern medicine places on people can overwhelm them, undermining the safety and effectiveness of healthcare. Health literacy, which is recognised internationally as a public health concern, is about people having enough knowledge, understanding, skills and confidence to use health information, to be active partners in their care, and to navigate health and social care systems successfully.

Making It Easy: A Health Literacy Action Plan for Scotland⁴¹ was published in 2014, setting out an ambition and the means for all of us to live well with any condition we may have by making sure that health and social care services cater for each of us, regardless of our abilities. The Health Literacy Demonstrator Programme, taken forward in NHS Tayside as part of this plan, started reporting in autumn 2016 with learning shared at a national event in Dundee⁴² in April 2017. A report on progress, Making it Easy: Progress Against Actions⁴³, was published in July 2017.

Welcoming Feedback and Using it for Improvement

The Scottish Government and NHSScotland are jointly committed to developing a culture of openness and transparency that values people's feedback and uses it to drive and inform continuous improvement.

In 2016/17, Healthcare Improvement Scotland continued to test 'real-time' and 'right-time' approaches to gathering and learning from feedback about people's experience of care as part of its Person-Centred Health and Care Programme⁴⁴. Experience Based Co-design Methodology⁴⁵, which involves people who access support or care working with the staff who provide it to co-design improvements to services, is being tested as part of the same programme in a diverse range of settings.

The Our Voice Citizens' Panel⁴⁶ was convened in 2016 and the first panel survey, which included questions on social care, better use of medicines and improved oral health, was issued in October. Our Voice was developed in partnership with the NHS, the Convention of Scottish Local Authorities (COSLA) and third sector partners (including the ALLIANCE) to support meaningful engagement with people who use health and social care services, families, carers and the public on continuously improving services.

The Scottish Government continues to support NHSScotland to engage with Care Opinion⁴⁷, which provides an independent, online route for people to share their experiences of care – whether good or bad – directly with those providing NHS services, and to engage in constructive dialogue with them about how services can be improved. All of Scotland's Territorial NHS Boards are now reading and responding to stories posted on Care Opinion. There were 2,637 stories shared on Care Opinion about NHSScotland in 2016/17, of which 62 per cent were positive, and these stories were viewed over 880,000 times. The increasing number of experiences shared has been mirrored by the numbers of NHS staff accessing the site, with over 780 staff now reading stories, a 48 per cent increase on the previous year. Sixty-eight changes and improvements to services were made or planned as a direct result of stories shared in this way. Scotland is the first country in the world to have such a system in place at national level, and is attracting international interest as a result of this bold and innovative approach. This type of system has the potential to strengthen the voice of people and communities in improving and shaping their health and social care services.

Measuring and Improving Satisfaction - National Surveys

Satisfaction with NHSScotland remains high. The 2015/16 Health and Care Experience Survey⁴⁸ reported that 87 per cent of people rated the overall care provided by their GP practice positively and the 2016 Inpatient Experience Survey⁴⁹ reported that 90 per cent of hospital inpatients rated their hospital care and treatment positively. The second Maternity Care Experience Survey⁵⁰ was conducted in 2015. It showed a positive picture of women's experiences of maternity care, with 92 per cent of women rating the overall care they received during pregnancy and birth as good or excellent.

In autumn 2015, the first national Cancer Patient Experience Survey⁵¹ was launched to provide high-quality national and local data on patients' experiences of cancer care. The results, which were published in June 2016, found that 94 per cent of patients rated their cancer care positively. They also show that some areas of care received results which are less positive and require service improvement, 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 Action⁵², which is supported by investment of £100 million. The next iterations of each of the Care Experience Surveys are being planned and will be run over the coming year.

The Patient Rights (Scotland) Act 2011⁵³ introduced the right for people to give feedback, make comments, and raise concerns and complaints about the services they receive from NHSScotland, and it places a duty on the NHS to actively encourage, monitor, take action and share learning from the views it receives. 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.

Revising the NHS Complaints Handling Procedure

The NHS Complaints Handling Procedure was revised during 2016/17 to support NHSScotland to handle and respond to complaints in a consistently person-centred way. The new procedure, which was implemented from 1 April 2017, brings the NHS into line with other public service sectors by introducing a distinct, five working day stage for the early, local resolution of straightforward complaints ahead of the 20 working day stage for complaint investigations.

The revised NHS complaints handling procedure was developed by a steering group chaired by the Complaints Standards Authority, part of the Scottish Public Services Ombudsman (SPSO) service, and involving representatives from across NHSScotland, the National Prisoner Healthcare Network, the NHS Complaints Personnel Association Scotland (NCPAS), the independent Patient Advice and Support Service (PASS) and Healthcare Improvement Scotland public partners.

The changes to the procedure reflect the broader ambition for the NHS in Scotland to be an open, learning organisation that listens and acts when people provide feedback or complain. They complement the Apologies (Scotland) Act 2016⁵⁴, the Duty of Candour provisions in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016⁵⁵, and the ongoing implementation of a national approach to reviewing and learning from adverse events.

There were 23,507 complaints made about NHS services in Scotland in 2016/17⁵⁶ – a 10 per cent increase compared to the previous year. An increase in complaints is not necessarily an indication of a diminished quality of healthcare or services. The number of complaints we are seeing reflects a better awareness of how people can make a complaint and confidence that their complaint will be listened to and acted on.

Supporting People to have Greater Choice and Control in Social Care

Through the Social Care (Self-directed Support) (Scotland) Act 2013⁵⁷, Local Authorities have a legal duty to offer people who are eligible for social care a range of informed choices on what their social care support looks like and how it is delivered. The principles in the Act should apply for all interactions even when the person is not eligible for support. This approach is known as Self-directed Support⁵⁸ and is based on the understanding that having greater control of your life and decision-making leads to improved health and wellbeing.

Throughout 2016/17, the Scottish Government engaged widely with key stakeholders to understand progress and issues in implementing Self-directed Support as Scotland's mainstream approach to social care and to develop a third phase of implementation activity.

Close collaboration between the Scottish Government, COSLA, Self Directed Support Scotland (a network of disabled people's organisations), Social Work Scotland, the Scottish Social Services Council, the Coalition of Care and Support Providers in Scotland and Scottish Care led to the Self-directed Support Strategy 2010-2020, Implementation Plan 2016-2018⁵⁹. This joint plan focuses the activities of local and national partners around the key challenges raised during engagement activity. The four outcomes of the plan are:

Supported people have more choice and control;

Workers are confident and valued;

Commissioning is more flexible and responsive; and

Systems are more widely understood, flexible and less complex.

The Scottish Government invested £60.4 million to transition to this new approach between 2011 and 2017. During 2016/17, this included £3.52 million to Local Authorities to support system and culture change.

In 2016/17, £2.9 million was invested in 34 third sector organisations through the Support in the Right Direction Fund, supporting people to: access existing community resources; receive training and development support; set up and manage their care packages; and employ and manage personal assistants.

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 April 2016 and March 2017 include: enabling people to use their social care budgets more creatively; developing training and materials for practitioners and providers on Self-directed Support; and supporting people to co-produce services or explore alternative models of support.

The Social Care Survey 2016⁶⁰ shows that 53,000 people made a choice about their support during 2015/16. This is nearly half of all social care clients once those solely receiving a community alarm service or with no support package are discounted from the overall total.

Supporting People in their Caring Role

There are an estimated 788,000 unpaid carers in Scotland, including 44,000 under 18 years of age⁶¹. Carers Scotland estimates that carers save the Scottish economy £10.3 billion per year.

There continued to be a strong emphasis during the year on carers and supporting them in the role they play in our communities. The Scottish Government has worked with people and organisations across Scotland to prepare for implementation of the Carers (Scotland) Act 2016⁶², the main provisions of which take effect from 1 April 2018. The Act extends and enhances the rights of carers in Scotland to help improve their health and wellbeing, so that they can continue to care, if they so wish, and have a life alongside caring. During 2016/17, work started with a range of stakeholders to co-produce the statutory guidance that will accompany the legislation and support authorities to implement the provisions of the Act.

The Scottish Government has provided over £38 million from 2008/09 to 2016/17 to NHS Board Carer Information Strategies, including £4.75 million in 2016/17. This contributes to local carer centres, young carer projects, and other information and support services. Other priorities for this funding have included supporting minority ethnic carers, workforce development and training for carers. The Act will increase the financial commitment to supporting carers.

Initiatives such as the 5th Young Carers Festival in August 2016 allowed carers to have their voices heard and feed into the development of legislation and policies, based on what is important to carers. In September 2016, a development day with stakeholders helped refine the approach to the regulation-making powers of the Act. A Carers Collaborative forum was established in 2016/17 to ensure carer representatives on Health and Social Care Partnerships are appropriately supported in their role as representatives. The implementation of the Carers Act will remain a high priority over the coming year.

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

While dementia is a debilitating and progressive condition for which there is currently no cure, people can nevertheless live satisfying and constructive lives with the right help and support. Our shared vision, as described in Scotland's third three-year National Dementia Strategy⁶³, is of a Scotland where people with dementia and those who care for them have access to timely, skilled and well-coordinated support from diagnosis to end of life which helps achieve the outcomes that matter to them.

The strategy, published in June 2017, is designed to support the progress which has already been made in transforming services such as Scotland's post-diagnostic support offer, and on outcomes for people with dementia and their carers, including better integrated home care. At the heart of this approach is close engagement with people with dementia, their family and carers and a human rights-based approach to treatment, care and support. The implementation of a national approach to providing palliative and end of life care for people with dementia is ongoing.

Workforce education, training and development, and implementation of the Standards of Care for Dementia in Scotland across the care pathway and in hospitals is at the centre of this work. The Scottish Government has a continuing national commitment to fund this activity through the implementation of Promoting Excellence: A Framework for all Health and Social Services Staff Working with People with Dementia, their Families and Carers⁶⁴, backed by around £500,000 a year.

As part of this activity, there are 710 Enhanced-trained Dementia Champions, with over 10 per cent in social services. In social services, over 1,000 Dementia Ambassadors have been inducted, with around 734 currently active⁶⁵. All Promoting Excellence initiatives are complemented by an on-going and expanded national approach to service improvement through the national dementia improvement programme, Focus on Dementia⁶⁶.

In December 2016, the Scottish Government published its first estimate of annual dementia diagnosis rates in Scotland⁶⁷. The first round of national performance data for the dementia post-diagnostic LDP Standard was published in January 2017, relating to performance during the period 2014/15. It showed that 6,660 people with dementia were offered the post-diagnostic service in 2014/15, the equivalent of 40 per cent of people estimated to be diagnosed with dementia in that period. Of that 40 per cent offered the post-diagnostic service, 73 per cent completed the service⁶⁸.

This year also saw publication of the independent evaluation of the effectiveness of Alzheimer Scotland's '8 Pillars' model of integrated home-based care and support for people with dementia, having completed the testing of this model in five areas of Scotland⁶⁹. The Scottish Government is considering the learning from the report in the context of the new dementia strategy.

Improving Palliative and End of Life Care

The Strategic Framework for Action on Palliative and End of Life Care⁷⁰, published by the Scottish Government in December 2015, sets out the ambition of ensuring that by 2021 everyone in Scotland who needs palliative care will have access to it. This commitment was reaffirmed in the Health and Social Care Delivery Plan.

Both the Health and Social Care Delivery Plan and the Strategic Framework for Action on Palliative and End of Life Care highlight not only the importance of identifying those who need palliative or end of life care, but also to ensure the professionals they encounter are appropriately skilled. The publication in early 2017 of the Palliative and End of Life Care Education Framework⁷¹ supports professionals in having timely, appropriate conversations to enable the planning of a person's care and support when time becomes short in line with their and their families' 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. This guidance will be available to Health and Social Care Partnerships by December 2017. Other commitments progressed with partners in health, independent hospice, academic, care and the third sector to contribute to achieving our ambition included supporting improvements in palliative care in six Health and Social Care Partnerships, the appointment of three training leads working across health and social care and the creation of a research forum.

Supporting People with Autism and Learning Disabilities to Live Healthier Lives

Scotland is now more than halfway through its 10-year Scottish Strategy for Autism⁷², which was launched in November 2011. The strategy's focus remains on outcomes intended to ensure people with autism live healthier lives, have choice and control over the services they use, and are supported to be independent and active citizens. During 2016/17, the Scottish Government has continued to invest in local autism projects throughout Scotland, which have reached more than 6,000 people. Investment has also been made in an Improvement Programme to reduce assessment waiting times by improving diagnostic services and increasing diagnostic capacity across child and adult services. Support was provided for the development and launch, in January, of the Principles to Good Transitions 3 and Autism Supplement⁷³, which provides a framework to encourage the continual improvement of support for young people with additional needs, including autism, who are making the transition to young adult life. Work is under way to develop the next outcomes framework and to identify strategic priorities for the next phase of the strategy.

The 10-year Keys to Life⁷⁴ learning disability strategy was published in 2013. In 2015, a refreshed delivery approach was developed which identified four strategic outcomes: a healthy life; choice and control; independence; and active citizenship. This approach continues to guide workstreams and aims to address the wider socio-economic factors that contribute to the significant inequalities people with a learning disability face, and is aligned to the United Nations Convention on the Rights of Persons with Disabilities. The Scottish Government has invested in a number of projects throughout Scotland to tackle these inequalities, under the themes of parenting, hate crime, complex care, social connectedness, employment and physical activity. Support has continued for the Changing Places toilets campaign⁷⁵ to ensure people with profound and multiple learning disabilities can participate in community life and day-to-day activities that most of us take for granted. There are now more than 150 Changing Places toilets throughout Scotland, with new ones opening over the course of 2016/17. Work has begun to develop a new outcomes framework for the next phase of the strategy.

Supporting Survivors

Scotland is one of the few countries in the world that has dedicated funding for support services for survivors of childhood abuse. The strategic framework Survivor Scotland Strategic Outcomes and Priorities 2015-2017⁷⁶, published in October 2015, continues to guide this support. The vision is that survivors should be supported to have equal access to integrated care, support and treatment resources and services which can reduce the impact of the inequalities and disadvantage experienced as a result of abuse. This approach is grounded in what survivors say 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.

Since 2007, the Scottish Government has invested up to £9 million to support delivery of these strategic outcomes and priorities. In addition, the Scottish Government has increased investment with up to £3 million per year for the next five years, from 2016, available to support adult survivors of in care abuse. Future Pathways, Scotland's in care survivor support fund, offers help and support to people who were abused or neglected as children while they were living in care in Scotland. 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. Healthcare Improvement Scotland has worked with a range of partners to create a new improvement resource called the Improvement Hub (ihub)⁷⁷. Since its establishment on 1 April 2016, it is continuing to support Health and Social Care Partnerships and NHS Boards to improve the quality of health and social care.

Improving Safety

The work of the SPSP has spread from acute adult to maternity, mental health, primary care, pharmacy and dentistry. NHS Boards are responsible for the quality and safety of the care they provide. Every hospital and every NHS Board is expected to scrutinise their data to drive improvement locally, drawing on all the support and expertise available.

