Copyright

© Crown copyright, 2014

You may use and re-use this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence v2.0.

Any email enquiries regarding the use and re-use of this information resource should be sent to: psi@nationalarchives.gsi.gov.uk

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

First published by The Scottish Government, December 2014
ISBN: 978-1-78412-915-6 (web only)

E-book in EPUB format first published by The Scottish Government, December 2014
ISBN: 978-1-78412-916-3 (EPUB)

E-book in MOBI format first published by The Scottish Government, December 2014
ISBN: 978-1-78412-917-0 (MOBI)

The Scottish Government
St Andrew’s House
Edinburgh
EH1 3DG

Produced for The Scottish Government by APS Group Scotland, 21 Tennant Street, Edinburgh EH6 5NA
PPDAS37700 (12/14)

Published by The Scottish Government, December 2014

Foreword

We are improving the quality of care and outcomes for the people of Scotland.

I am pleased to be able to bring you my first Chief Executive’s Annual Report. It outlines some of NHSScotland’s many achievements, and reflects on the opportunities and challenges ahead. I am extremely proud to lead the workforce – over 150,000 – of NHSScotland. The achievements in this report are a result of their compassion, professionalism and dedication and that of our partner organisations, and the wonderful contributions made by patients, carers, families and volunteers every day.

We have maintained commitment to our vision that by 2020 more people will be living longer healthier lives at home or in a homely setting. Our focus on person-centred, safe and effective care remains paramount, and I am delighted that the health and wellbeing of the people of Scotland continues to improve. But entrenched inequalities remain. Further impetus on tackling these inequalities is a key priority for the Scottish Government, and for me.

We know that, over the next few years, demand for health and social care services will continue to rise; people are living longer with multiple conditions. We need to ensure that care is delivered where it is most effective, and where we can secure the best outcomes for the people we serve. Our work with partners to integrate health and social care is central to that aim.

For the vast majority of people, their experience of NHSScotland is a very positive one, but we know things don’t always go right. The recent report into deaths related to Clostridium difficile infection at the Vale of Leven Hospital between 2007/08 was rightly critical of the care provided. We must redouble our efforts to ensure people receive the care they expect and deserve, and the Scottish Government will continue to act decisively to drive and sustain long-term improvements based on Lord MacLean’s recommendations.

NHSScotland is a world leader in using improvement science to deliver outstanding results. That needs to continue, but I believe that the experience of patients, families, carers and communities defines the reputation of NHSScotland. We will therefore also raise our game by focusing on the strengths of our people and communities, rather than perceived weaknesses, and by designing and delivering solutions with people, rather than for them.

I hope you enjoy reading the report.

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

High Quality Health and Care for Scotland

The right folk in his corner – community-based care for veteran army boxer.

John’s Story

At 86, John still shows the quick wit and spirit that made him a successful army boxer in the 5th Scottish Parachute Battalion. John served in the peace-keeping force that headed to Palestine in 1945, and on his return to Scotland he saw action of a different kind as a bouncer – or ‘chucker-out’ as they were called in the 60s – at Glasgow’s legendary Barrowland Ballroom.

The great-grandfather broke a hip last year, but was keen to get out of hospital as soon as possible – and back home to his flat in South Lanarkshire Council’s sheltered housing complex in East Kilbride. Supporting John in his determination to remain independent is a team effort – one that he likens to “having the right folk in his corner” during his boxing days.

The award-winning Integrated Community Support Team (ICST) that supports John brings together housing staff, social workers and healthcare professionals to provide a wide-ranging package of care. Physiotherapy and occupational therapy have helped to get him mobile again, and his home has been equipped with aids for his comfort and safety. John now gets a visit every day to make sure he’s well and happy.

John’s day begins with a care worker calling in to make his breakfast and have a chat, making sure he’s happy and comfortable. “John’s a proud man who likes to look after himself”, says home carer Billy. “It’s our job to support his independence.”

The multi-disciplinary team offers joined-up support under the national Reshaping Care for Older People programme (RCOP). The RCOP initiative is ensuring that many more older people like John can continue to enjoy the freedom and dignity of independent living for longer.

“I got a call button fitted in John’s house so he could easily contact me or the emergency services.”

Kate Beagan, Sheltered Housing Office, South Lanarkshire Council

Play video

Transforming care and delivering improved outcomes

Our 2020 Vision

Our vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting.

We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

Over the years ahead, the demands for health and social care and the circumstances in which they will be delivered will be radically different. John’s story shows how NHSScotland and its partners across the public and voluntary sectors are collectively recognising and responding to the most immediate and significant challenges we face. These include Scotland’s public health record and level of inequalities, our ageing population, the increasing expectations arising from new drugs, treatments and technologies, and the specific impact of inflation on the health service.

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

During 2012/13, A Route Map to the 2020 Vision for Health and Social Care[1] was developed and has continued to provide a focus on the priorities that will have the greatest impact on achievement of our vision. The Route Map describes priority areas for action in three domains:

Improving the quality of the care we provide;

Improving the health of the population; and

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

These domains are often referred to as the ‘Triple Aim’. For each of these domains there is a small number of priority areas for action, often building on existing work and all requiring focused attention and acceleration.

Through our approach to quality healthcare improvement as described in the Healthcare Quality Strategy for Scotland[2] we have continued to drive forward improvements in the care people receive. Our Quality Ambitions for person-centred, safe and effective care have continued to be the guiding light for the work that has been undertaken at national and local level, transforming care and delivering improved performance.

NHSScotland continues to have an important contribution to make to the Scottish Government’s Purpose and Outcomes in helping people to maintain and improve their health and wellbeing, especially in disadvantaged communities. Through the 2020 Vision, the Scottish Government has reaffirmed its commitment to high-quality publicly funded health and social care services for the people of Scotland. It recognises that these services contribute directly to growth in the Scottish economy by ensuring that the people of Scotland live longer, healthier lives and, with a focus on prevention and early intervention, remain active within their communities.

Of course, NHSScotland does not deliver improved outcomes for people in isolation. Effective partnership working with people, staff and partners across the public, voluntary and independent sectors and industry have delivered real results and are hallmarks of our approach. Many of the achievements you will read about in this annual report are a direct result of this.

The NHSScotland workforce will be vital in responding to the challenges faced. Our shared 2020 Workforce Vision is that 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. Everyone working in NHSScotland will be expected to live by our shared values of: care and compassion; dignity and respect; openness, honesty and responsibility; and quality and teamwork.

We will, however, need to go further. Achieving better outcomes for people from the care they receive will require NHSScotland to work more closely with its partners in local government, improving the quality and consistency of health and social care services, and ensuring that people receive the necessary service, at the right time, and in the most appropriate setting. The Public Bodies (Joint Working) Scotland Act – which received Royal Assent on 1 April 2014 – is transformational legislation that will introduce joint accountability arrangements for the planning and delivery of health and social care services, using the totality of adult health and social care budgets. New integrated authorities will be required to deliver national health and wellbeing outcomes.

Delivering Outcomes for People - Our Story of Achievement

Managing falls for older people.

Eva’s Story

When Eva suffered a fall in her Rothesay home and her husband Danny called an ambulance, the prompt arrival was impressive. Better still was the assessment by the crew that Eva didn’t need to go to hospital. She was given a full check-up, with the paramedics explaining exactly what was being done and why. Following up on the ambulance visit and as part of the pathway, Eva received a full screening and risk assessment, and a plan for ongoing support in the community is being tailored to her circumstances.