Both acute adult and primary care programmes concluded their previous phase of work at the end of March 2016. Development work was undertaken following this to shape the next phases for these programmes from April 2016 onwards⁷⁸. This identified three core themes under which future work will be planned: prevention, recognition and response to deterioration; medicines; and system enablers for safety. It will be the responsibility of NHS Boards and Health and Social Care Partnerships to set their own local priorities within those themes to meet local needs. The SPSP will tailor any improvement support required to meet these local priorities.

Acute Adult

Mortality Ratios

Hospital Standardised Mortality Ratios (HSMR) are a key measure of safety and the original aim of the SPSP was to reduce hospital mortality by 15 per cent by December 2012. This was subsequently extended to a 20 per cent reduction by December 2015. In 2016, there was a recognised need to consider the statistical basis for HSMR to ensure it reflected up-to-date information about predicted mortality. In order to support continued improvements in safety across Scotland, a new stretching aim was set to reduce hospital mortality by a further 10 per cent by December 2018.

HSMR at Scotland-level decreased by 8.4 per cent between January and March 2014 (first quarter after new baseline) and January and March 2017 (most recent quarter), with 11 out of the 29 hospitals having a greater than 10 per cent reduction⁷⁹.

Sepsis

The SPSP worked to support a Breakthrough Series Collaborative with the aim of reducing mortality through the Sepsis Six. A Breakthrough Series Collaborative is an intensive (six to 15-month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area. The Sepsis Six consists of three diagnostic and three therapeutic steps, all to be delivered within one hour of the initial diagnosis of sepsis. The Collaborative, which ran from January 2012 to December 2014, resulted in acute hospitals adopting an improved approach to identifying and treating patients with sepsis quickly and effectively, which is essential. Delivery of this intervention has improved to around 75 per cent of sampled patients and has helped to reduce mortality from sepsis by 21 per cent in NHSScotland since 2012⁸⁰.

The sepsis work is now part of the Deteriorating Patient Pathway and continues within local NHS Boards by local teams. The aim of the Deteriorating Patient Pathway is to reduce mortality and harm for people in acute hospitals through reliable recognition and response to acutely unwell patients. Progress is monitored through the outcome measures of hospital standardised mortality, mortality from sepsis and cardiac arrest rate.

In July 2016, an 18-month sepsis pilot project began in primary care. The aim is to ensure that patients with sepsis receive optimal care by improving early recognition and timely delivery of evidence-based tools and interventions. It uses the National Early Warning Score (NEWS) which is a guide to quickly determine the degree of illness of a patient. It is based on six vital signs (respiratory rate, SaO2 or amount of oxygen in the blood, temperature, blood pressure, heart rate, and AVPU⁸¹ response) and one other observation, and further aims to improve communication and collaboration across NHS teams when managing patients with sepsis.

Maternity and Neonatal

One of the key areas of focus for the SPSP is women and children's services. This work is overseen by the Maternity and Children's Quality Improvement Collaborative (MCQIC) which aims to improve outcomes and reduce unnecessary variation for all women, babies and families in Scotland. MCQIC updated its aims in 2016, looking to reduce avoidable harm to mothers, babies and children by 30 per cent by 2019. This aim is a continuation of the programme's previous work which began in 2013. To help meet this aim, the programme launched the national Paediatric Early Warning Score (PEWS), which is a tool to aid recognition of sick and deteriorating children. During 2016/17, the paediatric SPSP MCQIC programme has seen an impressive 78 per cent reduction in ventilator acquired pneumonia (VAP) rates in one of the paediatric intensive care units in Scotland⁸².

A review of maternity and neonatal services provided an excellent opportunity to identify best practice and also outline where further improvements could be made to our services in Scotland. The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland⁸³ was published in January 2017. The Report includes 76 recommendations based on the views of women and families, professionals and key stakeholders, as well as best available evidence and current good practice. A key recommendation is that every woman will have continuity of care from a primary midwife, who will provide the majority of their antenatal, delivery and postnatal care, as part of a new model of care for maternity services in Scotland.

Mental Health

The Scottish Patient Safety Programme Mental Health (SPSP-MH) is now part of the ihub, supporting improvement across health and social care. SPSP-MH aims to support National Health and Wellbeing Outcome 7: People using health and social care services are safe from harm, with the overall programme aim being that people should be and feel safe⁸⁴. Cultivating learning amongst those delivering and in receipt of care, and using that knowledge to improve safety, are core values of the SPSP-MH.

Through collaboration and innovation from staff, service users and carers, and the use of quality improvement and improvement science over the last four years, we are now starting to see significant reductions in self-harm, seclusion, violence and aggression, and restraint across a number of areas in Scotland.

There are examples of reduction in the rates of restraint of up to 60 per cent, a 28 per cent reduction in the percentage of patients who self-harm (overall reduction across 20/39 acute admission wards) and reduction in the rates of violence of up to 80 per cent. As of July 2017, ten wards show a reduction in the percentage of patients who self-harm; 17 wards show a reduction in the rates of physical violence; and 12 wards show a reduction in the rates of restraint. The programme has developed and integrated patient and staff climate safety tools into inpatient care, with over 700 facilitated patient safety climate tools completed and over 3,000 staff safety climate questionnaires completed⁸⁵.

Human rights are an overarching theme of the programme, which is working with the Scottish Human Rights Commission to actively consider ways to further embed rights-based approaches across its work.

Primary Care

Dentistry

Healthcare Improvement Scotland completed a collaborative across dentistry in primary care settings to test improvement interventions and tools. The collaborative was initially due to run until December 2016, but was extended to 31 March 2017. During that time, 15 dental practice teams and their patients: learned about improvement methodology; piloted the use of tools and interventions to deliver safer, more reliable care; explored their safety climate by undertaking a safety climate survey; and shared learning within their teams in their NHS Board and with other NHS Boards.

As part of that work, the dental practice teams identified that a key focus should be on ensuring accurate medical histories are recorded, with risk escalation processes put in place for those on high-risk medicines (due to the number of people who take blood thinners such as warfarin and then need tooth extraction with their blood unable to clot). It is now proposed that the collaborative will be extended for a further two years until March 2019 to support additional dental practices to become involved and to develop a national plan to spread good practice.

Pharmacy

Since September 2016, Community Pharmacies in Scotland have used continuous improvement methodology to support delivery of the highest quality healthcare services to the people of Scotland by ensuring patient safety practices are formalised and embedded in the delivery of services that Community Pharmacies provide. The results from this were monitored by the Scottish Patient Safety Survey (SPSS) until the end of September 2017. The SPSS is a tool to give comparisons between clinical and non-clinical staff, and management and non-management within the practice. Each time the survey is completed, it can be determined whether there has been a change in the perception of safety culture within the practice. The report is then discussed at a local team meeting, providing a focus for considering patient safety and developing the safety climate in practice and improving care for patients. Pharmacy teams also participate in local learning sessions in each NHS Board area and this provides proactive coaching and encourages sharing of the learning amongst all pharmacy teams.

During the pilot work for SPSP Pharmacy in Primary Care, NHS Fife developed an electronic reporting tool designed to improve the communication of non-urgent, patient-specific clinical queries between the Community Pharmacy and General Practice. This tool has been incorporated into the 'Pharmacy Care Record' (PCR) system used in all Community Pharmacies in Scotland.

Reducing Healthcare Associated Infections and Tackling Antimicrobial Resistance

Tackling Healthcare Associated Infections (HAIs) and reducing Antimicrobial Resistance (AMR) are key priorities and it is vital that people continue to have confidence in the quality and cleanliness of our healthcare environments. The Scottish Antimicrobial Resistance and Healthcare Associated Infection (SARHAI) Strategy Group oversees and co-ordinates the development and implementation of national strategies and policies for reducing HAI and controlling AMR.

The Scottish Government published its 5-Year Strategic Framework (2016-2021)⁸⁶ in October 2016. This framework maps out the Government's AMR/HAI workstreams over the next five years to realise its 2021 vision and commitment for the safety of patients, the public and all healthcare staff, to make our hospitals and communities safer places.

The Healthcare Environment Inspectorate (HEI) operates a robust inspection regime and scrutinises standards of cleanliness in healthcare settings across NHSScotland. The HEI publicly reports its findings together with any improvement action plans it has asked NHS Boards to develop and implement. It operates independently of NHS Boards and is an integral part of our drive to tackle hospital cleanliness and prevent infection⁸⁷.

There have been substantial reductions in HAI. Figures published in July 2017 show that cases of Methicillin-resistant Staphylococcus aureus (MRSA) have reduced by 90 per cent and cases of Clostridium difficile in patients aged 65 and over have reduced by 87 per cent since 2007⁸⁸.

Improving Care, Experience and Outcomes Following a Fall

A multi-agency improvement collaborative started in November 2016 to improve the care, experience and outcomes for the people the Scottish Ambulance Service (SAS) responds to following a fall. All Health and Social Care Partnerships and their SAS partners are working collaboratively to transform the way the SAS cares for older people who have fallen – around 45,000 calls each year⁸⁹. New care pathways enable SAS to refer a person directly to community-based services, including crisis care and rehabilitation. For an older person this can avoid an unnecessary, and often stressful, attendance at an Emergency Department. The collaborative aims to improve care following a fall by: preventing unnecessary conveyance to an Emergency Department; supporting recovery and return to independent living, in the home setting; and preventing recurrent falls and accumulated disability.

This integrated approach enables people to remain at home, with timely access to the right support, often at an earlier point in their care journey, and alleviates pressures in the hospital system. The collaborative will run to March 2018.

Developing Excellence in Care for Nursing and Midwifery in Scotland

Following the publication of the Vale of Leven Hospital Inquiry report⁹⁰ in November 2014, the Cabinet Secretary for Health and Sport tasked Scotland's Chief Nursing Officer and Scottish Executive Nurse Directors to develop a national assurance and improvement programme for nursing and midwifery. The programme is called Excellence in Care (EiC) and development is well underway.

EiC has four key deliverables: a small set of measures; a framework that sets out key principles and guidance for NHS Boards; development of a dashboard that enables reporting from ward to board (Care Assurance and Improvement Resource); and a set of record-keeping standards and principles. To ensure staff are involved in the work from the beginning, the Scottish Government is funding EiC leads within each NHS Board and is working with leads to co-develop the programme nationally with the opportunity to undertake quality improvement leadership training.

Regulating Independent Clinics

In April 2016, Healthcare Improvement Scotland commenced regulating independent clinics in Scotland. Independent clinics are defined in the National Health Service (Scotland) Act 1978 as clinics that are not part of a hospital and from which a medical practitioner, dental practitioner, registered nurse, registered midwife or dental care professional provides a service which is not part of the NHS. The term 'service' includes consultations, investigations and treatments. Service providers were given until April 2017 to register with Healthcare Improvement Scotland and meet the standards expected of them, prior to the inspection process beginning. Failure to meet the regulatory requirements could lead to the service provider being referred to the Procurator Fiscal's Office.

Effective Care

Many of the areas for improvement that have been prioritised during 2016/17 make a direct contribution to our Quality Ambition for more effective healthcare services and feature prominently in the Health and Social Care Delivery Plan. 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.

Investing in Elective Centres

We are investing £200 million over five years to expand the Golden Jubilee Hospital and create a new network of five elective and diagnostic centres in Aberdeen, Dundee, Edinburgh, Inverness and Livingston. Progress on plans for the new centres continued throughout 2016/17 and remain on track, supported by national work by Health Facilities Scotland and National Services Scotland. These centres will be completed by 2021 and will be fully integrated into local, regional and national health and social care systems to help ensure that people will receive the highest quality care before returning to their home or homely setting.

Providing Urgent Access to Emergency Care

In 2016/17, 94.1 per cent of patients were seen, treated and discharged or admitted within four hours in Scotland's A&Es. This is the best performance since 2011/12⁹¹. Scotland continues to see the best A&E performance across the UK administrations – and has done for over two years⁹².

The Scottish Government invested more than £9 million in 2016/17 to progress the national clinically-led unscheduled care Six Essential Actions improvement programme. The work supports local health and social care systems with a strong focus on ensuring that people get back to or remain in their home or community environment, avoiding unnecessary hospital stays. The programme will seek further improvements in 2017/18, including the promotion of regular local meetings of acute hospital, community, SAS and NHS 24 leaders.

Saving Lives. Giving Life Back – Scottish Trauma Network

In May 2016, Scottish Ministers set out a clear commitment to implement a Scottish Trauma Network. By December 2016, a National Implementation Group chaired by the Chief Medical Officer had developed a unique model of care that will save more lives, deliver improved outcomes for severely injured patients and fully support them to quickly return to normal life. The Network's vision is 'Saving lives. Giving life back' and aims to improve trauma patient care throughout the care pathway from prevention through to rehabilitation. The Network will involve hospitals across Scotland working together to realise this vision⁹³.

Given the scale and complexity of the changes required, we expect it will take up to five years to fully implement the network. For this reason, an extra £5 million was allocated in 2017/18 and significant further investment will be provided over the next few years in order to fully establish the Network.

Launching the Modern Outpatient Programme

In December 2016, the Scottish Government launched a new Modern Outpatient Programme, which aims to: deliver care closer to the patient's home; provide more person-centred care; utilise new and emerging technologies; and maximise the role of clinicians across primary, secondary and community-based services. We have seen successful improvements in the way some outpatient services are delivered in some NHS Boards which are recognised in the Modern Outpatient Programme.

The Modern Outpatient Programme will transform the way outpatient services are delivered across the whole of Scotland, building on Realistic Medicine and the National Clinical Strategy, and is based on the following principles:

Strengthening knowledge exchange and self-management in the community with people at the centre;

Accessing decision support, care planning and care services in the community wherever safe and appropriate;

Emphasising competency-based roles in secondary care (to focus consultant resource on more complex patients), recognising the role of the GP as the 'expert clinical generalist', and raising the profile and enhancing the role of the wider multi-disciplinary team of community-based practitioners;

Optimising eHealth and digital opportunities at the primary/secondary care interface as the norm; and

Reducing widespread variation in secondary care return appointments and review processes, wherever clinically appropriate.

Developing New Outpatient Pathways

A coeliac disease clinical pathway was developed during 2016/17⁹⁴ based on recent published coeliac disease guidelines⁹⁵ and during 2017/18 supporting tools will be developed, such as:

Clinical decision support to aid GPs to identify and manage diagnosis;

A Gastrointestinal mobile app to provide support to clinicians through the coeliac disease pathway; and

Simple telehealth to support patients to manage dietary treatment.

The pathway and tools developed ensure that this patient-centred, self-managed, community-based and dietetic-led approach will result in short- and long-term benefits for patients and the NHS. This will lead to faster diagnosis and treatment, reduced unnecessary investigations, improved information⁹⁶ and self-management support, reduced secondary care visits, follow-up close to home⁹⁷, reduced long-term complications, and improved quality of life and experience. The implementation of the clinical pathway will be used to demonstrate new transformational approaches to coeliac disease care in 2017/8 as the pathways are tested in four NHS Boards.

Primary and secondary care clinicians from across Scotland came together to update existing dermatology clinical pathways. The pathways are now available in a mobile app and website – Dermatology Patient Pathways⁹⁸. This aims to provide GPs and primary care professionals across Scotland with quick and convenient access to high-quality specialist dermatology advice. The majority of users are from Scotland, but there has been interest from other countries and the British Association of Dermatologists is currently discussing the potential of the material across the UK.