We know there are significant benefits in keeping older people out of hospital if they don’t need to be there – for their health as well as for their continued independence and quality of life – so treating them at home when possible is highly beneficial. It could also release resources and budget that could help pay for community services.

Falling at home is a distressingly frequent event for many older people, with around half of the over-80s experiencing a fall in any one year[3]. When an ambulance is called to someone who has fallen, the chances are he or she will be taken to hospital even when it may not be necessary.

NHS Highland is bringing community and service providers together to design solutions that work locally. A number of sites are testing a system where ambulance teams have a single point of access to integrated health and social care services.

Immediate support for the person at home can help avoid a hospital admission. When someone has fallen, they are screened for risk, in order to help them stay independent. Depending on the individual’s wishes, support can come from befrienders, sensory impairment teams, dementia specialists, occupational and physiotherapists, independent providers and the third sector, as well as the patient’s own GP and social workers.

“During a 14-month test period on the Isle of Bute we’ve reduced fall-related hospital conveyance for older people by 40 per cent. If we can scale that up to Scotland as a whole, the benefits will be phenomenal. Follow-up in the community is the critical part, with specific strength and balance exercises significantly reducing the risk of more falls in the future. Home exercise programmes or community classes may be an option. It’s all about joining together the resources that are already present in the local community, and getting the support right for the individual.”

Dr Christine McArthur, NHS Highland Co-ordinator, Prevention and Management of Falls.

Source: National Records Scotland: Vital Events, Deaths: Age Standardised Death Rates

Through a relentless focus on quality improvement, NHSScotland is striving to secure the best possible outcomes for people through the care and support they receive and is working with partners to ensure that people receive the necessary service, at the right time, and in the most appropriate setting.

During 2013/14, NHSScotland continued to make progress in a number of key areas in the delivery of a high quality healthcare service for the people of Scotland. It continued to build on many of the advances in service delivery secured in previous years, maintaining or improving performance despite the ongoing challenges it faces.

This chapter highlights many of these successes, reflecting on what NHSScotland has delivered over both the short and longer term. It will set this in the context of the challenges faced by NHSScotland and its partners – such as tackling pressures in unscheduled care and behaviour-led health inequalities. Despite the challenges, NHSScotland is well positioned to deliver the aim of being recognised as world-leading in the delivery of healthcare services.

Through its work to improve people’s health, NHSScotland has contributed significantly to the continued reduction in Scotland’s mortality rate[4] – a trend which continued during the latest year. In 2013, the death rate was 1,152 deaths per 100,000 population, a decrease of 20 per cent since 2003. Reductions were greater still for certain conditions, with death rates due to diseases of the circulatory system, heart disease and stroke all down by over 40 per cent during the past 10 years.

Premature mortality (deaths amongst those aged under 75 years) has also reduced substantially, down 24 per cent since 2003 – including a 2 per cent reduction during the latest two years. Again, some causes of premature mortality have seen a sharper fall during this time, with early deaths due to heart disease down by almost half at 48 per cent and stroke deaths down by 43 per cent. Crucially, there has also been a significant reduction in early deaths due to heart disease and stroke in Scotland’s most deprived communities, demonstrating one of the ways in which NHSScotland is supporting those areas with the poorest health outcomes[5].

Source: Scottish Government: Scottish Household Survey, 2013 Annual Report

NHSScotland has supported improved population health in a number of ways. There have been recent improvements in the early detection of cancer, the biggest cause of early death in Scotland. The sooner that cancer is diagnosed and treated, the better the survival outcomes. In 2012/13, 24.3 per cent of lung, breast and colorectal cancers were diagnosed at the earliest stage, an increase of 4.7 per cent on the previous two years[6]. Early detection will become all the more important in the future as an ageing population will mean increases in cancer incidence.

NHS Boards continued to work with partners to prevent suicide, a major public health challenge. Significant progress has been made against a long-term target to reduce the national suicide rate by 20 per cent, with rates down 19 per cent from 17.4 per 100,000 population in 2000-2002 to 14.0 per 100,000 in 2011-13[7].

Work continued to improve the health and wellbeing of Scotland’s population at all stages of the life-cycle. Antenatal support has increased, with 74.6 per cent of pregnant women in Scotland’s most deprived areas booking for antenatal care by the twelfth week of gestation in 2012/13, up from 65.2 per cent one year earlier. This work builds on previous improvements in pregnancy outcomes, with smoking levels amongst expectant mothers falling from 24 per cent in 2004 to 18 per cent by 2013 – with an equivalent drop in deprived areas from 40 per cent to 30 per cent[8].

In early years, dental decay is the most common reason to admit a child to hospital. To help tackle this almost totally preventable condition NHSScotland has been delivering applications of fluoride varnish to 3 and 4 year olds, with a particular focus on those living in the most deprived areas. In 2014, 68 per cent of Primary 1 children had no obvious tooth decay, a slight increase from 67 per cent in 2012[9]. NHSScotland also delivered almost 17,000 Child Healthy Weight Interventions during the three years to 2013/14[10], with the aim of preventing the burden of disease that accompanies obesity in later life. In 2013, 69.6 per cent of children were a healthy weight, up slightly from 67.5 per cent in 2012[11].

Smoking remains the biggest cause of preventable ill health in adults and NHSScotland, through its smoking cessation services, made a significant impact over the three years to 2013/14. Over 70,000 users from the most deprived NHS Board areas quit for at least one month during this time[12] – with the programme contributing to a decrease in the national smoking rate from 25.4 per cent in 2006 to 23.1 per cent by 2013[13]. Over the same time, the proportion of 15-year-old school pupils who smoke regularly fell from 15 per cent to 9 per cent[14]. NHSScotland also delivered over 100,000 Alcohol Brief Interventions to help prevent the increased morbidity, mortality and social harm that results from excessive consumption[15]. The proportion of males drinking to hazardous or harmful levels fell from 33 per cent in 2003 to 22 per cent by 2013, with the female rate dropping from 23 per cent to 16 per cent[16]. Despite these improvements in levels of smoking and alcohol consumption, Scotland still lags behind many other countries and significant further progress will need to be made in the years ahead.

When NHS treatment is needed, shorter waiting times lead to earlier diagnosis and better outcomes, minimising unnecessary worry and uncertainty for patients. Over 2013/14 as a whole, NHSScotland continued to deliver the 18-week Referral-to-Treatment waiting time Standard[17], which applies to the whole ‘pathway’ from referral up to the point the patient is treated. During this time, 316,217 patients (98 per cent of the 322,550 treated) also benefited from the 12-week Treatment Time Guarantee for planned inpatient or day case procedures[18].

Source: ISD Scotland: NHS Waiting Times, Cancer Waiting Times

Over 2013/14, NHSScotland also continued to deliver shorter waits for specific procedures. The 31-day Decision-to-Treat to treatment cancer waiting time Standard was met and whilst some challenges remain for the 62-day urgent referral with suspicion of cancer to treatment waiting time measure, almost 93 per cent of patients met the Standard in April to June 2014[19]. Those needing treatment to help tackle drug and alcohol misuse benefited from another strong year of NHSScotland support, with almost 97 per cent beginning treatment within three weeks of referral during April to June 2014[20] and work continued to deliver the first waiting times target for those requiring IVF treatment, due by April to June 2015.