Making Local Improvements in Inpatients and Day Case Services

Through the FLOW programme, Glasgow Royal Infirmary has been implementing the Institute of Healthcare Optimization's (IHO) Variability Methodology since April 2015. There has been a focus on improving theatre scheduling and, as a result, they have achieved improvements to the safety and quality of patient care. A standardised approach to classify the urgency of each patient has been implemented across all specialties accessing emergency theatres, with patients consistently getting to theatre without delay.

A trauma and orthopaedic improvement programme has worked with clinicians to improve care for orthopaedic patients by developing dashboards based on best-practice/clinical evidenced interventions that make a difference to the experience and outcome for patients and enable teams to focus local improvement initiatives. For hip fracture, between 2015 and April 2017, six measures saw improvement, including use of nerve-blocks to ease pain straightaway, cognition assessments, and comprehensive geriatric assessment of frail patients who often have multiple co-morbidities. The important post-operative mobilisation of patients and Occupational Therapy input to support their readiness for discharge home also increased. The renewed focus of the work is on preparing patients to be discharged directly home into the care of support services in the community. There is increasing evidence that mobility, recovery and general wellbeing are enhanced in the home environment. For patients undergoing hip and knee replacement surgery, there has been an increase in the proportion of patients admitted on the day of surgery and an increase in the proportion of patients discharged by the end of day three post-operatively⁹⁹. Patients are receiving more and earlier information about their care through informative booklets and DVDs.

Improving Mental Health Services

Mental Health Strategy 2017-2027

The Mental Health Strategy 2017-2027¹⁰⁰ launched in March 2017, a significant component of the Health and Social Care Delivery Plan, describes a 10-year vision for Scotland. Following the Creating a Healthier Scotland national conversation¹⁰¹, it was shaped by feedback from over 600 people and organisations.

The vision is of 'a Scotland where people can get the right help at the right time, expect recovery, and fully enjoy their rights, free from discrimination and stigma'. Its themes include the need to prevent and treat mental health problems with the same commitment, passion and drive as we do physical health problems. It recognises the importance of early intervention and access, especially in relation to children and young people, and commits to action to improve physical health in those with mental health problems, a focus on rights, and work to improve how outcomes are better measured to allow quality improvement.

The Strategy recognises that we all have mental health. Improvement will require work across policy areas and services. People are at the centre of the Strategy and for that reason a biannual forum of stakeholders has started to meet to monitor and advise on progress, influencing the direction of travel and future actions.

Distress Brief Intervention

A better response by services across the NHS, emergency services, social services and the third sector to people in distress is seen as a key component in supporting people at risk of non-fatal self-harm, and of future suicide prevention.

In July 2016, the Scottish Government announced the host organisation and four partner organisations to develop pilot work to test the Distress Brief Intervention (DBI) – a time-limited, supportive and problem-solving contact with an individual in distress. North and South Lanarkshire Health and Social Care Partnerships are hosting the DBI central team and participating as one of four partnership test sites running local pilots, along with Penumbra in Aberdeen, Support in Mind in Inverness, and NHS Borders Joint Mental Health Service. Development work on the pilots has been taking place since late summer 2016 and DBI training has been in the process of development by the University of Glasgow. The pilot will run until March 2021 and will be evaluated independently.

Suicide

The Scottish suicide rate reduced by 18 per cent between the periods 2001-2005 and 2011-2015, using five-year rolling averages (European Age Standard Rates) – from 16.7 per 100,000 population to 13.7 per 100,000 population. The statistics, published in August 2016 by ISD Scotland and National Records of Scotland¹⁰², show that 672 people died by suicide in 2015, compared with 696 in 2014. Based on the old coding system, which is used for longer-term comparisons, the number of suicides in 2015 was the lowest in a single year since 1974¹⁰³.

Suicide is extremely complex so it is impossible to ascribe any single reason for the long-term downward trend in the suicide rate. However, over the past several years a range of Scottish Government-funded actions have been underway to help improve mental health and wellbeing, including some action specifically focused on suicide prevention. This includes work led by the NHS Health Scotland Suicide Prevention Programme¹⁰⁴, the Breathing Space¹⁰⁵ telephone and web advice service for people experiencing low mood or depression, and a programme of action to improve recognition and treatment of depression and anxiety, including development of better access to psychological therapies. In addition, the See Me programme¹⁰⁶ has led much work to tackle the stigma and discrimination which can be associated with mental ill-health. The programme, co-funded by Comic Relief, is thought to have helped more people feel comfortable about coming forward to ask for help when they need it.

Managed Clinical Network for Perinatal Mental Health

In January 2017, funding was announced to establish a Managed Clinical Network (MCN) for perinatal mental health. This is the first Managed Clinical Network in Scotland dealing with mental health. The network will bring together health professionals who work in the area of perinatal and infant mental health. This joint expert leadership will identify gaps in current perinatal care and pathways for care. It will develop and implement guidelines and best practice, helping to improve standards and make sure everyone gets the same high level of care regardless of where they live. The long-term aim is that all women, their infants and families, have equity of access to perinatal mental health provision, at the level appropriate to need, in all NHS Board areas in Scotland. A lead clinician, together with dedicated maternity, nursing and infant mental health experts and management support, are in place. They have started delivering their work plan with initial mapping and identification of gaps of geographical service provision.

Enhancing the Role of Primary Care

Primary Care Transformation

Shifting the balance of care to ensure that more healthcare services are provided in the community is a critical part of our National Clinical Strategy and the Health and Social Care Delivery Plan. We have provided funding of £23 million in 2016/17 to support and deliver the redesign of primary care across Scotland, including the treatment of mental health in primary care, daytime and out of hours.

Health and Social Care Partnerships and NHS Boards have identified their priorities for improvement within their own areas. These include tests looking at redirecting patients to see the most appropriate healthcare professional, ensuring GPs see patients with more complex needs, supporting patients with mental health, expanding the multi-disciplinary team within GP practices and exploring the provision of safe and effective primary care services in rural settings.

Following the publication in November 2015 of the National Review of Out of Hours Services, Pulling Together, Transforming Urgent Care for the People of Scotland¹⁰⁷, led by Professor Sir Lewis Ritchie, a Peer Review Group was established drawn from a group of experts across the Review's main task group themes: workforce and training; information and technology; quality and safety; and models of care. The group also drew in other professionals and stakeholders as appropriate. The objective of this peer-review-based approach was to enable a co-production-based design with mutual understanding of the aims and outcomes for local urgent care services.

Following an initial investment of £1 million to carry out tests of change in eight pilot areas in 2015/16, a further £10 million was made available in 2016/17 to roll out the transformation of urgent care across Scotland. The Scottish Government asked all key delivery partners, through lead Health and Social Care Partnerships, to propose funding bids which would deliver the report's recommendations locally. All funding bids were assessed by the Programme's Peer Review Group. Tests of change include the development of Urgent Care Hubs and better use of multi-disciplinary teams to support out of hours services.

A New GP Contract

Although primary care goes beyond General Practice, General Practice services remain one of the most critical parts of healthcare delivered in the community. The Scottish Government and the Scottish General Practitioners Committee of the British Medical Association (BMA) are currently negotiating a new General Medical Services (GMS) contract for 2018, as a foundation for developing multi-disciplinary community care teams and a clearer leadership role for GPs.

Their vision is: for General Practice to be at the heart of the healthcare system; for those who need care to be more informed and empowered than ever, with access to the right person at the right time, while remaining at or near home wherever possible; and for multi-disciplinary teams in every locality, both in and out of hours, involved in the strategic planning and delivery of services.

In November 2016, the Scottish Government and the BMA published a joint letter and Principles of the Scottish Approach to GP Contract. These were followed by a second publication in May 2017 outlining progress in negotiations, culminating in the announcements made at the Scottish Local Medical Committee Conference held on 10 March 2017 by the Cabinet Secretary for Health and Sport. These announcements included the pledge to increase overall annual funding for primary care by £500 million by 2021/22. It was announced that £250 million of that investment will, in negotiation with the BMA, be in direct support of General Practice.

GP Recruitment and Retention

General Practice is under significant pressure due to the increasing healthcare demands of the population. Difficulties in recruiting and retaining GPs presents a significant risk. The GP Recruitment and Retention Fund invested a further £1 million in 2016/17. This increased investment will enable the scheme to expand and continue to explore with key stakeholders the issues surrounding GP recruitment and retention across Scotland. Pilots tested in 2016/17 include:

A range of GP fellows, including a project in Deep End practices;

Royal College of General Practitioners (RCGP) GP Recruitment Programme;

Island-wide practice Mull and Iona – to develop a sustainable GMS service model which is attractive to recruit and retain staff, address professional isolation, reduce the burden of on-call, establish and strengthen primary care team services to better meet needs, and enhance access to specialities;

GP Returner Scheme run by NHS Education for Scotland (NES);

NHS Shetland – a short term project March-May 2016 to work in collaboration with Promote Shetland to take forward a GP recruitment campaign; and

The 'Being Here' remote and rural primary care sustainability project hosted by NHS Highland also successfully bid for funding to provide a stand at the RCGP Conference in Harrogate in October 2016. The aim of the stand was to promote the recruitment of GPs in remote and rural areas of Scotland through hi-profile networking at the largest UK GP conference, with approximately 4,000 attendees. This was an opportunity for rural boards, including Shetland, Orkney and Western Isles, to work together to raise awareness of alternatives to urban GP practice as a rewarding and interesting career choice.

Improving Eye Health

Scotland is rightly proud of its world-leading approach to eye health. We have just celebrated the 10th anniversary of General Ophthalmic Services (GOS), which has supported not just universal free eye tests, but also a more systematic focus on improving eyecare. The time was right to review GOS, and so the Cabinet Secretary for Health and Sport commissioned the Community Eyecare Services Review in August 2016.

The Review considered eyecare services currently provided across Scotland to identify areas of good practice that could be rolled out nationally. The Review was published on 19 April 2017¹⁰⁸ and made a number of recommendations including: schemes to reduce geographical differences in services; more tailored arrangements for patients with specific complex needs to support care closer to home; and suggesting that some eye services traditionally offered in hospitals (such as post-cataract surgery appointments and managing stable glaucoma patients) should be made available locally. The Scottish Government is in the process of implementing the recommendations of the Review and will be engaging with a range of stakeholders, including health professionals and patients, as it does so.

Improving Oral Health

In response to a commitment within the 2016 Programme for Government¹⁰⁹, the Scottish Government launched a consultation exercise on Scotland's oral health on 15 September 2016¹¹⁰. The consultation exercise recognised some of the key challenges around oral health inequalities, an ageing population and how we begin to shift the emphasis from restorative dentistry to a more preventive-focused approach. The analysis of responses was published in June 2017¹¹¹ with the final Oral Health Improvement Plan due for publication before the end of 2017.

Despite the success of the Childsmile programme, health inequalities in oral health persist in Scotland. People of all ages who live in the most deprived areas are more likely to experience poor oral health than the rest of the population. We know that poor oral health can have a negative impact on an individual's general health so it is vital we do as much as we can to reduce oral health inequalities. Tackling oral health inequalities is seen as a priority for practitioners and the public.

Action 23 of the Fairer Scotland Action Plan¹¹² commits the Scottish Government to extend the delivery of Childsmile interventions, such as nursery and school fluoride varnish application, to reach even more comparatively deprived communities. This will particularly benefit children in Greater Glasgow and Clyde, and Ayrshire and Arran.

Achieving Excellence in Pharmaceutical Care

Following a two-year long process led by the Scotland's Chief Pharmaceutical Officer, Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland¹¹³ set out the priorities, commitments and actions for improving and integrating NHS pharmaceutical care in Scotland over the next five years. The strategy refreshes the 10-year vision and action plan Prescription for Excellence¹¹⁴ launched in September 2013. It aligns pharmaceutical care with the strategic and policy direction described in the Health and Social Care Delivery Plan, National Clinical Strategy, Realising Realistic Medicine, and transformational change in urgent and primary care.

Over the next five years, Achieving Excellence in Pharmaceutical Care will be driven by two main priorities: improving NHS pharmaceutical care and enabling NHS pharmaceutical care transformation. This is supported by nine commitments and a series of 29 actions which focus on integrating and enhancing the role of pharmacy across all areas of pharmacy practice in both hospital and in the community, increasing capacity, and offering the best possible person-centred care. It also describes a range of ways that pharmacy and pharmacy services are already adapting: pilot projects to test new ways of working; and plans to evaluate developments in order to gather evidence to help these new approaches to pharmaceutical care to become sustainable across the NHS in Scotland.

Pharmacy – Building Clinical Capacity

Building capacity through multi-disciplinary team working is a core plank of the programme to transform primary care. Good progress is being made to deliver the Programme for Government commitment to ensure that every GP practice in Scotland has access to a pharmacist with advanced clinical skills by 2021. By the end of 2017/18 we expect to have invested up to £20.4m to support this commitment. Through this investment, we are on track to recruit the 140 WTE pharmacists announced in June 2015 and, in addition to this, 28.8 WTE technicians, benefiting patients in around a third of GP practices across Scotland. Further progress during 2017/18 will put in place the strong foundations to deliver the Programme for Government commitment¹¹⁵.

These pharmacists and technicians are supporting GP practices with a range of medication management and clinical activities including medicines reconciliation, high-risk medicine reviews, polypharmacy reviews and specialist clinics such as pain management and other long term conditions. Evidence from robust research is an essential part of future decision-making. As this Programme for Government commitment is taken forward, the two Scottish Schools of Pharmacy will evaluate the new ways of working emerging for pharmacy teams in General Practice to inform sustainable models of care going forward and the considerations for the wider pharmacy workforce.

Access to New Medicines

Access to new medicines has been improved significantly in recent years as a result of investment and reforms. Between 2011 and 2013, the combined acceptance rate for orphan/cancer medicines by the Scottish Medicine Consortium (SMC) was 48 per cent and between 2014 and 2016, the SMC approved 75 per cent of ultra-orphan, orphan and end of life medicines under the new approach. Nevertheless, we recognise that there is more to do and fresh reforms are now underway to change the way new medicines are approved to ensure better access for patients in Scotland. The Scottish Government is working in collaboration with partners and stakeholders across Scotland, including NHSScotland, the third sector and the pharmaceutical industry, to take forward the recommendations of Dr Brian Montgomery's Review of Access to New Medicines¹¹⁶ which sets out how the process for appraising medicines could be made even more open, transparent and robust. These additional reforms will help patients get access to medicines that can give them longer, better quality lives.

Tackling Polypharmacy

The Scottish Government has provided national leadership for three significant medicines-use improvement strategies in 2016/17. The National Polypharmacy, Respiratory and Diabetes prescribing strategies aim to provide a consistent approach to improving the safe and effective use of medicines through the use of a holistic person-centred medication review. There is widespread implementation of the strategies via the Scottish Prescribing Advisers Association and prescribing data demonstrates the impact on reducing variation across Scotland.