NHSScotland’s waiting times performance also continues to compare favourably with the other three countries of the United Kingdom. A comparison of waits for 11 common procedures undertaken in 2012/13, including hip and knee replacements and cataract surgery, showed that patients in Scotland had the shortest average waits for nine of them[21]. As well as ensuring shorter waits, it is also vital that NHSScotland delivers the highest standard of quality and safety when providing treatment. Hospital Standardised Mortality Ratios, which compare observed deaths to predicted deaths, fell by 14.4 per cent between October-December 2007 and January-March 2014[22]. This demonstrated that, in the period leading up to early 2014, fewer patients died following treatment than would have been expected based on factors that are known to affect the underlying risk of death.

A further improvement made in patient safety is the significant reduction in levels of Healthcare Associated Infection (HAI). Rates of Clostridium difficile amongst those aged 65 and over fell by 8 per cent between 2012/13 and 2013/14, contributing to a 78 per cent decrease overall since 2007/08[23]. Rates of Methicillin-resistant Staphylococcus aureus (MRSA) fell by 16 per cent between 2012/13 and 2013/14, again contributing to an overall fall of 81 per cent since 2007/08[24].

Source: Health Protection Scotland: Clostridium difficile Quarterly Report

Those treated by NHSScotland in 2014 also continued to report a positive experience, with 89 per cent of inpatients rating their care as good or excellent, the highest figure since the survey began in 2010[25]. Overall, patients reported a more positive experience than the previous survey in a number of areas of service delivery – including the hospital and ward environment, their care and treatment and interaction with staff. Other surveys of GP patient experience and maternity care also reported broadly positive outcomes – with 87 per cent of GP patients[26] and 93 per cent of pregnant women rating their care received during labour and birth as good or excellent[27].

Sometimes NHS treatment is needed on an emergency or unplanned basis and pressures in this area continue to be felt by some Accident and Emergency (A&E) departments. NHSScotland has worked hard to tackle this over the past year and has had some success in reducing the longest waits. In 2013/14, 651 patients waited in A&E departments for over 12 hours, a reduction of 56 per cent on the previous year[28]. Progress was also made in reducing the rate of A&E attendance with a 4.8 per cent decrease between 2009/10 and 2013/14. Challenges also remain with the flow of patients out of hospital and into the community, with the number of bed days lost to delayed discharge increasing by 8 per cent between 2012/13 and 2013/14 from 491,721 to 532,499[29]. However, delays of four weeks remain far lower than those experienced 10 years ago, dropping 85 per cent from 1,166 in April 2004 to 173 in April 2014.

Source: ISD Scotland: Emergency Department Activity and Waiting Times

Improvements in the areas of unscheduled care and patient discharge will be a key outcome of the work undertaken by NHSScotland and its delivery partners in local government to integrate health and social care. Some progress is already being made – with more treatment being provided in an outpatient or daycase setting and with rates of emergency bed days for people aged 75 and over dropping significantly between 2009/10 and 2013/14[30], demonstrating that patients were spending less time in hospital before getting back into the community.

The achievements summarised in this chapter show that, while challenges remain, NHSScotland had another strong year of delivering high quality care in 2013/14. The following chapters will highlight how NHSScotland is achieving better health and care outcomes for the people of Scotland, with a focus on how it is improving quality of care, improving the health of the population, and securing value and financial sustainability.

Improving Quality of Care

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

THE QUALITY AMBITIONS
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.

Improving Quality of Care - Person-centred Care

Listening to families.

Evelyn and David’s Story

David has cerebral palsy and his condition means that he has had to spend a lot of time in hospital. And that means his mum, Evelyn, and the rest of the family are regular visitors too.

“I think what’s so important with any child, disabled or not, is to remember he or she is a wee person, who’s probably a bit scared and obviously not feeling very well. Our local hospital is great, because we’ve had time to build up a relationship with the staff there and it’s kind of a home from home”, says Evelyn.

When David was about a year old and started to go into hospital on a regular basis, Evelyn felt she was being asked the same questions again and again, every time she visited. She understood that they were important questions, and as she and her son would tend to be seen by different members of staff on each occasion, it wasn’t surprising that they were asked repeatedly. She did find it distressing, however, particularly as some of the information was quite personal and sensitive.

A simple solution was found by keeping a note of David’s basic information on a single sheet of paper in his file, so any new healthcare worker meeting the family for the first time would have instant access to the key facts. This saves time for the professionals, as well as making David and his family feel more comfortable. If the family travels to another part of the country, their community children’s nurse will contact a local hospital to let them know of David’s current condition, writing a letter in advance and providing the family with a copy. This means that if David suddenly needs attention, the local healthcare staff will have all essential background information to hand, even though they may not have met him or his family before.

Evelyn sees it as a partnership between the family and the healthcare workers. Through good communication and co-operation, they’re working together for everyone’s benefit.

“My other, older son Callum often comes to visit his brother on the ward and the staff are fantastic with him. They know him by name and take time to talk to him, so he actually enjoys going in to see David, which is a great help for me.”

Evelyn

“I think when healthcare professionals care for the whole family, they’re actually doing a better job for the patient. A few extra words of support and understanding make all the difference.”

Evelyn

Delivering person-centred care is a strategic priority for NHSScotland and the Scottish Government, and essential to the delivery of our 2020 Vision for Health and Social Care. In 2013/14, activity across NHSScotland focused on strengthening the voices of people using services, their families and carers, and supporting health and care services to listen, learn and make improvements as a result.

Healthcare Improvement Scotland continued to work across NHSScotland and with third sector partners, to test and spread best practice in person-centred care as part of the Person-Centred Health and Care Collaborative.

More patients and families benefited from person-centred visiting in 2013/14. Analysis in March 2014 revealed that people are benefiting from a range of more flexible visiting arrangements in 500 wards across the country. Staff are being supported to develop and test new ways to ensure that patients can spend more time with the people who matter to them.

NHS Tayside’s approach, for instance, has seen patients name the visitors they would like to have 24-hour access. All NHS Boards are now being supported, through the Collaborative, to enable friends and family to visit loved ones in hospital at more convenient times.

In NHS Greater Glasgow and Clyde, the What Matters to Me programme at the Royal Hospital for Sick Children gave every child old enough to take part the opportunity to draw or write a list of what matters to them on a poster displayed by their bed. This has helped children to feel more in control of their stay, and contributed to shaping a service that is informed by an understanding of how each child would like to be cared for. The approach has been rolled out to other wards and departments, and paediatric lead nurses from across Scotland have been invited to participate in the Collaborative, so that this approach can be spread across the country, and more children can be involved in their care in this way.

Data collected through the Scottish Care Experience Survey Programme in 2013/14 suggests that most people are positive about their care. In particular:

89 per cent of Scottish inpatients say overall care and treatment was good or excellent;[31]

87 per cent of patients rated the overall care provided by their GP Practice as good or excellent;[32] and

93 per cent of women rated the overall care received during labour and birth as good or excellent.[33]

In particular, the results from the Inpatient and Health and Care Experience Surveys show that health services are generally good at listening to patients, providing appropriate explanations and treating individuals well.

PATIENT OPINION
At the beginning of the year the Cabinet Secretary for Health and Wellbeing announced funding for the independent website Patient Opinion[34] to be rolled out across Scotland. Funding for a second year was confirmed in December 2013. Patient Opinion enables people to post their experiences of NHSScotland services – whether good or bad – anonymously online, wherever and whenever suits them. It complements existing processes in NHS Boards for dealing with feedback and complaints, but operates independently of government and the NHS, adding an independent dimension to the mix of ways in which NHS Boards can hear the voices of patients, families and carers.