The Polypharmacy Guidance 2015¹¹⁷ focuses the review of frail patients and those with multiple morbidities on multiple medicines, which include those considered as high risk. Consistent evidence shows that up to 11 per cent of hospital admissions are attributable to adverse medicine events, and the majority of those that are preventable are for patients over the age of 65 years on multiple medicines¹¹⁸. The Respiratory Prescribing Strategy 2014-16¹¹⁹ focuses on person-centred review with the emphasis on effective inhaler use and the reduction in steroid burden for suitable patients. Excessive use of steroids is associated with increased risk of developing osteoporosis, growth retardation in children and adrenal suppression. For patients with chronic obstructive airways disease there is also an increased risk of developing community-acquired pneumonia with high-dose steroid use. The Diabetes Prescribing Strategy 2014-16¹²⁰ focuses on promoting medicines that provide the greatest evidence-based benefits for patients, and the withdrawal of therapies that are no longer working.

Since the introduction of the Polypharmacy Guidance 2012, there has been a reduction in the annual volume increase from 3 per cent to 1.5 per cent¹²¹. This reduction correlates to the 120,000 polypharmacy reviews performed each year. Since the introduction of the Respiratory Prescribing Strategy 2014-16, there has been a reduction in the proportion of high-dose inhaled corticosteroids from 25.1 per cent to 18.8 per cent¹²². Since the introduction of the Diabetes Prescribing Strategy 2014-16, there has been an increase in the use of the first-line medicine, metformin, to it being used by over 90 per cent of patients with type 2 diabetes¹²³.

Enhancing the Role of the Ambulance Service

New Clinical Response Model

In November 2016, the Scottish Ambulance Service (SAS) began piloting a new response system which aims to save more lives and improve the quality of care for patients. Patients with immediately life-threatening conditions, such as cardiac arrest, are prioritised and receive the fastest response. In less urgent cases, call handlers may spend more time with patients to better understand their health needs and ensure they are sent the most appropriate resource for their condition. The new model has been developed following the most extensive clinically-evidenced review of its kind ever undertaken in the UK, with nearly half a million calls examined. It is the first major change to the time-based targets system since 1974. Initial results are encouraging, with the latest statistics showing that, on average, 66 per cent of patients suffering a witnessed cardiac arrest by ambulance crews were successfully resuscitated and alive on arrival at hospital over the last six months¹²⁴. Another improvement in 2016/17 saw conveying resources sent first time to 95 per cent of patients likely to need to be taken to definitive care, further improving outcomes for patients¹²⁵.

New Ways of Working

The SAS strategy, Towards 2020: Taking Care to the Patient¹²⁶, aims to provide more patients with the care they need, where and when they need it. In 2016/17, the SAS managed more than 30 per cent of eligible unscheduled cases either by telephone or face-to-face assessment, avoiding unnecessary hospital admissions¹²⁷. This work is being supported by the introduction of specialist paramedics, whose enhanced skills enable more patients to be treated within community settings.

Skills Enhancement

The SAS is continuing to invest in its workforce. In 2016/17, it trained 193 new paramedics and recruited 82 specialist paramedics. A further 254 technicians were recruited and commenced training¹²⁸. Paramedics are increasingly working within primary care teams, enabling more patients to be treated within community settings. Additional investment in the development of clinical advisors in ambulance control centres also supported the aim of the SAS to provide more patients with the care they need, where and when they need it, and avoid unnecessary hospital admissions. The establishment of a trauma desk will enable more effective trauma recognition, triage and tasking, with the SAS having a key role in the Scottish Trauma Network.

Improving Cancer Outcomes

Increase in Cancers Diagnosed at the Earliest Stage

Overall cancer death rates have dropped by 10.6 per cent over the past ten years and early detection is vitally important to continuing this trend¹²⁹. During 2016/17, our Detect Cancer Early Programme has successfully carried out social marketing campaigns on bowel cancer screening, lung cancer and breast screening. The campaigns aim to highlight the benefits of earlier presentation of symptoms to a GP and of screening participation through a combination of targeted media campaigns, digital engagement and extensive work with primary care, NHS Boards and the third sector. This has helped contribute to an increase in the proportion of breast, lung and colorectal cancers diagnosed at the earliest stage. In 2015 and 2016 (Year 5), 25.5 per cent of people were diagnosed at stage 1 for breast, colorectal and lung cancer (combined) – this is a 9.2 per cent increase from the baseline of 23.3 per cent (in 2010 and 2011). The largest increases were observed in early stage lung cancer diagnoses (an increase of 39.2 per cent) and for those living in the most deprived areas of Scotland (an increase of 17.4 per cent) since baseline¹³⁰.

Cancer Strategy

In 2016/17, more than £13 million has been invested in delivering the commitments in the Beating Cancer: Ambition and Action¹³¹ strategy, including £2 million on the provision of robots to deliver prostate cancer surgery and £4.3 million on radiotherapy equipment.

Supporting People to Start Their Lives Well

Health, Wellbeing and Learning Outcomes for Children, Young People, Families and Communities

Through the Children, Young People and Families Early Intervention and Adult Learning and Empowering Communities Fund, the Scottish Government provided £14 million in 2016/17 to 118 third sector organisations to use early intervention and prevention to improve health, wellbeing and learning outcomes for children, young people, families and communities. This fund is tackling inequality and building opportunity, making a difference to the lives of thousands of children and families, in many cases preventing the need for costly acute service input. One of the themes supported by the Fund is ensuring that children reach their full potential through strengthening early child development. A number of organisations were supported under this theme, including Children's Health Scotland, which promotes children's healthcare rights and needs, and Place2Be, which delivers counselling in schools, often meaning that the requirement for input from Child and Adolescent Health Services can be avoided. Another organisation that benefited from this fund is Bobath Scotland which, working in partnership with NHSScotland, helps children with cerebral palsy make the most of their abilities and reach their full potential.

In Vitro Fertilisation

Scotland leads the way on In Vitro Fertilisation (IVF) access in the UK. Targets for improved IVF waiting times continue to be met by NHSScotland as a result of £6 million investment in NHS IVF treatment to drive down waiting times. In June 2016, the National Infertility Group published a report¹³² recommending changes to IVF criteria, which were accepted by Scottish Ministers. Implementation of the first of these – allowing access to IVF treatment for couples with an existing child in the home – commenced in September 2016 and work commenced to implement introduction of a third funded cycle of NHS IVF treatment for all eligible couples from 1 April 2017. This means that more people are accessing IVF treatment more quickly, which is good news for couples in what can be a very stressful time.

Improving Care and Outcomes for People Living with Diabetes

Access to Insulin Pump Therapy

Achieving good glucose control is key to living well with diabetes and reducing risk of associated complications such as diabetic retinopathy and kidney disease. In 2012, the Scottish Government introduced a programme of work to support a substantial increase in access to insulin pump therapy for people with type 1 diabetes, supported by £7.5 million of funding. By the end of 2015, the initial target had been exceeded, with over 30 per cent of young people under 18 years and over 7 per cent of adults using the therapy¹³³. In 2016, the number of people maintaining good glucose control increased from 22.1 per cent in 2015 to 24.5 per cent, and the percentage with poor glucose control decreased from 36.6 per cent to 33.9 per cent¹³⁴. In supporting continued improvement in glucose control, in December 2016 the Scottish Government announced funding of £10 million over the course of the Parliament to support further increase in access to insulin pump therapy for adults and to deliver increased access to Continuous Glucose Monitors.

Improving Inpatient Care

Approximately one in five hospital inpatients at any given time will have diabetes¹³⁵. Nearly half of these will be insulin dependent, with most admitted to hospital cared for in non-diabetes specialist inpatient areas. Insulin is considered to be in the top three high-risk medications for error and harm, with the effect of poor insulin dosing including hypoglycaemia, hyperglycaemic emergencies (diabetic ketoacidosis and diabetic coma) and foot ulceration, all of which are largely avoidable and are associated with longer stays in hospital.

Following the completion of the Think, Check, Act project in March 2016, Healthcare Improvement Scotland introduced a range of tools and resources to improve the care and experience of people with diabetes admitted to hospital¹³⁶. This package of online learning modules provides essential skills training in treatment with insulin, hypoglycaemia management, foot CPR (Check Protect Refer), and glucose monitoring. The project also recommends that 'hypo boxes' are available in hospital wards to ensure access to prompt and effective treatment for all patients in the event of hypoglycaemia. Evidence from the project has demonstrated improved hypoglycaemia management, reduced bed days and improved patient experience¹³⁷. It is estimated that adoption of Think, Check, Act across the whole of NHS Greater Glasgow and Clyde alone could save in excess of 2,900 bed days per annum. Implementing CPR for feet across Scotland could prevent 75 per cent of new foot ulcers developed in hospital, save £15 million per annum and reduce unscheduled bed days¹³⁸. Work continues with funding from the Scottish Government to purchase hypo boxes, while National Co-ordinators are working with NHS Boards to spread the learning of the project and embed this work.

Improving Motor Neurone Disease Care

In January 2015, the First Minister announced an additional £2.5 million per annum to enhance the provision of specialist nursing and care. NHS Boards have enhanced support in ways that reflect local needs, including the creation of 31.4 WTE additional specialist nurse roles (at May 2017) which are supporting patients and families affected by a wide range of conditions, across the life spectrum and in hospital and community settings. The number of Motor Neurone Disease (MND) nurse specialists had more than doubled, increasing by 7.64 WTE¹³⁹, including the appointment of a National Co-ordinator, funded by the Scottish Government in collaboration with MND Scotland and the University of Edinburgh to develop a strategic approach to delivering MND services and promote the delivery of first-class, evidence-based care. Patient contact with the MND Clinical Team has risen significantly¹⁴⁰. Care is now proactive, with patient and clinical specialists both reporting an improvement in service provision, including quality and frequency of time spent with patients and families.

Saving Lives at Risk from Cardiac Arrest

Out-of-Hospital Cardiac Arrest: A Strategy for Scotland¹⁴¹ sets out the commitment to improve survival and outcomes from cardiac arrest. Over 140,000 people have been equipped with cardiopulmonary resuscitation (CPR) skills by Save Life for Scotland partners since its launch in October 2015¹⁴². A main aim in the Strategy for Scotland is to equip an additional 500,000 people with CPR skills by 2020 in order to increase rapid bystander intervention in an out-of-hospital cardiac arrest. Save a Life for Scotland is the partnership that has come together to help many more people learn CPR skills. It co-ordinates activities that raise awareness of cardiac arrest and help people learn CPR via the partner organisations.

Improving Organisational Resilience

In 2016, new standards covering organisational resilience were published for NHSScotland¹⁴³. These provide a framework for NHS Boards to improve resilience against disruptive events, ranging from severe weather and transport disruption to dealing with potential terrorist incidents. These will help to ensure that health services are robust to cope with disruption and that arrangements ensure the safety of patients and staff. To support the aims of the standards, two major exercises have taken place in Scotland during 2016 to enhance the resilience of NHS Boards.

Developing Healthcare Science

Healthcare scientists are pivotal within the collaborative professional environment to ensure that NHSScotland can appropriately manage waste and unwarranted variation in diagnostic testing. While some NHS Boards are reporting a 15 per cent year-on-year increase in diagnostic testing activity and associated costs, the Carter Review of pathology services in England¹⁴⁴ estimates that around 25 per cent of diagnostic tests currently undertaken are inappropriate. This significant waste impacts on patient pathways and experiences, increases service workload and consumes precious resources. Variation in practice at NHS Board level is evident across a range of variables, including costs, quality and patient experience. The healthcare science community has published guidance and recommendations to help achieve a Scottish approach to demand optimisation which will ensure the right test at the right time to the right person.

Healthcare scientists have worked with their medical colleagues to reduce waste and optimise patient pathways. The realistic approach achieved by implementing the use of B-type natriuretic peptide (BNP), a blood test to triage breathless patients for echocardiography, has demonstrated reductions of approximately 10-11 weeks from General Practice appointment to the patient commencing treatment, with a new model of delivery in 2-3 weeks. In addition, these models have reduced echo and outpatient appointments by approximately 50 per cent, with projected savings (avoided cost) of around £30,000¹⁴⁵.

Investing in Cutting-edge Medical Research

The Scottish Government has continued to invest in high-quality applied research across a very wide health and social care remit. In addition to £3 million in 2016/17 for 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 – and £0.5 million for the Scottish Genomics Partnership¹⁴⁶, around £61 million has been invested to enable NHSScotland to host and participate in research across a wide range of disciplines and disease areas.

This funding has supported the necessary research infrastructure across NHSScotland, including: clinical research facilities; research units; biorepositories; data safe havens; 24 Clinical Leads across key areas such as Cancer, Diabetes, Stroke, Dermatology and Rare Diseases; and the SHARE register of patients willing to take part in clinical research and trials which is now approaching 200,000 participants – a real testament to the willingness of the Scottish population to support and be involved in clinical research.

It has also enabled Scotland-based researchers access to UK-wide research funding, supported collaborative working with other research funders such as the Medical Research Council and various medical research charities, and has helped to build future research capacity in NHSScotland and academic institutions through clinical research fellowships.

The Golden Jubilee Research Institute approved a record number of 40 academic and commercially sponsored research projects in 2016/17. The Golden Jubilee was the first in the world to participate in the Ready MRI study, treating a patient with an Implantable Cardioverter Defibrillator using a Magnetic Resonance Imaging (MRI) scan. This could allow thousands more patients at risk of sudden cardiac arrest to safely undergo MRI tests. The T-TIME study also started in 2016/17, aiming to assess more than 600 heart attack patients with a new drug to restore blood flow to the small heart vessels. The new Golden Jubilee Motion Analysis Lab will allow for improved analysis of impact and movement, with the goal of helping a person achieve optimum mobility, balance and performance. This is a major development in how orthopaedic patients are assessed and has the potential to benefit patients with sports injury, spinal injury, stroke, prosthetics and cerebral palsy.

Empowering People and Improving Care through Digital Health

Digital technology has a key 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 and wellbeing through the use of technology and information contributes to achieving our aim for everyone to live longer, healthier lives at home, or in a homely setting.

The publication of the Health and Social Care Delivery Plan committed to a new Digital Health and Care Strategy. This new integrated Strategy will build on achievements to date but will provide greater alignment between the already-strong foundations in eHealth, technology-enabled care and the use of data, intelligence and research.

NHSScotland is already a technology-driven organisation, with all aspects of care touched by the use of technology. This includes how staff communicate with each other, the use of patient records and the transfer of images and lab results, the use of technology to help people to manage their own conditions, and the use of data generated from this to better plan and deliver services.

Significant developments in 2016/17 include the launch of the Scottish Primary Care Information Resource (SPIRE)¹⁴⁷, used by local GP practices to manage their own information and provide evidence for quality improvement, audit and performance appraisal as well as using depersonalised and anonymised data for research into population health, including multi-morbidity and cancer. A public information campaign was launched in March 2017 using radio advertising, leaflets and posters in GP surgeries to inform the public about the purposes for which data would be used and offer an opportunity to opt out if preferred. Further public information will be issued in the coming year as SPIRE continues to roll out in each area.