Over 650 stories were posted across Scotland on Patient Opinion in 2013/14, and at the time of publication they have been viewed almost 300,000 times. These stories opened a constructive dialogue between people and healthcare providers that has, in a number of cases, led directly to change.

In 2013/14, for example, new arrangements were introduced for communicating results to patients travelling between Shetland and Grampian for breast screening, as a direct result of feedback posted on Patient Opinion.

THIRD SECTOR PARTNERSHIPS
NHSScotland’s strategic partnerships with third sector organisations continued in 2013/14. The People Powered Health and Wellbeing Programme[35], led by the ALLIANCE, brought together a number of third sector partners with expertise in delivering person-centred care, to enable people with lived experience to contribute to the design and delivery of services and to support local NHSScotland teams to make their services more person-centred.

The ALLIANCE and Royal College of General Practitioners received funding to explore ways in which Primary Care teams can support people to live well in their communities, by connecting them with local resources and support.

Funding was also provided to support the ALLIANCE and Thistle Foundation to work with three early adopter sites in NHS Tayside, NHS Greater Glasgow and Clyde and NHS Lothian to take forward the House of Care[36] approach to care planning. This approach, which has an internationally-recognised evidence base, puts people and their families in the driving seat of their care. It supports people to develop their own plan of care in active partnership with health and care professionals, and to make full use of the wide range of community assets which can help them stay well.

Work continued to support people to have the knowledge, understanding, skills and confidence they need to use health information, to be active partners in their care, and to navigate health and social care systems. Making it Easy: A Health Literacy Action Plan for Scotland[37], was launched at the NHSScotland Event in June 2014. It was published alongside an online resource, the Health Literacy Place[38], which provides resources to help staff collaborate with patients in decisions about their care and support them to live well, on their own terms, with any health conditions they have.

CARERS
Carers have a vital role to play in our society, with more unpaid carers in Scotland than the total health and social care workforce. It is estimated that replacing the care provided by unpaid carers would cost Scotland £10.3 billion a year[39].

It is important that carers, the person they care for, and those working in health and social care work together as partners to achieve better outcomes for all involved. When carers are recognised and involved as equal partners, this can improve the health, care and treatment of patients. Caring Together and Getting it Right for Young Carers: The Carers Strategy for Scotland 2010-2015[40] set out 10 key actions to improve support to carers to sustain their caring role, which in turn supports the cared for person and alleviates the pressure that unplanned emergency hospital admissions place on NHSScotland.

The recent Health and Care Experience Survey[41] indicated that around 15 per cent of respondents look after or provide regular help or support to others. Of these, almost one in three provided a significant time commitment of more than 50 hours care a week. Carers’ responses to specific questions regarding their experiences were mixed. Carers were most positive about spending time with other people and having a good balance between caring and other activities. Carers were less positive about the impact of caring on their health with 32 per cent indicating that caring had a negative impact.

NHS Education for Scotland received funding to work with the Scottish Social Services Council to produce Equal Partners in Care (EPiC): Core Principles for Working with Carers and Young Carers[42]. These principles and framework were developed in collaboration with a range of carers, carers’ organisations, workers, educators, and professional and regulatory bodies, and were launched by the Scottish Government in 2013.

Funding of £28.9 million has been provided to NHS Boards and the Scottish Ambulance Service for direct support to carers between 2008-15, with £5 million in 2013/14 to take forward a wide range of initiatives to support carers and young carers. In 2013/14, NHS Boards were asked to continue to support previous priorities including funding of carers centres across Scotland which provide a range of services such as advocacy and advice, carer training, workforce training and short breaks.

NHS Lanarkshire and PAMIS – Lanarkshire Postural Management Project

PAMIS provides support to families caring for someone with profound and multiple learning disabilities. Through engagement with carers, it was recognised that poor postural management can significantly impact on the body shape, image and pain levels of the cared for, detrimentally impacting on the quality of life for the cared for person and the carer. In response, NHS Lanarkshire provided funding to PAMIS Family Support Service for the development of a project to promote the benefits of postural management. As a result of this, carers have engaged with NHS Lanarkshire physiotherapists in the development of a postural management pathway. Carers have developed materials which have helped families understand the importance of postural management and help prevent the development of significant body distortion.

SELF-DIRECTED SUPPORT
The Scottish Government and CoSLA are committed to driving a cultural shift around the delivery of care and support in Scotland with Self-directed Support (SDS) becoming the mainstream approach. The National Strategy[43] for SDS is a 10-year strategy which was launched jointly with CoSLA in November 2010. The strategy aims to give individuals more choice and control over their health and social care support, empowering them to identify and communicate the outcomes which they feel will lead to them living a more independent and fulfilling life. It is based on five key principles: respect; fairness; independence; freedom; and safety.

During 2013/14, work was undertaken to progress the Self-directed Support (Direct Payments) (Scotland) Regulations through Parliament in readiness for the Act commencing in 2014. Statutory guidance on SDS was also developed in collaboration with stakeholders to provide a ministerial steer to local authorities. The Social Care (Self-Directed Support) (Scotland) Act 2013 came into force on 1 April 2014. The Act places a duty on local authorities to offer people choice as to how they receive their support. Local authorities will also be required to provide information and support to ensure that individuals can make informed choice as well as ensuring that the resources they allocate to a person are sufficient to meet their needs, and any provision or assistance should be based on a detailed and outcomes-focused social care assessment of which the individual should be an integral part.

FEEDBACK AND COMPLAINTS
In the majority of cases, the care people receive is exceptionally good. However, we know that this sometimes falls below the standards people expect and deserve.

Across NHSScotland, complaints increased to 20,364 in 2013/14, an increase of 23 per cent compared to 2012/13. The total number of complaints received by hospital and community health services increased by 29 per cent. This reflected a significant increase in prisoner complaints (from 151 in 2012/13 to 2,967 in 2013/14), and showed that actions taken by NHS Boards in 2013/14 to ensure that prisoners have easier access to the NHS complaints procedure are now having an effect.

Whilst it is encouraging that more people are aware of how to use NHS complaints system, every complaint is regrettable and should be used to identify changes or improvements that could be made to further improve quality of care and treatment.

This was the first year NHS Boards were required to publish annual reports showing where lessons have been learned, and action taken to improve services, as a result of feedback and complaints. NHS Boards have since reported on their handling of feedback, comments, concerns and complaints in 2013/14, and these reports outline some of the work underway across Scotland to listen to people’s voices and use the feedback to make services more person-centred.

NHS Forth Valley’s report, for instance, describes how the Board set out to hear and understand the voices of young carers, and use this learning to support staff to improve outcomes. NHS Orkney reports that it has introduced yellow ‘Nurse in Charge’ badges, so that people know who to approach with any concerns about their care, and NHS Fife describes how the Board takes a person-centred approach to complaints handling by engaging with the person making a complaint from the outset. This approach enables the Board to determine what matters most to the individual, and to tailor the way in which the complaint is handled.

Improving Quality of Care - Safe Care

Raising awareness of a global killer.

Craig’s Story

In less than 62 hours, Craig’s life changed dramatically and irrevocably as a result of sepsis.

Falling ill at his workplace, Craig’s initial flu-like symptoms were diagnosed as sepsis during an emergency appointment with his GP. Prompt treatment with antibiotics and intravenous fluids saved his life. The following day his wife Fiona, who was 35 weeks pregnant, was herself rushed to hospital with sepsis. Despite immediate treatment her condition quickly became very grave, the baby girl she was carrying died in utero, and she herself passed away the following morning.

Sepsis is a life-threatening whole-body inflammation which occurs when the body’s response to infection damages its own tissues and organs. It’s one of the world’s biggest killers, with at least 18 million people dying of the condition every year. In the UK alone, sepsis kills around 37,000 each year – more than breast, bowel and colon cancer put together. And the incidence of sepsis is rising by somewhere between 8 and 13 per cent each year.

The onset of sepsis is extraordinarily fast, which is what makes the condition so dangerous. If the patient is treated with antimicrobials and intravenous fluids within the first hour, survival rates can be higher than 80 per cent – but that means prompt diagnosis is literally a matter of life and death.

In the aftermath of his terrible experience of the condition, Craig helped to found a charity, the Fiona Elizabeth Agnew Trust or FEAT, named after his late wife. FEAT campaigns for sepsis research and education, and has raised over £50,000 since its inception in 2013. Much of that money is being made available to fund research through a series of FEATURES awards, and the first grants will be awarded early in 2015. The charity works closely with both the Scottish Patient Safety Programme and Healthcare Improvement Scotland, collaborating on initiatives including World Sepsis Day, and in distributing information throughout the NHS in Scotland.

Sepsis is an extremely serious condition, but FEAT is run on the principle that raising funds and building awareness can and should be fun. The charity’s Sock it to Sepsis campaign saw hundreds of stripy red-and-white socks appearing throughout Scotland – and helping to kick this horrific condition into touch.

“Even as a small charity, living in the information age means we can reach thousands, perhaps millions of people really quickly. Working with Healthcare Improvement Scotland, for instance, we’ve produced a short animated film that’s raised awareness amongst health professionals and the general public.”

Craig Stobo,
Founding Chair, FEAT

Play audio

Sepsis is just one of the harms being tackled by the Scottish Patient Safety Programme, with NHSScotland continuing to receive international acclaim for its approach to implementing improvements in patient safety. During 2013/14, the Programme continued to show evidence of improvements in the safety of care with demonstrable improvements in reliability for the Sepsis 6 treatment package, including antibiotics within one hour of sepsis diagnosis and venous thromboembolism (VTE) risk assessments have been achieved across many NHS Boards.

The Scottish Patient Safety Programme (SPSP) was launched in January 2008 to reduce avoidable harm in NHSScotland and transform the safety of acute care for patients. The Programme’s ambition to improve safety has increased as it has spread into complementary areas.

The SPSP is the world’s first national safety improvement programme. It aims to support frontline staff to improve care using applied improvement methodology to reliably implement key processes and successful improvements. The SPSP has promoted the application of a set of tested, evidence-based interventions using an improvement model and plan- do-study-act (PDSA) cycles.

A key element of the programme is that the changes have been led by the staff who are directly involved in caring for patients. Staff can monitor improvements through the collection of real time data at the individual unit level. The work is dependent on the full participation of NHS Boards and staff, and is supported and led nationally by Healthcare Improvement Scotland (HIS).

The second phase was launched in January 2013 to build on the established practices and progress made in the first phase and to bring focus to a number of priority areas for improvement. It was launched with the aims to achieve a 20 per cent reduction in Hospital Standardised Mortality Ratios (HSMR) and 95 per cent harm-free care, by December 2015. The work in acute care has been extended to include sepsis and VTE. Complementary programmes to improve safety in Primary Care and mental health are underway. In March 2013, the Maternity Care Quality Improvement Collaborative (MCQIC) was launched. This name was subsequently changed to Maternity and Children Quality Improvement Collaborative to reflect wider work on paediatric and neonatal care.

In September 2013, the Scottish Government wrote to NHS Boards (Chief Executives Letter CEL 19[44]) to set out expectations for the universal implementation of 10 Patient Safety Essentials to be delivered to all patients who might benefit. NHS Boards have been asked to ensure that staff are supported to deliver these measures reliably and consistently. The Scottish Government requested that the emphasis should now shift from testing and spread towards sustainable universal implementation. This will require different approaches to ensuring that these interventions are adopted as standard in all clinical areas.

Source: Aggregated SPSP self-reported data – shown from participating sites/wards only

Outcomes for a number of the Patient Safety Essentials are reflected in the Annual Scottish Intensive Care HAI Prevalence Report[45] published by Health Protection Scotland and the Scottish Intensive Care Society Audit Group. Data from January to December 2013 showed the lowest rates since reporting commenced in 2010 for Ventilator Associated Pneumonia (VAP), Blood Stream Infections (BSI) and Catheter Related Blood Stream Infections (CR-BSI). The rates for VAP and BSI are at the lower end of the range of those seen across the rest of Europe.

There is widespread implementation of the surgical brief and pause (also known as the World Health Organization surgical safety checklist), with an 18.7 per cent reduction in surgical mortality between 2008 and 2014.

Work is underway to better integrate improvement and inspection processes. Healthcare Environment Inspectorate (HEI) inspections report emerging evidence that Peripheral Vascular Catheter (PVC) bundle reliability is being delivered reliably and consistently to patients in NHSScotland.

Executive Director walkabouts where Executive Board Members meet with staff locally to look at ways of doing things better and safer have proved to be very popular and have led to many simple but effective improvements within wards and clinical areas.

Hospital Standardised Mortality Rates (HSMR) are a way of measuring mortality rates in acute hospitals, attempting to adjust for age, gender and reason for admission. Scotland’s HSMR has decreased by 14.4 per cent between October to December 2007 and January to March 2014. Twenty-nine hospitals participating in the SPSP have shown a reduction in HSMR since October to December 2007. Thirteen of these hospitals had a reduction in excess of 15 per cent, with five showing a reduction in excess of 20 per cent – Crosshouse Hospital, NHS Ayrshire and Arran (33.3 per cent); Southern General Hospital, NHS Greater Glasgow and Clyde (21.3 per cent); Ninewells Hospital, NHS Tayside (20.9 per cent); Wishaw General Hospital, NHS Lanarkshire (21.2 per cent); and Western Isles Hospital, NHS Western Isles (22.6 per cent). Rolling annual HSMRs show that there was a sustained reduction in hospital mortality between 2009 and 2011; the level remained relatively constant until mid-2013, with subsequent data showing a further reduction in hospital mortality[46].

Source: ISD Scotland

Following concerns about the quality of care in NHS Lanarkshire, Healthcare Improvement Scotland published its Rapid Review of the Safety and Quality of Care for Acute Adult Patients in NHS Lanarkshire[47] in December 2013. Following this, NHS Lanarkshire has made significant changes in the structures and processes it has in place to support the actions that Healthcare Improvement Scotland identified as necessary. It has increased improvement support resources, invested in additional nurse and medical staffing, implemented new hospital management structures and has changed the way in which it measures, monitors and reports on the quality and safety of care. NHS Lanarkshire has also significantly improved the way in which it responds to feedback and complaints. The NHS Board is now working to ensure that there is a sustained focus in all of the areas identified for improvement – ensuring that there is staff engagement and involvement with this work at all levels – and that the changes it has made in quality monitoring and improvement support are consistently and effectively implemented.

The SPSP has developed a range of tools and resources to support those working within Primary Care to improve safety and reduce harm. During 2013/14, the number of GP Practices across NHSScotland participating in the safety climate survey has increased to 90 per cent.