The Golden Jubilee Foundation is the first NHS Board to trial pre-assessment clinics for ophthalmology via telehealth links. This innovative collaboration with NHS Fife sees patients attend their local hospital for a high-tech consultation by secure video link, reducing travel time and allowing faster access to treatment. A further redesign of the Golden Jubilee ophthalmology service has introduced optometrist and nurse-led clinics, allowing them to treat an additional 1,000 patients every year. The Golden Jubilee Patient Portal will revolutionise the way electronic records are managed and will allow more patients to be directly involved in their care. Currently, the system enables patients to access their clinical information from their laptop, smartphone or tablet, allowing them to share this information with other clinicians. In the future, patients will have direct access to upload their own documents and information, enabling new ways of engaging with health and social care.

NHS inform¹⁴⁸, Scotland's Health and Care Information service originally established in 2010, was redesigned and re-launched in November 2016. The refreshed NHS inform hosts an extended range of health and social care information topics, a new Self Help Guide, National Services Directory and personalisation tool 'Info for Me'. In October 2016, NHS inform was attracting around 40,000 visits a month and since then access to the online service has risen to more than 300,000 visits per month in July 2017. At launch, web chat was offered as an alternative public access channel which now receives around 1,000 monthly contacts. NHS 24 continues to engage with the public and partners to ensure the service remains relevant for the people who use its services.

Work continued during 2016/17 on scaling up telehealth. The European-funded United4Health¹⁴⁹ programme ended, with almost 7,000 Scottish patients benefiting from being able to remotely monitor their long term condition. Data from around 4,500 patients were evaluated, making this one of Europe's largest ever studies into how to implement telehealth at scale. This work has continued through the home and mobile health monitoring workstream of the Technology Enabled Care Programme, with a National Service Model for Home and Mobile Health Monitoring¹⁵⁰ released to support local implementation.

An example of the potential for remote monitoring is provided by NHS Lanarkshire. A 90-day test of change ran from March-May 2016, aiming to assess the benefits and challenges of remotely monitoring patients' blood pressure using SMS text messaging. GPs were asked to recruit patients at the point of diagnosis or initiation of medication. Nine practices and 115 patients contributed to the study. An average of 4.4 face-to-face contacts per patient were saved compared to usual care, with 100 per cent of clinicians involved in the study agreeing that the monitoring had been an aid to decision-making. In 69 per cent of cases it led to faster decision-making, with 99 per cent of patients reporting that it was easy to use, 84 per cent feeling it helped them to monitor their blood pressure and 94 per cent stating they would use it again if they needed to. Interestingly, it revealed no treatment was required in 33 per cent of cases. The study demonstrated that remote monitoring of blood pressure improves efficiency and supports clinical decision-making. Most people find it easy to use and would use it again if required. Fifteen months after the 90-day test started, the pathways remain intact with around 1,000 patients benefiting in total. A further analysis of the 820 patients who had used the service estimated that the number of clinical contacts avoided was over 3,200¹⁵¹. Experience in this area will inform the development of a Patient Portal, through which people will be able to access and contribute to their health record.

If all new cases of hypertension in Scotland were diagnosed in this way, it is estimated that some 140,000 primary care appointments would be avoided each year.

Chapter 3 
Improving the Health of the Population

'NHSScotland and its partners are committed to reducing the deeply ingrained health inequalities that continue to persist in Scotland'

NHSScotland and its partners are committed to reducing the deeply ingrained health inequalities that continue to persist in Scotland. At its root this is an issue of income inequality – the rising cost of living combined with stagnant incomes makes life more difficult for many, which can have both direct and indirect effects on health and wellbeing.

The Scottish Government continues with decisive action to address alcohol consumption, reduce smoking rates, encourage active living and healthy eating, and to invest in improving mental health services. It is doing so whilst seeking a shift in emphasis from dealing with the consequences to tackling the underlying causes, such as ending poverty, promoting fair wages, supporting families and improving our physical and social environments.The actions we need to take are a key part of the Health and Social Care Delivery Plan. They are issues which are not for the NHS to address alone, but require collaborative working across agencies and organisations.

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 16 per cent since 2006 to a death rate of 439.7 deaths per 100,000 population in 2016 (see Chart 1). Early deaths due to cancer – the leading cause of death – have reduced by 15 per cent over the last decade. Deaths due to heart disease and cerebrovascular disease are down by 39 per cent and 33 per cent respectively, while deaths due to diseases of the respiratory system have reduced by 12 per cent¹⁵². The overall rate of premature mortality remained relatively stable in comparison to 2015, where there had been an increase from 2014 of 4 per cent – likely due to the impact of the specific flu strain prevalent over the winter period, as similar patterns were seen in other European countries.

Chart 1 - European Age-standardised Mortality Rates per 100,000 Population for People Aged Under 75 in Scotland
Chart 1 - European Age-standardised Mortality Rates per 100,000 Population for People Aged Under 75 in Scotland

Source: National Records of Scotland: Age-standardised Death Rates Calculated Using the European Standard Population

Promoting Healthier Behaviours

NHSScotland has a key responsibility for promoting health and wellbeing in the population it serves; it recognises that it should also be an organisation that values and promotes health among its workforce and those that engage with the service. This is implemented through the Health Promoting Health Service programme.

The Health Promoting Health Service is about promoting health and addressing health inequalities in NHSScotland settings, and has actions to support staff, visitors and patients. Examples are the development of pathways for smoking cessation and weight management services and linking them to clinical care. To help people to make healthier choices, healthy options are available along with appropriate support and encouragement. Taking an holistic, person-centred approach, Health Promoting Health Service goes further than just treatment, recognising broader issues that impact on people's health and recovery, such as money worries and housing issues, so that those at risk of poverty and inequality achieve the best possible health outcomes. The focus in 2016/17 has been the particular actions the NHS can undertake to address inequalities.

Improvements in the hospital environment have been particularly evident over the reporting year, with healthier food choices not just being offered in staff canteens and visitor cafés, but also within the retail areas, and the continued ban and forthcoming legislation on smoking on NHSScotland grounds.

Tackling Alcohol-related Harm

Scotland continues to be 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 Action¹⁵³, which includes a package of over 40 measures to reduce alcohol-related harm by helping to prevent problems arising in the first place. This strategy is currently being refreshed to ensure it continues to meet Scotland's needs in tackling alcohol-related harm.

Alcohol Brief Interventions (ABIs) play an important preventative role in tackling problem alcohol use as part of a wider strategic approach. The ABI Programme has focused delivery on three priority settings: primary care, Accident and Emergency and antenatal services. There is also increased ABI delivery in wider settings, increasing coverage of harder-to-reach groups and supporting a focus on communities where deprivation is greatest. In 2016/17, 86,560 ABIs were carried out, exceeding the target of 61,081 by 42 per cent¹⁵⁴. The target will be continued into 2017/18 to support the long-term aim of embedding ABI delivery into routine practice.

In the case of the LDP Standard, which states that 90 per cent of clients will wait no longer than three weeks from referral to receive appropriate drug or alcohol treatment, national standards continue to be met or exceeded. In 2016/17, 45,524 people who started their first drug or alcohol treatment waited three weeks or less, which helps ensure that people with problem drug and alcohol use can continue to quickly access treatment and support to aid their recovery¹⁵⁵.

In 2016/17, responsibility for drugs policy in the Scottish Government moved from Justice to Health, opening up the possibility of problem substance use being tackled as part of wider health inequality strategies.

Reducing Smoking and Tackling its Harmful Effects

Considerable progress has been made in reducing the devastating impact of tobacco on society. Once a social norm, smoking rates are decreasing. Only 21 per cent of adults now smoke¹⁵⁶ and the number of young people lighting up regularly has dropped by more than two-thirds in the last decade.

Yet, tobacco remains the biggest cause of preventable ill-health and premature death in Scotland. Over 10,000 people die (one fifth of all deaths) and 128,000 are admitted to hospital each year from smoking-attributable illness¹⁵⁷. The impact of tobacco also costs NHSScotland more than £300 million per year¹⁵⁸. Lowering this death toll and narrowing the social inequalities which see smoking rates of up to 35 per cent in some deprived communities are core Scottish Government aims.

In 2013, the Scottish Government published the Tobacco Control Strategy – Creating a Tobacco-Free Generation¹⁵⁹, which set out targets to reduce the prevalence of smoking to five per cent or less by 2034. We continue to work towards creating a tobacco-free generation where young people do not want to smoke or suffer the negative health and economic impacts nicotine addiction creates.

The need to minimise the risks to public health led to the introduction of the historic ban on smoking in enclosed public spaces in 2006. While this has transformed work and leisure spaces in Scotland, more action was needed to protect young people in particular from second-hand smoke and to de-normalise smoking itself.

The Take it Right Outside campaign of 2014 further raised awareness of the dangers of second-hand smoke in enclosed spaces such as homes and cars. The world-first target to substantially reduce children's exposure to second-hand smoke to six per cent by 2020 was met in 2015. There was a slight increase to seven per cent in 2016, although this change was not statistically significant¹⁶⁰. Safeguarding the right of children to grow up in smoke-free environments was bolstered by the Smoking Prohibition (Children in Motor Vehicles) (Scotland) Act 2016, which makes it an offence to smoke in a private vehicle when someone under 18 years is present.

While hospitals are exemplars in providing smoke-free environments for staff, patients and visitors, some challenges remain in encouraging people to comply with the policy. The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 includes measures to introduce new laws which will make it an offence to smoke within a designated perimeter around hospital buildings. This aims to support NHS Boards' smoke-free grounds policies by extending the existing indoor ban a set distance from the structure of a hospital building making it an offence, liable to penalties or fines on conviction, to smoke or knowingly allow others to smoke tobacco products within this perimeter area. The regulations are currently in planning.

The reduction in smoking prevalence among adults is testimony to the key role NHSScotland plays in tobacco control efforts. The 2016/17 performance target for smoking cessation was significantly higher than the 2015/16 target, at 9,404 successful 12-week quits in the 40 per cent most deprived communities (60 per cent for island NHS Boards) between April 2016 and March 2017. Amidst falling numbers of smokers making quit attempts, NHSScotland did not achieve the 2016/17 target. 7,842 successful quit attempts were achieved in the 40 per cent most deprived most communities¹⁶¹.

Encouraging and Enabling a Healthy Weight

Excess weight brings with it a risk of disease and a cost to society. Similar to other developed countries, Scotland has a high proportion of its population overweight or obese. The Scottish Health Survey Results 2016¹⁶² showed almost two-thirds of adults (65 per cent) in Scotland are overweight or obese, with 29 per cent classified as obese. Work continues to support a series of healthy weight interventions, including supporting adult and child healthy weight interventions in NHS Boards.

Overweight and obesity, though, cannot be tackled by just relying on people to change their behaviour, as the factors that contribute to gaining weight have been interwoven into the very fabric of our lifestyles to such an extent that weight gain is almost inevitable in today's society. It is therefore imperative that the obesity-promoting environment is tackled to make it easier for people to make healthier choices. The prospect of the Soft Drinks Industry Levy¹⁶³ has encouraged manufacturers to lower the calorie content of many soft drinks.

Implementing the Healthcare Retail Standard

As part of the Health Promoting Health Service, NHSScotland has implemented the new Healthcare Retail Standard (HRS) in all stores and trolley services operating in its hospitals. This work complements the Healthyliving Award Plus that already requires restaurants and cafés to meet certain standards for healthy food and is the first of its kind in the UK.

The HRS means that at least 50 per cent of food and 70 per cent of drinks have to be healthier and it puts restrictions on what can be promoted in-store, whether by price or position. Retailers like the Royal Voluntary Service and WHSmith have worked hard to change their offer, especially on snacks and soft drinks, in order to meet assessments carried out by the Scottish Grocers Federation. Early signs suggest that consumers are responding positively to the changes, with a noticeable shift away from confectionery and sugary drinks towards options that are better for people's health¹⁶⁴. A formal evaluation is underway and will report in 2018.

Many consumers are NHSScotland staff so the move has been made very much with staff in mind, not just in the purchase and consumption of food, but also in consideration of their own health and wellbeing and as role models for patients and visitors to hospitals. The evaluation will therefore ask the views of consumers as well as retailers and will consider whether any of these healthier practices could be rolled out in other settings.

Promoting Physical Activity through 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 weight¹⁶⁵. The programme was also cost-effective. With funding from the 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 FFIT. 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.

Football Fans In Training is now internationally-recognised and the programme has successfully been extended to women. It has been transferred to the English Leagues with clubs such as Southampton, Middlesbrough, Blackburn Rovers and Torquay actively involved. Work is also underway to transfer the programme to the German Bundesliga. This is just one of a number of programmes delivered by football clubs in Scotland which is promoting physical activity and helping to deliver positive outcomes.

Expanding the Care... About Physical Activity Programme

In Scotland, older adults are significantly less likely than younger adults to achieve the recommended amount of 150 minutes of moderate to vigorous physical activity per week¹⁶⁶. Physical inactivity is particularly common amongst older people who use care services, whether at home or in a care home. Some do not receive the support that is needed to encourage them to participate in physical activity and many spend much of their day seated.

In 2016/17, the Scottish Government provided nearly £1 million in funding to the Care Inspectorate to further develop and expand their successful Care… About Physical Activity (CAPA) programme¹⁶⁷. Working with eight Health and Social Care Partnerships across Scotland, the programme will run until October 2018 and the CAPA team will build on the skills, knowledge and confidence of staff to enable those they care for to increase their levels of physical activity and move more often. People who work in community health and social care services will also discover ways to be more active themselves.

The programme includes:

Working with care homes for older people to embed the use of CAPA;

Working with care at home, housing support and other support services for older people to equip staff to promote physical activity and scope out what specific resources they may require to be developed;

Developing Care Inspectorate staff;

Developing and testing a module on physical activity to embed into the health and social care curriculum; and

Holding a national event in September 2018 to share good practice widely and to celebrate success.

Although at an early stage, the programme is already demonstrating impact¹⁶⁸.

Reducing Health Inequalities

Links Workers

As we develop the medical and wider clinical support in the community, new forms of professional practice are developing. This includes links workers, who help people primarily in socially deprived communities access and make the most of resources to improve their health and life chances. The Scottish Government has committed to recruiting an additional 250 links workers in practices in deprived areas, with the first 40 in place by September 2017. The roll out will be phased until 2021, with the first 40 links workers based in Inverclyde, North Ayrshire, Edinburgh, Dundee and Glasgow. The first phase will be evaluated in 2017/18. The focus in 2016/17 has been on completing the pilot projects and developing plans to roll the programme out across Scotland.

Child Poverty

Income matters to health; poverty adversely impacts on children's social, emotional and cognitive outcomes and subjects families to additional stress¹⁶⁹. One in four children in Scotland is living in poverty and 70 per cent of those children are in households where at least one person is working¹⁷⁰. Increasing income amongst pregnant women and families with young children contributes to reducing child poverty. NHS Health Scotland supported NHS Boards, Health and Social Care Partnerships and partners across Scotland to map current referral pathway activity, develop national tools and deliver learning sessions to embed good practice models. This work will support midwives and health visitors to ask pregnant women and families with young children about money worries and offer referral to a local advice service. E-learning modules on child poverty were also developed to raise awareness of poverty and its impact on health and wellbeing, and these were embedded in undergraduate and continuing professional development programmes.