Oakley Health Centre in Fife used its positive survey results in a recruitment advert and the practice found itself being able to quickly fill vacancies for two new doctors.

“It has been a real bonus to reap such a positive spin-off benefit from the survey. This had undoubtedly had an impact on the candidates we were able to attract, but during the interview process the survey was also discussed in great depth, allowing us to highlight our commitment to continually improve the safety and care of our patients.”

Dr Iain Mathie, Oakley Health Centre

GP Practices are also being supported to improve processes for the prescribing and monitoring of high-risk medications. To date, 819 GP Practices across Scotland have introduced care bundles with 83 per cent monitoring at least one bundle in areas such as warfarin and disease modifying anti-rheumatic drugs.

Work in the mental health programme is focused on reducing levels of harm in adult psychiatric inpatient units and includes the development and implementation of the Patient Safety Climate Tool, a Scottish innovation that is leading the way in person-centred, safe delivery of care. With the facilitation of a number of third sector organisations, over 200 patients across Scotland have had the opportunity to participate in this survey to date. The results are then used to inform improvement work locally.

“The Patient Safety Climate Tool will give patients the chance to express their feelings and concerns about their safety while on a ward. This information will then allow services to make any improvements needed, resulting in a better patient experience of hospital care.”

Gordon Johnstone, Director of Voices Of eXperience

The Mental Health Safety Programme has co-opted, tested and developed a safety climate tool with patients and service users. This enables people to share how they feel about their experience of care. It has been used in 11 NHS Boards with 270 service users.

Funding has also been secured from the Health Foundation to explore the contribution that pharmacists can make to delivering safer care in community pharmacy and general practice settings.

Measurement of safety climate in Scottish maternity units is underway as part of the Maternity and Children Quality Improvement Collaborative (MCQIC). Since its launch, there has been a 125 per cent increase in the number of pregnant women offered carbon monoxide monitoring. This is a test which can help pregnant women to understand the dangers smoking can cause them and their unborn baby, and is a useful aid in reducing smoking during pregnancy.

Source: ISD Scotland: Hospital Standardised Mortality Ratio

It is important that improvement efforts and inter-relationships between person-centredness, safety and flow are integrated. The hospital safety huddle (for safety prediction and flow) has been successfully implemented in all three Scottish paediatric hospitals and is being implemented in a growing number of acute adult hospitals, with NHS Lothian and NHS Ayrshire and Arran recently introducing this fundamentally-important team activity. One objective of the SPSP is to support the spread of this to all acute hospital sites in Scotland.

Work has been undertaken to provide better and integrated reliable anticipation, recognition and person-centred response to deteriorating patients across the continuity of care from primary and community settings to hospital. Data from NHS Boards indicates progress towards a reduction in cardiac arrests amongst participating NHS Boards.

The Scottish Patient Safety Fellowship was introduced to develop and strengthen clinical leadership and improvement capability to support the implementation of the SPSP. A total of 105 fellows have now been trained and the 7th cohort has recently commenced its fellowship programme. NHS Education for Scotland (NES) currently leads the delivery of the fellowship programme in collaboration with Healthcare Improvement Scotland (HIS). The programme attracts international participants from The Republic of Ireland, Northern Ireland, England, Denmark and Norway.

The Quality Improvement Hub was established to support NHS Boards and clinicians to build and embed improvement capability.

Don Berwick, former adviser to President Obama, and the founder of the Institute for Healthcare Improvement, who was tasked with improving patient safety in NHS England has said that “the Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world”. His report, published in August 2013, drew on the expertise of Jason Leitch, Scottish Government lead for the SPSP. Ten of the 11 recommendations that Berwick made were already in place in Scotland.

HEALTHCARE ASSOCIATED INFECTION
Reducing Healthcare Associated Infection (HAI) is a priority for Scottish Government Ministers and NHSScotland. It is vital that people have confidence in the quality of healthcare they receive in hospitals and other healthcare settings and that zero tolerance to infections is adopted. A wide range of measures has been put in place to reduce HAI and improve healthcare outcomes.

From 2008 to 2011, the Scottish Government provided over £65 million to tackle HAI and continues to provide substantial financial support for the HAI Delivery Plan[48]. This includes nearly £2 million annually to NHS Boards to employ key infection control personnel consisting of Infection Control Managers, Antimicrobial Pharmacists, and HAI Quality Improvement Facilitators. A revised National Cleaning Services Specification[49] has been implemented and over £5 million of additional resources made available to NHS Boards annually since 2009 to pay for hundreds of additional cleaning staff.

Evidence of work to reduce HAIs is demonstrated by the latest NHSScotland statistics (published October 2014) which show that, since 2007, cases of Clostridium difficile in patients over 65 have reduced by almost 82 per cent and that MRSA has fallen by just over 89 per cent in the same timescale (the lowest number of MRSA cases since mandatory surveillance began)[50].

Point Prevalence Survey (PPS) results, last published in 2012, indicated that cases of HAI in Scotland were around a third lower than when the previous PPS was published in 2007. PPS results are published for acute settings and care homes. A further PPS will be undertaken in 2016.

Compliance with hand hygiene remained at 95 per cent to 96 per cent during 2012. Health Protection Scotland published bi-monthly reports into hand hygiene compliance until the final report on 25 September 2013 which confirmed 96 per cent national compliance with hand washing opportunities. Monitoring is now reported locally by NHS Boards.

Source: Aggregated SPSP self-reported data; shown from participating sites/wards only

The latest figures published by Health Facilities Scotland on 7 August 2014 show that NHS Boards continue to achieve high cleaning standards with national domestic services (cleaning) compliance for the period April to June 2014 remaining high at 95.6 per cent for Scotland and that all acute hospitals, health boards had achieved a Green compliance rating. For the same period, estates services reported an overall Green rating compliance of 95.7 per cent.

Over £6 million has been invested in HAI-related research since 2007 via the Scottish Infection Research Network (SIRN). SIRN is about to establish a Scottish National Research Consortium to develop research that deals with emergent threats to the Scottish population from HAI and emergent organisms. The Consortium will strengthen the HAI research infrastructure within Scotland by integrating both local and national expertise, and will include collaborations from across Scotland and, where necessary, the UK.

A review of HAI priorities for the next five years is underway.

ANTIMICROBIAL PRESCRIBING
Prudent prescribing and active stewardship of antibiotics is vital in the prevention and control of infections such as Clostridium difficile, MRSA, MSSA and E. coli bacteraemia.

Figures from the latest Scottish Antimicrobial Prescribing Group (SAPG) report[51] published in October 2014 show that there has been a decrease of 6.5 per cent in the total number of prescriptions for antibacterials in Scotland. This is equivalent to a decrease of 276,383 prescriptions in 2013/14. The use of broad spectrum antibacterials associated with higher risk of Clostridium difficile infection reduced by 11.6 per cent (44,173 fewer prescriptions) in 2013/14 than in 2012/13. This is the fifth successive year in which a reduction has been observed.

INSPECTION
The Scottish Government operates a robust scrutiny and inspection regime, which continues to drive improvements in HAI. It is the remit of the Healthcare Environment Inspectorate (HEI) to undertake a programme of inspections in acute, non-acute and community-based hospitals. It carries out a cycle of at least 30 risk-based inspections each year, most of which are unannounced.

The HEI Chief Inspector’s fourth and latest annual report was published in February 2014[52]. Headline figures show that the Inspectorate made 104 requirements and 90 recommendations. Requirements and recommendations have reduced significantly since the Chief Inspector’s first annual report, demonstrating the improvements and progress that have continued to be made by staff across hospitals in NHSScotland.

In the HEI Chief Inspector’s fourth and latest annual report, published in February 2014, HEI Chief Inspector, Susan Brimelow, stated: “Overall, the public should be assured by our findings which show that NHSScotland continues to make good progress in raising standards of hospital cleanliness, hygiene and infection control.”

Older People in Acute Hospitals Inspections began in 2012, following an announcement by the then Cabinet Secretary for Health and Wellbeing in June 2011. The inspections were to provide assurance that the care of older people in acute hospitals is of a high standard. As of 31 March 2014, there had been 25 inspections of which five were unannounced and four additional unannounced follow-up inspections. The inspection programme continues with a revised methodology, following the recommendations set out in the Report for the Review and Methodology and Process for the Inspection of the Care of Older People in Acute Hospitals (the Whittle Report) which was published in November 2013[53]. Healthcare Improvement Scotland continues to test out new elements with its methodology for the inspection process.

Improving Quality of Care - Effective Care

Breaking with the old ways – a world-leading virtual fracture clinic at Glasgow Royal Infirmary.

Margaret’s Story

Under the old system at Glasgow Royal Infirmary, a patient with a minor fracture injury would typically attend the Emergency Department for initial treatment. They’d be told to come back within a day or so to attend the Fracture Clinic, where they might wait hours to see a consultant even if the injury did not require attention. The experience was often distressing and inconvenient for the patient, and an inefficient use of valuable resources.

A new, more efficient pathway costs practically nothing to implement but delivers a significantly improved patient experience while saving time and resources. It may sound almost too good to be true, but by making a complex system simple, a redesigned fracture service has achieved this win-win scenario. Now it’s being emulated throughout the UK and beyond.

The new pathway has been developed by Glasgow Royal Infirmary’s Orthopaedic and Emergency Departments and Stobhill Minor Injuries Unit. Now patients who can be safely discharged are given information to help them monitor their own condition, together with contact details for the Virtual Fractures Clinic. They can phone or walk in to the Clinic any time it’s open – and as of 2014, it’s been a seven day service.

“The Virtual Clinic is an open-door system, so patients can come back any time they like. The great thing is that they usually don’t need to, so everyone benefits” says Margaret.

In most cases the patient can be dealt with on the spot, but if they do need to see a consultant, they’re given an appointment with the appropriate specialist at a defined time.

By promoting self-care and shared decision making, the pathway avoids unnecessary visits, freeing up time and resources to improve standards of patient care in more complex situations.

The new system is resulting in markedly increased patient satisfaction, together with cost savings calculated at up to £156,000 per year.

Unsurprisingly this local solution has attracted global interest, with more than sixty hospitals talking to GRI about implementing a similar system.

“With built-in failsafe features including x-ray reviews, the new system is more secure and it saves patients – many of them elderly – the distress of travelling to attend hospital when they’re in pain or feeling vulnerable. There’s also a welcome side-effect in that patients spend less time in the Emergency Department. We give them practical, simple self-care information and discharge them quickly, knowing they have access to the Clinic as and when they need it.”

Alastair Ireland, Clinical Director, Emergency Medicine, NHS Greater Glasgow and Clyde

“Before the new system was in place, patients would automatically come to the clinic with minor injuries which didn’t need operative treatment. We’d often see a patient wait three hours to spend five minutes with a consultant, only to be sent away and told to rest. That just doesn’t happen anymore – they’re here only when they need to be, and they see the right specialist first time.”Margaret Nugent, Fracture Clinic (FC) Redesign Audit Nurse, Glasgow Royal Infirmary

Play audio

Many of the areas for improvement that have been prioritised during 2013/14 make a direct contribution to our Quality Ambition for more effective healthcare services. A focus of this activity has been to identify those improvements where there is clear and agreed evidence of clinical and cost-effectiveness, and to support the spread of these practices where appropriate to ensure that unexplained and potentially wasteful or harmful variation is reduced.

INTEGRATING CARE
What people expect are services that work in a co-ordinated way with them, to understand what matters most in their lives, and to build support around achieving the outcomes that are important to them. Many of those outcomes will involve keeping them safe, physically and mentally well – out of hospital, in their homes and local communities, in the best possible health; but as important will be that the co-ordinated support people receive also enables them to live their lives the way they would like to live them, including in relation to their housing, mobility and social needs.

At the beginning of April 2014, the Scottish Parliament unanimously passed the Public Bodies (Joint Working) (Scotland) Act 2014 which will come into effect from April 2015. It puts in place a framework to make sure that health and social care services are planned, resourced and delivered together by NHS Boards and Local Authorities to improve outcomes for people using services, their carers and families. The new arrangements, which apply primarily to adult health and social care services (NHS Boards and Local Authorities can also choose to include other functions in their integrated arrangements locally), includes a strong role for the third and independent sectors, clinicians, social workers, other professionals, and local service users and communities.

NHS Boards and Local Authorities will establish integrated partnership arrangements, called Integration Authorities, which will replace Community Health Partnerships, and will deliver national outcomes for health and wellbeing. Integration Authorities will set up locality arrangements with local professional leadership of service planning. There will be a heavy emphasis on the importance of effective strategic commissioning of services underpinned by a good, shared understanding of the population’s needs, and informed by professional and local community input.

“The integration of health and social care presents the opportunity for the radical redesign of health and care services through the creation of seamless, person-centred care pathways from the home, through the community to our acute services. The empowerment of our local communities to shape these new services through the participation of elected council members, health professionals, service users, carer and voluntary groups in making the vital strategic decisions, in areas traditionally controlled by councils and by the NHS, is also, I believe, essential to ensuring the delivery of efficient and effective high quality services tailored to best meet the needs of our communities.”Councillor Peter Johnston, COSLA Spokesperson for Health & Wellbeing

NHS Boards and Local Authorities are now setting up shadow integrated arrangements and developing their integration scheme which must be submitted to Ministers for approval. Integration Authorities must be fully functioning by 1 April 2016.

NHSScotland and its partners in local government, and the third and independent sectors are committed to putting in place a system of health and social care that is robust, effective and efficient, and which reliably and sustainably ensures the high quality of support and care for people who use health and social care services.

“The Public Bodies (Joint Working) (Scotland) Act 2014 is an important step towards transforming health and social care across Scotland. People who use support and services, carers and the third sector have long argued for integrated, high quality support that enables people to access their right to good health, dignity and independent living.“As we move beyond the legislation the real work begins. The new Health and Social Care Partnerships have a crucial role in building on the Reshaping Care for Older People Programme and Change Fund, and driving the shift towards person-centred, sustainable models of support.”

Ian Welsh, Health and Social Care Alliance

Health and Social Care Integration in TaysideIn Tayside, three new Integration Authorities are being set up in Perth and Kinross, Angus and Dundee. A Chief Officer has been appointed to each Integration Authority to lead the transition arrangements in their local area. The new Integration Authorities will be accountable to NHS Tayside and to their Local Authority.

“In Perth and Kinross we are keen to build on the existing strengths of our collaborative working with our local partners. This will allow us to concentrate straight away on improving outcomes for service users.