Human Papilloma Virus Vaccination

Vaccination programmes in Scotland continue to protect our population against serious vaccine preventable diseases. The Human Papilloma Virus (HPV) vaccination programme was introduced in 2008 with the aim of helping to protect girls against developing cervical cancer. Around 80 per cent of cervical cancers in Scotland are caused by the human papilloma virus, in particular types 16 and 18¹⁷¹.

The efficacy of the HPV vaccine has been monitored since the programme began in 2008 and it has already begun to show encouraging and positive signs of preventing the occurrence of cervical cancer caused by HPV. A recent longitudinal population study measuring the impact of the HPV vaccination programme has shown that following its introduction, the level of cancer-causing HPV in Scotland has dropped by 90 per cent in young women who have received the HPV vaccine. The study compared the anonymous cervical screening results of women born in 1995, who would have been eligible for vaccination, with women born between 1989 and 1990, who were unvaccinated. In doing so, the researchers could assess the presence and levels of HPV, including genotype, for both groups of women. The researchers found that 21.4 per cent of women born between 1989 and 1990 tested positive for HPV 16/18 compared to only 0.5 per cent of women born in 1995. These new findings demonstrate the significant and continued benefits of the HPV vaccination programme in Scotland¹⁷².

Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.

Chapter 4 
Securing Value and Financial Sustainability

'...more needs to be done than simply giving the NHS extra money – which is why our plans for change and approach to investment and reform are so important'

While continuing to operate in a challenging financial environment, NHSScotland continues to make advances in securing value and financial sustainability, supported by year-on-year real-term increases in funding.

Financial Overview

In 2016/17, spending on health received an above-inflation increase and rose to almost £13 billion. NHS Territorial Boards received a 5.5 per cent increase compared to 2015/16 budget levels. This included an additional £250 million which the new Health and Social Care Partnerships invested in social care under arrangements for the integration of health and social care.

Over the course of this Parliament, the NHSScotland revenue budget will increase by £2 billion, which will enable shifting the balance of care to mental health and to primary, community and social care, and will include additional investment of £500 million in primary care. As the First Minister has set out, this means that, for the first time ever, more than half of frontline spending will be on community health services, delivering primary, community and social care.

In 2017/18, funding on health has exceeded £13 billion. As part of this, the Scottish Government has committed an additional £327 million to NHS Boards, which is £176 million more than inflation. This is an important step towards achieving the Scottish Government's commitment to increasing the NHS revenue budget by £2 billion.

Despite the increased level of resources, it is clear that more needs to be done than simply giving the NHS extra money – which is why our plans for change and approach to investment and reform are so important. This is why the funding for NHS Boards in 2017/18 includes an additional £128 million to reform services to meet the changing needs of the population, take advantage of new technology and innovation and explore the added value and opportunities which working across traditional geographical boundaries brings.

Reform

The integration of health and social care is one of the most significant reforms since the establishment of the NHS. It is about ensuring that those who use services get the right care and support whatever their needs, at any point in their care journey.

Under the Public Bodies (Joint Working) (Scotland) Act 2014, Territorial NHS Boards and Local Authorities delegate some of their functions and resources to new Health and Social Care Partnerships. These functions cover primary and community health services, social care and unplanned admissions to hospital and give Health and Social Care Partnerships a unique position in being able to innovate and direct improvements across the entire care pathway to deliver best value.

Based on local priorities and working in partnership with the third and independent sectors, Health and Social Care Partnerships decide through their strategic plans how best to allocate their pooled budget to fund capacity where it is most needed, in order to improve outcomes for their local populations. By focusing on improving palliative and end of life care, reducing unplanned hospitalisation as well as delayed discharges, the Partnerships are key to ensuring the Health and Social Care Delivery Plan objectives are achieved.

In 2016/17, Territorial NHS Boards delegated £5.7 billion of their budgets to Health and Social Care Partnerships and Local Authorities delegated a further £2.5 billion, creating pooled budgets of £8.2 billion across the 31 Health and Social Care Partnerships. Despite this being the first full year of their operation, the Partnerships have already had a significant impact. For example, the Glasgow City Health and Social Care Partnership has seen significant improvement in performance following the introduction of discharge to assess, which aims to ensure patients are discharged within 72 hours of being medically fit. This, alongside the increase in step-down intermediate care beds commissioned from private sector care homes, has resulted in a reduction in the number of bed days lost to delay by over 50 per cent, from 46,250 to 23,770, over the last two years (2014/15 to 2016/17)¹⁷³.

Sustainability and Value Programme

In order to manage within the levels of funding allocated, every year NHS Boards identify a level of savings which are then retained for local reinvestment in services. Plans based on these savings are continually developed throughout the year to deliver better services, better care and better value.

During 2016/17, there has been a focus on ways in which these challenges may be met through the Sustainability and Value Programme Board that oversees a range of work to deliver real productivity, efficiency and cash-releasing gains. This work is delivered by NHS Boards and their partners working collaboratively to implement transformational changes in practice across clinical and infrastructure services. These programmes of work (outlined below) have had some success in supporting NHS Boards to achieve their required efficiency savings. The focus on these areas will continue in 2017/18, along with digital transformation and capital planning.

Workstreams

The Sustainability and Value Programme Board currently oversees four workstreams: effective prescribing; workforce; clinical transformation; and shared services. The maturity of the model, as well as evidence from other healthcare systems working towards similar goals, suggested the need for a refresh of the workstreams in order to capture the range of activity being delivered. While the Sustainability and Value Programme Board does not 'own' most of the activities, its role is to identify, promote, support, monitor and report on the widest possible range of activities being delivered across NHSScotland.

The Effective Prescribing programme was established to accelerate change through clinical leadership, removing barriers to change and adding focus and pace to work already under way in NHS Boards or to identify new areas of work. The adoption of a 'once for Scotland' approach ensures the best use of resources through joint working in order to improve patient healthcare outcomes. Chart 2 highlights key areas of work during 2016/17:

Chart 2 - Effective Prescribing Impact Report for 2016/17*

Intervention | Efficiency Impact (approx. £m)
Biologics – switch to 'once for Scotland' procurement and prescribing | 8.4
Polypharmacy reviews – cost avoidance | 2.4
Respiratory prescribing – implementing recommendations | 0.3
Single National Formulary – preliminary work on local compliance | 3.0
Total | 14.1

*These are approximate figures and may manifest in the service through greater productivity, cost avoidance or efficiencies.

The workstreams for 2017/18 are: effective prescribing; workforce; clinical transformation; infrastructure; digital; and capital.

Work included in the programmes may flow from a number of sources and can be drawn from any evidence base (currently in place in Scotland; tried successfully in another healthcare system; potential carry-over from non-healthcare setting) but, crucially, all need to meet a number of criteria, namely:

Outcomes are better;

Staff gain from the initiative by, for example, improved utilisation of skills and competencies; and

It is proven to be more cost-effective at a local, regional or national level.

Capital Investment

In order to support a shift in the balance of care, the hub investment programme has taken forward a number of projects that will support the more-effective delivery of primary and community services across the country. These projects include: NHS Greater Glasgow and Clyde's Health Centres in Maryhill, Eastwood and Inverclyde; NHS Lothian's three health centres in Muirhouse, Firrhill and Blackburn in West Lothian; and the Stirling Care Centre, which is a joint venture involving NHS Forth Valley, Stirling Council, Forth Valley College and the Scottish Ambulance Service. NHS Lothian also started construction on the East Lothian Community Hospital which will provide a variety of community inpatient and outpatient services and is expected to open in 2019/20.

Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.

Chapter 5
Making Change Happen – Our People

'Our workforce is our greatest asset and is key to delivering modern, sustainable health services.'

Our workforce is our greatest asset and is key to delivering modern, sustainable health services. NHSScotland needs to have a committed, supported workforce that has the right skills, flexibility and support. Everyone needs to be valued, treated well and supported to give their best – we know that this improves patient care and overall outcomes for patients. Everyone Matters: 2020 Workforce Vision remains the key strategic statement of our commitment to our workforce.

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.

Promoting Our Values

The NHSScotland values are:

Care and compassion;

Dignity and respect;

Openness, honesty and responsibility; and

Quality and teamwork.

To support the delivery of the 2020 Workforce Vision, our priorities remain:

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 person-centred, safe, effective care;

Integrated Workforce – working to deliver integrated 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 people to deliver the 2020 Vision.

Everyone Matters: 2020 Workforce Vision¹⁷⁴ was published in 2013. During 2016/17, the focus started to shift to the period beyond 2020 by taking stock of the progress made to date and considering what is needed to support both the health and the social care workforce in the future. This involved engaging with partners to consider the development of a workforce vision for both health and social care staff working in integrated settings. This work will continue during 2017/18, and will involve engagement across health and social care. During this time, Everyone Matters: 2020 Workforce Vision will continue for NHSScotland staff, and is being refreshed during 2017/18 to align it with recent and current policies and developments.

Valuing All Our Staff

Everyone Matters: 2020 Workforce Vision recognises the importance of supporting and valuing all of our workforce. However, the result of the EU Referendum in June 2016 brought uncertainty for some of those working across NHSScotland. That is why, on the day following the referendum result, I wrote to the Chairs and Chief Executives of all NHS Boards, emphasising how much I valued the contribution of all members of staff, regardless of citizenship. Scottish Ministers have also emphasised their support on many occasions, and have given their commitment to do all they can to ensure that those European Economic Area (EEA) citizens from outside the UK who are working in NHSScotland can continue to live and work in Scotland.

Healthy Organisational Culture

Improving Staff Experience

A key action in promoting a healthy organisational culture over recent years has been the implementation of iMatter, the continuous improvement model to improve staff experience across NHSScotland. The implementation programme has gone from strength to strength during 2016/17. This transformational approach, which was developed by NHSScotland staff, has now been rolled out by all NHS Boards. Between 2015 and August 2017, a total of 172,281 health and social care staff have checked into the system. Furthermore, 23 Health and Social Care Partnerships have chosen to participate in this staff experience measure, and it is anticipated that this number will grow. This demonstrates the recognised success of the iMatter model and the benefits of involving staff in decisions that affect them, particularly as the integrated health and social care landscape continues to mature.

Ultimately, improved staff experience should benefit patient and client care. During 2017, to ensure a full picture of staff views on working for NHSScotland and to build on the success of iMatter, the approach will be supplemented with a short dignity at work survey. The survey will give NHSScotland staff and Local Authority staff working in participating Health and Social Care Partnerships the opportunity to express their views on dignity at work issues not currently covered by iMatter, including: bullying and harassment, discrimination, abuse and violence from patients and the public, resourcing and whistleblowing. The results of this survey, together with the national iMatter results, will provide a full overview of staff experience and will inform a national report which is expected to be published in February 2018.

Enabling an Engaged and Empowered Workforce

A healthy organisational culture is one which ensures that it is safe and acceptable for staff to speak up about wrongdoing and malpractice within their organisation. Working with NHS Boards, the Scottish Government continues to develop policies to support and promote an open and transparent reporting culture across NHSScotland. Development of the role of the Independent National Whistleblowing Officer (INWO) for NHSScotland has continued during 2016/17, with a focus on getting the role right. The Scottish Government is working to ensure that the INWO role is introduced as soon as possible and that it has the ability to provide independent challenge and oversight with the powers it needs to make a real difference. It is anticipated that this role will be introduced in late 2018. The service that provided the NHSScotland Confidential Alert Line (NCAL) has been expanded and, from 1 August 2017, became the Whistleblowing Alert and Advice Services for NHSScotland. The service continues to offer support to staff from legally-trained advisers on whether or how to whistleblow but also now has an increased focus on resources and support for staff and managers. The oversight and assurance role of non-executive Whistleblowing Champions in NHS Boards has also been maturing. This role was introduced in 2015 to ensure that NHS Boards comply with their responsibility to promote whistleblowing, support whistleblowers, and ensure that all concerns raised are appropriately investigated. The Whistleblowing Champions meet on a regular basis to share their experiences and learn from each other to ensure that their role makes a difference.

Building a Sustainable Workforce

Everyone Matters: 2020 Workforce Vision also recognises the importance of having a sustainable workforce with the right people available to deliver the right care, in the right place, at the right time. The numbers of NHSScotland staff continued to rise during 2016/17, with the March 2017 figures showing 139,431 WTEs¹⁷⁵. During the reporting year, considerable progress was made on workforce planning issues, including a number of manifesto and Programme for Government commitments which had a direct impact on the NHSScotland workforce, including: commitments for an additional 500 health visitors to be recruited by 2018; a commitment to increase the number of GP training places from 300 to 400 a year; and to train another 1,000 paramedics to work in the community, helping to reduce pressure on A&E services.

Scottish Ministers also signalled a new approach to workforce planning, making a commitment to the Scottish Parliament in autumn 2016 to publish a national workforce plan. This recognised the need for workforce planning to keep pace with changing services. The Health and Social Care Delivery Plan was explicit about the need for workforce issues to be considered alongside service and financial planning issues, and emphasised the importance of better coordination of national, regional and local workforce planning against a complex and shifting health and social care background.

A series of discussions with stakeholders across health and social care identified issues for further consideration, and a discussion document was produced for public consultation in January 2017. This identified recommendations covering a number of key areas including governance, roles, data, recruitment and retention, guidance and student intakes. The response to the consultation was very positive, with 79 responses received. These contributed to key themes in the eventual publication in June 2017 of Part One of the National Health and Social Care Workforce Plan¹⁷⁶, with Parts Two and Three, on integrated social care and primary care respectively, scheduled to follow later in the year (with Part Three subject to the conclusion of GMS contract negotiations).

Part One of the National Health and Social Care Workforce Plan strengthens and harmonises NHSScotland workforce planning practice nationally, regionally and locally. Measures set out in Part One – including the establishment of a National Workforce Planning Group and increases in the number of training places for medicine, nursing and midwifery – focus on ensuring NHSScotland has the workforce it will need to address future demand for safe, high-quality services for Scotland's people. These important steps will enable different health and social care systems to move together towards publication of a second full Health and Social Care Workforce Plan in 2018 and beyond.

Supporting Decisions on Safe and Effective Staffing

The link between safe and sustainable staffing levels and high-quality care is well established. It is vital to have the right number of staff in place, with the right skills. The Scottish Government's Programme for Scotland 2016/17, published in September 2016, made a commitment to begin work to engage with stakeholders to shape the consultation on enshrining safe staffing levels in law, putting Scotland's innovative nursing and midwifery planning tools on a statutory footing, and exploring how this model can be extended to other parts of the health and social care workforce. A formal consultation period began in April 2017¹⁷⁷. Proposals are being developed in consultation with stakeholders, including staff bodies, reflecting our ongoing commitment within NHSScotland to work in partnership with staff side colleagues. The timetable for the work will continue through to 2019 when the legislation will be enacted.

Meeting Recruitment Challenges

The Scottish Government has continued to work with NHS Boards across Scotland to review existing recruitment arrangements and explore new recruitment models, particularly in areas of acute staffing need. Scoping activity is being undertaken by human resource (HR) specialists to examine the sequencing of the international recruitment process and identify potential barriers and disincentives at all stages, from the advertisement of roles, to appointment and induction. This work is taking place as part of proposals to design a pan-Scotland international recruitment campaign across radiology specialisms. It is anticipated that the outcomes of this programme will provide a model for pursuing regional and national approaches to recruitment across other medical specialties. In addition, NHS Boards are looking at the recruitment challenges presented by Scotland's distinctive demographic structure, including how they might work together to increase the attractiveness of recruitment to posts in hard-to-fill specialties. NHS Boards continue to monitor areas of staffing need and gather evidence of shortages across services, and a series of actions are also being progressed by NHS Education for Scotland to improve the approach to recruitment and retention, reflecting its inclusion as one of the key themes in Part One of the National Health and Social Care Workforce Plan.

Developing the Young Workforce

During 2016/17, NHS Boards and the Scottish Government have been working in partnership to pursue a strategic approach to youth employment that aligns the current and future staffing needs of NHSScotland with opportunities for young people to pursue NHS careers. A Young People Working Group has been developed and was convened in June 2017. The Group comprises HR specialists from NHS Boards and representatives of the Scottish Government, and will specifically examine how existing pre-employment support might be expanded across NHS Boards, with a view to providing onward access entry-level posts, including Modern Apprenticeships, for young people from disadvantaged backgrounds. More broadly, the Scottish Government is working with NHS Education for Scotland (NES) to gather data to improve our strategic planning activity in relation to developing the young workforce, including funding for a dedicated post to audit current youth employment activity across NHS Boards.

This post will also examine the implementation of new frameworks and initiatives to increase the youth employment talent pipeline, in line with the commitments made in the National Workforce Plan.

Developing a Capable Workforce

Widening Access to Medicine as a Career

The 2020 Workforce Vision also prioritises ensuring that all staff have the skills they need to deliver person-centred, safe and effective care. Widening participation in medicine contributes to this, both through addressing inequality for those from social and geographically disadvantaged situations and creating a diverse environment that benefits all our students and medical practice in Scotland. The Scottish Government has developed a package of measures supporting these aims. It includes funding for a new pre-medical entry programme with Glasgow and Aberdeen Universities, providing 40 places for students from disadvantaged backgrounds to provide the best possible chance of meeting the entry requirements to study medicine.

In 2016, university medical schools successfully recruited an additional 50 medical undergraduates, with a focus on widening access principles¹⁷⁸. Medical schools are being encouraged to maintain and improve on this in 2017.

Discussions on delivering Scotland's first Graduate Entry Medicine (ScotGEM) programme in partnership with Dundee and St Andrew's Medical Schools are progressing well and this will commence in autumn 2018. The Scottish Government will pay the tuition fees of eligible students who are accepted onto ScotGEM. This provides exception to the normal rules which apply to those who already have a degree.

An additional 100 new GP Specialty Training posts were added from 2016, taking overall annual GP trainee posts advertised to 400 and, following national recruitment, there were 37 successful applicants¹⁷⁹. In tandem, to promote General Practice as an attractive career choice, a one-off taxable bursary of £20,000 is available to trainees in posts that historically have been more difficult to recruit to. The bursary payment is made to trainees as a lump sum on taking up the post and in return they agree to complete the three-year placement in that location¹⁸⁰.

Supporting Access to Nursing and Midwifery Education and Careers

The Scottish Government's Programme for Government 2016/17¹⁸¹ committed to create 1,000 additional training places for nurses and midwives over the course of this Parliament, to keep tuition for nursing and midwifery students free and to retain the nursing and midwifery student bursary at least at its current level.

To help deliver these commitments, in January 2017, the First Minister announced measures to increase the number of nurses and midwives in Scotland and help widen access to training places. The number of funded university places for those starting nursing and midwifery training will increase by 4.7 per cent in the 2017/18 academic year, bringing the total recommended intake to 3,360 places – the fifth successive increase. Adult nursing, mental health nursing, children's nursing and midwifery will all see an increased number of new students. The number of student training places in the north-east of Scotland will also increase. In addition, the First Minister announced that an extra £3 million per year will be invested to increase financial support for nursing and midwifery students with children or dependants – supporting 800 to 1,000 students who are most in need. A £1 million discretionary fund to provide a safety net for student nurses and midwives has also been put in place and commenced in October 2016.

During 2016/17, the Scottish Government also continued to provide financial 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 continues to be much more successful than originally planned, with a total of 310 former registrants taking up the opportunity to retrain between May 2015 and February 2017¹⁸².

Transforming Roles

To ensure that nursing roles keep pace with changing needs, the Chief Nursing Officer's Transforming Roles programme continued work to agree nationally-consistent roles and education preparation for advanced nurse practitioners, district nurses and school nurses.

In November 2016, a further important step was taken along the pathway to empowering patients to take control of their own health to maintain independence and reduce unnecessary use of healthcare services by extending supplementary prescribing rights to dietitians and independent prescribing rights to therapeutic radiographers. The measure followed a UK-wide public consultation in 2015 and makes better use of the skills of Allied Health Professionals.

Effective Leadership and Management

Executive Leadership and Talent Management Programme

Work to develop the Executive Leadership and Talent Management Programme continued during 2016/17. The Leadership and Talent Management Group continued discussions to set out the rationale, aims and outcomes for the development of a new end-to-end approach to executive level leadership and talent management within the NHS in Scotland. The approach, which was being discussed across a range of stakeholders – including NHS Board Chairs and Chief Executives and the Chairs of the Executive Director level professional groups – was looking specifically at six key workstreams to be planned and delivered nationally. These cover: values-based recruitment; executive performance management and appraisal; talent management and succession planning; leadership development; governance and oversight; and communications and engagement. An overview paper was published in May 2017, setting out the new approach.

Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.

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

National 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.scot
Scottish Ambulance Service | www.scottishambulance.com
The State Hospital Board | www.tsh.scot.nhs.uk
Golden Jubilee Foundation | 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. Learning from Scotland's NHS, The Nuffield Trust, July 2017. Access at: www.nuffieldtrust.org.uk/research/learning-from-scotland-s-nhs

3. Health and Social Care Delivery Plan, The Scottish Government, December 2016. Access at: www.gov.scot/healthandsocialcaredeliveryplan

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

5. Further information on Realistic Medicine can be found in the Chief Medical Officer's Annual Report 2014/15: Realistic Medicine, The Scottish Government, January 2016 which can be accessed at: www.gov.scot/Resource/0049/00492520.pdf and in the subsequent Chief Medical Officer for Scotland Annual Report 2015/16 Realising Realistic Medicine, The Scottish Government, February 2017 which can be accessed at: www.gov.scot/Publications/2017/02/3336

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

7. Further information on the Montgomery Supreme Court judgement can be found at: www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_Judgment.pdf

8. Promoting Professionalism and Excellence in Scottish Medicine: A Report from the Scottish Medical and Scientific Advisory Committee, The Scottish Government, June 2009. Access at: www.gov.scot/Publications/2009/06/12150150/0

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

10. 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

11. Review of Targets and Indicators, The Scottish Government. Access at www.gov.scot/Topics/Health/Quality-Improvement-Performance/Review-Targets-Indicators

12. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Healthcare, The Commonwealth Fund, July 2017. Access at www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

13. Learning from Scotland's NHS, The Nuffield Trust, July 2017. Access at: www.nuffieldtrust.org.uk/research/learning-from-scotland-s-nhs

14. National Performance Framework, The Scottish Government. Access at www.gov.scot/About/Performance/purposestratobjs

15. NHS Local Delivery Plan Standards, The Scottish Government. Access at www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets

16. Core suite of Integration Indicators, The Scottish Government, March 2015. Access at www.gov.scot/Topics/Health/Policy/Health-Social-Care-Integration/Statutory-Guidance-Advice/Indicators

17. Scotland Performs, The Scottish Government. Access at www.gov.scot/About/Performance/scotPerforms

18. Information Services Division, access at www.isdscotland.org. Scottish Government Health Statistics, Scottish Government, access at
www.gov.scot/Topics/Statistics/Browse/Health?utm_source=website&utm_medium=navigation&utm_campaign=statistics-topics. Health Protection Scotland. Quarterly Epidemiological Commentaries, access at www.hps.scot.nhs.uk

19. For example, Edinburgh Integration Joint Board Annual Performance Report 2106/17. Access at www.edinburgh.gov.uk/transformedinburgh/downloads/file/147/annual_performance_report_2016_17

20. Scottish Government press release 29 August 2017. Access at: https://news.gov.scot/news/new-initiative-to-tackle-waiting-times

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

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

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

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

25. ISD Scotland: Emergency Department Activity & Waiting Times, access at: www.isdscotland.org/Health-Topics/Emergency-Care/Publications/index.asp. 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

26. Health Protection Scotland: Quarterly Epidemiological Commentaries. Access at: www.hps.scot.nhs.uk/news/newsdetail.aspx?id=22224

27. Core suite of Integration Indicators, The Scottish Government, March 2015. Access at www.gov.scot/Topics/Health/Policy/Health-Social-Care-Integration/Statutory-Guidance-Advice/Indicators

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

29. ISD Scotland: Inpatient and Day Case Activity. Access at www.isdscotland.org/Health-Topics/Hospital-Care/Inpatient-and-Day-Case-Activity

30. Health and Care Experience Survey 2015/16, The Scottish Government, May 2016. Access at www.gov.scot/Publications/2016/05/9045

31. Scottish Care Experience Survey Programme, The Scottish Government. Access at www.gov.scot/Topics/Statistics/Browse/Health/careexperience

32. The Care Opinion website can be accessed at: www.careopinion.org.uk

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

34. Further information on 'What Matters To You?' can be found at: www.whatmatterstoyou.scot

35. What Matters To You?' Day Report 2016, Healthcare Improvement Scotland, August 2016. Access at: www.ihub.scot/media/1176/20160707-wmtyday-2016-report-v10.pdf

36. Further information on the House of Care approach can be found at: http://www.alliance-scotland.org.uk/health-and-social-care-support-and-services/house-of-care/

37. Scotland's House of Care Learning Report, The Health and Social Care Alliance Scotland (the ALLIANCE), December 2016. Access at: http://www.alliance-scotland.org.uk/blog/resources/house-of-care-learning-report/

38. Further information on ALISS can be found at: www.aliss.org

39. Further information on the Transforming Self Management Fund can be found at: http://www.alliance-scotland.org.uk/self-management-and-co-production-hub/self-management-policy-and-funding/transforming-self-management-in-scotland-fund/

40. Further information on the Self Management Awards can be found at: http://www.alliance-scotland.org.uk/blog/news/self-management-awards-2017-undefined-now-open

41. Making It Easy: A Health Literacy Action Plan for Scotland, The Scottish Government, June 2014. Access at: www.gov.scot/Publications/2014/06/9850

42. Further information on the Health Literacy Demonstrator Event can be found at: www.healthliteracyplace.org.uk/blog/2017/news/presentations-from-health-literacy-demonstrator-event

43. Making it Easy: Progress Against Actions, The Scottish Government, July 2016. Access at: www.gov.scot/Publications/2017/07/7806

44. Further information on the Person-centred Health and Care Programme can be found at: www.healthcareimprovementscotland.org/our_work/person-centred_care/person-centred_programme.aspx

45. Further information on Experience Based Co-design Methodology can be found at: www.kingsfund.org.uk/projects/ebcd

46. Further information on the Our Voice Citizens' panel can be found at: www.ourvoice.scot/citizens-panel

47. Further information on Care Opinion can be found at: www.careopinion.org.uk/info/patient-opinion-scotland. The report of the Care Opinion Scotland Annual Review 2016 – 2017 published in July 2017 can be accessed at: www.careopinion.org.uk/resources/scotland-annual-review-16-17.pdf

48. 2015/16 Health and Care Experience Survey, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey/HACE2015-16

49. 2016 Inpatient Experience Survey, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/InpatientSurvey/Inpatient2016

50. 2015 Maternity Care Survey, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/maternitysurvey/2015Results

51. 2015 Cancer Patient Experience Survey, The Scottish Government. Access at: www.gov.scot/Topics/Statistics/Browse/Health/cancersurvey/SCPES2015

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

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

54. Further information on the Apologies (Scotland) Act 2016 can be found at: www.legislation.gov.uk/asp/2016/5/contents/enacted

55. Further information on the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 can be found at: www.gov.scot/Topics/Health/Services/Smoking/HealthAct2016

56. Further information on NHSScotland Complaints Statistics can be found at: www.isdscotland.org/Health-Topics/Quality-Indicators/NHS-Complaints-Statistics

57. Further information on the Social Care (Self-directed Support)(Scotland) Act 2013 can be found at: http://www.legislation.gov.uk/asp/2013/1/contents/enacted

58. Further information on Self-directed Support can be found at: www.selfdirectedsupportscotland.org.uk

59. Self-directed Support Strategy 2010-2020, Implementation Plan 2016-2018, The Scottish Government, December 2016. Access at: www.gov.scot/Publications/2016/12/5432

60. Self-directed Support, Scotland, 2015-16, The Scottish Government. Access at: www.gov.scot/Publications/2017/07/1120/downloads

61. Scotland's Carers, The Scottish Government, March 2015: www.gov.scot/Publications/2015/03/1081

62. Further information on the Carers (Scotland) Act 2016 can be found at: www.gov.scot/Topics/Health/Support-Social-Care/Unpaid-Carers/Implementation/Carers-scotland-act-2016

63. Scotland's National Dementia Strategy 2017-2020, The Scottish Government, June 2017. Access at: www.gov.scot/Publications/2017/06/7735

64. Promoting Excellence: A framework for all health and social services staff working with people with dementia, their families and carers, The Scottish Government, June 2011. Access at: www.gov.scot/Publications/2011/05/31085332/0

65. Source: Management Data, NHS Education for Scotland and The Scottish Social Services Council

66. 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: http://ihub.scot/focus-on-dementia/

67. Estimated and Projected Diagnosis Rates for Dementia in Scotland 2014-2020, The Scottish Government, December 2016. Access at: www.gov.scot/Publications/2016/12/9363

68. Dementia Post Diagnostic Support: NHS Board Performance 2014/15, ISD Scotland, January 2017. Access at: www.isdscotland.org/Health-Topics/Mental-Health/Publications/2017-01-24/2017-01-24-DementiaPDS-Report.pdf

69. Further information on Focus on Dementia: Integrated Care Co-ordination in the Community can be found at: www.ihub.scot/focus-on-dementia/integrated-care-co-ordination-in-the-community

70. 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

71. Palliative and End of Life Care: A framework to support the learning and development needs of the health and social service workforce in Scotland, NHS Education for Scotland and the Scottish Social Services Scotland, 2017. Access at: http://www.sad.scot.nhs.uk/education-learning-resources/resource/?id=1186

72. Further information on The Scottish Strategy for Autism can be found at: www.autismstrategyscotland.org.uk

73. Further information on Principles to Good Transitions 3 and Autism Supplement can be found at: www.autismnetworkscotland.org.uk/the-principles-of-good-transitions

74. Further information on the Keys to Life can be found at: www.keystolife.info

75. Further information on Changing Places can be found at: www.changing-places.org

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

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

78. www.ihub.scot/media/1828/20160613-spsp90dayprocessfinalreport-v-3-0.pdf

79. Hospital Standardised Mortality Ratio Quarterly Release, ISD Scotland. Access at: www.isdscotland.org/Health-Topics/Quality-Indicators/HSMR

80. www.ihub.scot/media/1828/20160613-spsp90dayprocessfinalreport-v-3-0.pdf

81. The AVPU scale (an acronym from 'alert, voice, pain, unresponsive') is a system by which a healthcare professional can measure and record a patient's responsiveness, indicating their level of consciousness.

82. Improvement data submitted by NHS Boards to Healthcare Improvement Scotland as part of the MCQIC programme.

83. The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland, The Scottish Government, January 2017. Access at: www.gov.scot/Publications/2017/01/7728

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

85. Scottish Patient Safety Programme for Mental Health, iHub. Access at: www.ihub.scot/spsp/mental-health

86. AMR/HAI - SARHAI 5 Year Strategic Framework, The Scottish Government, October 2016. Access at: www.gov.scot/Topics/Health/Services/Preventing-Healthcare-Infections/SARHAI5YrStrategicFramework

87. Further information on HEI Inspections can be found at: http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/nhs_hospitals_and_services/hei_inspections/all_hei_reports.aspx

88. Commentary on quarterly epidemiological data on Clostridium difficile infection, Escherichia coli bacteraemia, Staphylococcus aureus bacteraemia and Surgical Site Infection in Scotland January to March (Q1) 2017, Health Protection Scotland, 4 July 2017. Access at: http://www.hps.scot.nhs.uk/haiic/sshaip/resourcedetail.aspx?id=3277

89. Towards 2020: Taking Care to the Patient, the Scottish Ambulance Service. Access at: www.scottishambulance.com/TheService/towards2020.aspx

90. Further information on the Vale of Leven Hospital Inquiry can be found at: www.valeoflevenhospitalinquiry.org/report.aspx

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

92. 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 Wales: Time Spent in NHS Wales Accident and Emergency Departments: Monthly Management Information. Access at: https://statswales.gov.wales/Catalogue/Health-and-Social-Care/NHS-Hospital-Waiting-Times/Accident-and-Emergency 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

93. The proposed model and the CMO's report are available at: www.traumacare.scot

94. National Institute for Health and Care Excellence (NICE).(2015) Coeliac disease: recognition, assessment and management. Access at: www.nice.org.uk/guidance/ng20

95. Ludvigsson et al. (2014) Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Access at: www.bsg.org.uk/images/stories/docs/clinical/guidelines/sbn/bsg_coeliac_14.pdf

96. NHS Inform, Coeliac disease (2017). Access at: www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/coeliac-disease

97. NHS Inform, Gluten Free Food Service (2017). Access at: www.nhsinform.scot/care-support-and-rights/nhs-services/pharmacy/gluten-free-food-service

98. Dermatology Patient Pathways website. Access at: www.dermatology.nhs.scot/dermatology-pathways

99. Data is not published but is collected by ISD in the MSK Audit and is available in the Trauma and Orthopaedic Dashboard.

100. Mental Health Strategy 2017-2027, The Scottish Government, March 2017. Access at: www.gov.scot/Publications/2017/03/1750/0

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

102. Probable Suicides: Deaths which are the Result of Intentional Self-harm or Events of Undetermined Intent, National Records of Scotland. Access at: www.nationalrecordsofscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/suicides

103. Suicide, The Scottish Public Health Observatory. Access at: www.scotpho.org.uk/health-wellbeing-and-disease/suicide/key-points

104. Further information on the NHS Health Scotland Suicide Prevention Programme can be found at www.chooselife.net

105. Further information on Breathing Space can be found at www.breathingspace.scot

106. Further information on the See Me programme can be found at www.seemescotland.org

107. 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: http://www.gov.scot/Publications/2015/11/9014

108. Community Eyecare Services Review, The Scottish Government, April 2017. Access at: http://www.gov.scot/Publications/2017/04/7983

109. A Plan For Scotland: The Scottish Government's Programme For Scotland 2016-17, The Scottish Government, September 2016. Access at: www.gov.scot/Publications/2016/09/2860/0

110. 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

111. Scotland's Oral Health Plan. A Scottish Government Consultation Exercise on the Future of Oral Health - Analysis of Responses, The Scottish Government, June 2017. Access at: www.gov.scot/Publications/2017/06/2471

112. Fairer Scotland Action Plan, The Scottish Government, October 2016. Access at: www.gov.scot/Publications/2016/10/9964

113. Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland, The Scottish Government, August 2017. Access at: www.gov.scot/Publications/2017/08/4589

114. Prescription for Excellence: A Vision and Action Plan for the Right Pharmaceutical Care through Integrated Partnerships and Innovation, The Scottish Government, September 2013. Access at: www.gov.scot/Publications/2013/09/3025

115. Source: Management data, Pharmacy and Medicines Division, The Scottish Government (based on information collected directly from NHS Boards)

116. Review of Access to New Medicines, The Scottish Government, December 2016. Access at: www.gov.scot/Publications/2016/12/9192/0

117. Polypharmacy Guidance, The Scottish Government, March 2015. Access at: www.sehd.scot.nhs.uk/publications/DC20150415polypharmacy.pdf

118. Kongkaew C, Hann M, Mandal J, Williams SD, Metcalfe D, Noyce PR et al. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy. 2013; 33(8): 827- 837.

119. Respiratory Prescribing Strategy 2014 to 2016, Developed by the Respiratory MCN Working Group, The Scottish Government. Access at: www.sehd.scot.nhs.uk/cmo/CMO(2014)14-Respiratory%20Prescribing%20Strategy%20June%202014.pdf

120. Diabetes Prescribing Strategy 2014-16, NHSScotland Diabetes Managed Clinical Network, The Scottish Government. Access at: www.sehd.scot.nhs.uk/cmo/CMO(2014)14-Diabetes%20Prescribing%20Strategy%20June%202014.pdf

121. Prescribing Cost Analysis, ISD 2009/10, 2010/11, 2011/12, 2012/13, 2013/14, 2014/15, 2015/16, 2016/17

122. National Therapeutic Indicators, 2012/13, 2013/14, 2014/15, 2015/16

123. National Therapeutic Indicators, 2012/13, 2013/14, 2014/15, 2015/16

124. Scottish Ambulance Service press release, 16 October 2017. Access at: www.scottishambulance.com/newsDesk/NewsItem.aspx?NewsID=218

125. Scottish Ambulance Service Annual Review Self-Assessment 2016/17. Access at: www.scottishambulance.com/userfiles/file/TheService/2017-04-08AnnualReviewSelfAssessment%20201617%20vFinal.pdf

126. Towards 2020: Taking Care to the Patient, The Scottish Ambulance Service. Access at: www.scottishambulance.com/TheService/towards2020.aspx

127. Scottish Ambulance Service Annual Review Self-Assessment 2016/17. Access at: www.scottishambulance.com/userfiles/file/TheService/2017-04-08AnnualReviewSelfAssessment%20201617%20vFinal.pdf

128. Scottish Ambulance Service Annual Review Self-Assessment 2016/17. Access at: www.scottishambulance.com/userfiles/file/TheService/2017-04-08AnnualReviewSelfAssessment%20201617%20vFinal.pdf

129. Cancer Incidence in Scotland (2015), ISD Scotland, April 2017. Access at: www.isdscotland.org/Health-Topics/Cancer/Publications/2017-04-25/2017-04-25-Cancer-Incidence-Report.pdf

130. Detect Cancer Early Staging Data, Information Services Division. Access at: www.isdscotland.org/Health-Topics/Cancer/Publications/2017-07-25/2017-07-25-DetectCancerEarly-Report.pdf

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

132. National Infertility Group Report, The Scottish Government, June 2016. Access at: http://www.gov.scot/Publications/2016/06/9960

133. Scottish Diabetes Survey 2015, Scottish Diabetes Survey Monitoring Group. Access at: www.diabetesinscotland.org.uk/Publications/SDS2015.pdf

134. Scottish Diabetes Survey 2016, Scottish Diabetes Survey Monitoring Group. Access at: www.diabetesinscotland.org.uk/Publications/Scottish%20Diabetes%20Survey%202016.pdf

135. National Diabetes Audit (NADIA). Access at: www.content.digital.nhs.uk/diabetesinpatientaudit

136. All of the resources are available through the iHuB website. Access at: www.ihub.scot/diabetes-think-check-act/learning

137. News item 'Think, Check, Act cuts hypoglycemia by 20 per cent in diabetes patients', 19 June 2015, diabetes.co.uk. Access at: www.diabetes.co.uk/news/2015/jun/think,-check,-act-cuts-hypoglycemia-by-20-per-cent-in-diabetes-patients-90173924.html

138. Inpatient and Day Case Activity, ISD Scotland. Access at: www.isdscotland.org/Health-topics/Hospital-care/Inpatient-and-day-case-activity

139. Report on the Specialist Nursing and Care Fund, The Scottish Government, September 2017. Access at: www.gov.scot/Publications/2017/09/7753

140. Report on the Specialist Nursing and Care Fund, The Scottish Government, September 2017. Access at: www.gov.scot/Publications/2017/09/7753

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

142. Source: Save a Life for Scotland website, June 2017. Access at: www.savealife.scot

143. NHSScotland Standards for Organisational Resilience, The Scottish Government, May 2016. Access at: www.readyscotland.org/media/1157/nhsscotland-standards-for-organisational-resilience-1st-edition-may-2016.pdf

144. Report of the Second Phase of the Review of NHS Pathology Services in England, Chaired by Lord Carter of Coles, Department of Health, 2008. Access at: http://webarchive.nationalarchives.gov.uk/20130124044941/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091984.pdf

145. Realising Realistic Medicine, The Scottish Government, February 2017. Access at: www.gov.scot/Publications/2017/02/3336

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

147. Further information on the Scottish Primary Care Information Resource (SPIRE) can be found at: www.spire.scot

148. NHS inform can be accessed at: www.nhsinform.scot

149. Further information on United4Health can be found at: www.sctt.org.uk/programmes/home-and-mobile-monitoring/united4health-new/project-main-achievements-eu-level-outcomes

150. A National Service Model for Home and Mobile Health Monitoring, Scottish Centre for Telehealth and Telecare. Access at: www.sctt.org.uk/programmes/home-and-mobile-monitoring/national-service-model-home-mobile-health-monitoring

151. Technology Enabled Care Strategic Briefing Paper: Responding to the fast growing demand for health services in a resource constrained environment. Access at: www.sctt.org.uk/wp-content/uploads/2017/04/TEC-Strategic-Briefing-Note-Final-Version-HMHM-March-2017SH.pdf

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

153. Changing Scotland's Relationship with Alcohol: A Framework for Action. Access at: www.gov.scot/Publications/2009/03/04144703/0

154. Information Services Division Publication Summary: Alcohol Brief Interventions 2016/17. Access at: www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2017-06-27/2017-06-27-AlcoholBriefInterventions-Summary.pdf

155. Information Services Division Publication Summary: National Drug and Alcohol Treatment Waiting Times Summary January – March 2017. Access at: www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2017-06-27/2017-06-27-DATWT-Summary.pdf

156. Scottish Health Survey 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

157. Scottish Public Health Observatory (ScotPHO) [2015]. ScotPHO Online Profiles Tool. Access at: www.scotpho.org.uk/comparative-health/profiles/online-profiles-tool

158. Scottish Public Health Observatory (ScotPHO) [2012]. ScotPHO Smoking Ready Reckoner - 2011 Edition. Access at: http://www.scotpho.org.uk/publications/reports-and-papers/smoking-ready-reckoner

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

160. Scottish Health Survey 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

161. NHS Smoking Cessation Statistics (Scotland) 2016/17, October 2017, ISD Scotland. Access at: www.isdscotland.org/Health-Topics/Public-Health/Publications/2017-10-24/2017-10-24-SmokingCessation-Report.pdf

162. Scottish Health Survey 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

163. Further information on the proposed Soft Drinks Industry Levy can be found at: www.gov.uk/government/publications/budget-2016-documents/budget-2016

164. Unpublished, commercially sensitive data indicates a shift in behaviours

165. 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

166. Scottish Health Survey 2016. Access at: www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey

167. Care… About Physical Activity: Promoting physical activity in care homes in Scotland – a good practice resource pack, The Care Inspectorate. Access at: www.careinspectorate.com/images/documents/2732/Physical%20activity%20guidance%20booklet.pdf

168. No published evaluation at this stage. Formal evaluation is at an early stage but the evidence so far is encouraging with: people experiencing care improved in the number of sit to stands they could complete after six weeks, by on average one stand, and in some cases up to four stands; and on average, at baseline people experiencing care had a medium fall risk, according to the Berg Balance scale. Those measured at six weeks reported higher average scores in standing and sitting unsupported, standing to sitting and standing with eyes closed than at baseline.

169. MacDonald W, Beck S, Scott E. Briefing on child poverty: Evidence for Action, NHS Health Scotland, 2013. Access at: www.healthscotland.com/uploads/documents/20578-ChildpovertybriefingMarch2013.pdf

170. Poverty and Income Inequality in Scotland: 2015/16, The Scottish Government, March 2017. Access at: www.gov.scot/Publications/2017/03/2213

171. Journal of Clinical Pathology, BMJ Journals / Volume 68, Issue 2. Access at: www.jcp.bmj.com/content/68/2/135.long

172. Human papillomavirus - vaccination campaign impact. Access at: www.hps.scot.nhs.uk/haiic/ic/wrdetail.aspx?id=72701&wrtype=2

173. Source: ISD Scotland, Delayed discharges – bed days occupied

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

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

176. National Health and Social Care Workforce Plan - Part One a framework for improving workforce planning across NHSScotland, The Scottish Government, June 2017. Access at: www.gov.scot/Publications/2017/06/1354

177. Further information on the Safe and Effective Staffing in Health and Social Care Consultation which opened on 11 April and closed on 5 July 2017 can be found at: https://consult.gov.scot/nursing-and-midwifery/safe-and-effective-staffing-in-health-care-setting/

178. Scottish Government press release, 10 February 2016. Access at: https://news.gov.scot/news/a-modern-health-workforce. Further information can be found in A Plan For Scotland: The Scottish Government's Programme For Scotland 2016-17. Access at: www.gov.scot/Publications/2016/09/2860/6

179. Scottish Government press release 9 August 2016. Access at: https://news.gov.scot/news/drive-to-recruit-gp-trainees. Further information can be found in A Plan For Scotland: The Scottish Government's Programme For Scotland 2016-17. Access at: www.gov.scot/Publications/2016/09/2860/6

180. Further information on the bursary can be found at: www.scotmt.scot.nhs.uk/recruitment/gp-recruitment/feb-18-intake-scottish-targeted-enhanced-recruitment-scheme-round-2-2017.aspx

181. A Plan For Scotland: The Scottish Government's Programme For Scotland 2016-17, the Scottish Government, September 2016. Access at: www.gov.scot/Publications/2016/09/2860

182. Management Data, NHS Education for Scotland