“I’m excited by the possibilities of health and social care integration becoming truly patient and service user-focused in Perth and Kinross. We need to move away from doing things ‘to’ people and towards having a conversation with them, finding out what care and support they want, and making sure they understand their options. There’s also a real chance to pool local knowledge so that we can target early intervention where it is most needed.

“With more choice and control for patients, service users and their families and carers, we are working towards providing an integrated service that produces real, positive outcomes for individuals.”

John Walker, Chief Officer Integrating Health and Social Care in Perth and Kinross

PRIMARY CARE
For many people, Primary Care is the part of NHSScotland service provision that they will come into contact with most, covering day-to-day interactions with GPs, Pharmacists, Dentists and Optometrists. It also spans many of the community nursing and allied health professional services received in the community or at home. In General Practice alone, there are around 25 million appointments in Scotland every year. These professionals deal daily with a wide range of people in many different settings. They have a significant role in understanding the needs of their community and in ensuring services are tailored to meet those needs.

As in other parts of the service, pressure on Primary Care continues to increase as the population grows and people are living longer with one or more long term conditions. Achieving our 2020 Vision will require a major shift in thinking and resources from acute hospitals towards primary and community care. Supporting Primary Care professionals to help people manage their long term conditions within the community and ensuring that as much time as possible is freed up to deal directly with patients and in planning for their needs are key priorities.

In pharmacy, Prescription for Excellence[54] charts the development of the pharmacy profession over the next 10 years to ensure all patients, regardless of their age and setting of care, will receive the highest quality of pharmaceutical care using the clinical skills of the pharmacist to their full potential.

In order to meet the needs of people in areas of high deprivation, NHS Boards are delivering new models of services such as Link Workers in some Deep End GP Practices.

Given the challenges presented by an aging population, health inequality, rurality and many other factors there is still a long way to go. But meeting these challenges is crucial to ensuring safe and effective patient care throughout health and social care.

Key to achieving this has been a new approach to the GP Contract. Until 2012, the GP Contract had been negotiated annually on a UK-basis with some Scottish variation. In late 2013, however, a Scottish contract was negotiated which reduced GP bureaucracy, emphasised quality of service, and asked that every GP Practice in Scotland conduct an annual review of access to support patient appointments. This was welcomed by GPs and, with later confirmation that this contract would apply until 2017, has brought much needed stability to General Practice. The aim for 2017 is to have a much simpler GP Contract in place that supports the role of GPs in primary and community care, ensures they have the time to deliver safe and effective care for those who need it, and supports the integration of health and social care.

Developments in Community Optometry have resulted in the first NHS Prescribing Pads being issued to 68 Optometrists across Scotland. These independent prescribers are now managing more patients than ever before within the community without the need to refer on to the hospital eye service. Over £1 million has also been provided to develop the skills of Community Optometrists through education delivered by NHS Education for Scotland. Advanced clinical skills are being taught to support improved patient care within Optometry practices.

UNSCHEDULED CARE
The challenges witnessed during the 2012/13 winter period were unprecedented in recent years and, as a result, unscheduled care performance deteriorated in line with other parts of the UK and, indeed, other similar health systems across the world. The Scottish Government recognised that radical measures had to be put in place to improve performance and launched the three year, £50 million Unscheduled Care Action Plan in February 2013[55]. The key elements of the Action Plan support improvements, transformation and sustainability of unscheduled care performance whilst supporting patient flow through the hospital.

Substantial funding was invested during 2013/14, both centrally and locally (£30 million), in recognition that NHS Boards would need to commit considerable resources in the first year of the Action Plan. This has led to significant results, particularly for those patients waiting over 12 hours in A&E with a 56 per cent reduction between 2012/2013 and 2013/2014. Fewer than 1 per cent of all patients waited longer than 8 hours[56].

Other improvements include the recruitment of additional staff, including 18 A&E consultants and the roll out of digital whiteboards to improve the flow of patients throughout hospitals right across Scotland.

The first year of the Action Plan is already delivering better and faster care for the people of Scotland, with years two and three focusing on further sustainable improvements and whole system approaches – creating local Community Partnerships where hospitals and primary/community care services are aligned and focused on patients being seen by the right member of the multi-disciplinary team, at the right time.

While the majority of patients continue to get the excellent care they deserve within shorter waiting times, there is still more to be done. There are ongoing challenges also being experienced by the other UK countries and beyond. NHSScotland is continuing to work with its partners to address these challenges and bring about sustained improvements for the people of Scotland.

CARE FOR MULTIPLE AND CHRONIC ILLNESS
Helping people to live longer, healthier lives at home or in a homely setting will involve people having to manage their health condition. With an aging population, for many that will mean managing multiple and chronic illnesses. An action plan[57] was developed to improve the care and support for people who live with multiple conditions. This Action Plan describes actions we must take on whole person, whole team, and whole system levels.

For the whole person, this will mean changing the conversations we have and shifting the relationship between the person and the professional in every consultation. From April 2013, more than 120,000[58] people have had an Anticipatory Care Plan developed and shared so that other health and care providers are aware of their care preferences in the event of a future deterioration, or a sudden change in circumstances for their carer.

Three community wards in Ayrshire and Arran provide an anticipatory care service for people with long term conditions and home-based health care wherever possible. The various skills used include advanced clinical assessment, differential diagnosis, review and administration of medications, and proactive anticipatory care planning and co-ordination.“I feel less anxious knowing I can get help and advice at the end of the telephone, knowing that community ward staff will explain what is happening and what I should do to remedy the situation.”

Patient

“The community ward service has helped to keep me out of hospital for over one year and I am very grateful to them.”

Patient

For the whole team, this will involve developing new ways for health and care professionals to work together, and with volunteers and community support services, around the GP Practice. For example, a Lothian GP used headroom funding to participate in a cross-sector leaders programme in order to learn more about the worlds of others and to consider how to work better together. As a result of this, the GP invited Thistle[59] to establish a presence in her surgery to build a relationship with the Primary Care team. Thistle is receiving a small but consistent number of referrals to their lifestyle management programmes.

At a whole system level, improvements will be required in the way that care and support is planned and coordinated across the whole pathway between home and hospital.

DEMENTIA
Scotland’s second three-year National Dementia Strategy was published in June 2013[60]. It continues to focus on supporting local change and improvement in dementia services and individual outcomes in all care settings and for all stages of the illness.

From April 2013, everyone in Scotland newly diagnosed was given what has been described by Alzheimer Scotland as a world-leading guarantee of a minimum of a year’s worth of dedicated post-diagnostic support coordinated by an appropriately-trained and named Link Worker. The service adopts Alzheimer Scotland’s ‘5-Pillar’ model of support and is designed to enable people with dementia and their carers to adjust to a diagnosis, connect better to the range of services and support available and plan early for future care options. The guarantee is underpinned by a HEAT target that everyone newly diagnosed will be receiving this service by 2016. The target is also helping to sustain the HEAT diagnosis standard by focusing services on the benefits of timely diagnosis as a gateway to effective post-diagnostic support.

Throughout 2013/14, funding has been provided for the ongoing roll-out of the Promoting Excellence[61] national dementia health and social care workforce framework, to support the workforce in implementing the Standards of Care for Dementia in Scotland and achieving better quality and more consistent outcomes for people with dementia. This includes updating pre-registration education, increasing access to psychological therapies and improving training and awareness about dementia for adult day care and residential care home staff.

In 2013 a national action plan[62] was published to improve dementia care and outcomes in general hospital settings, and funding was provided along with Alzheimer Scotland for the Alzheimer Scotland dementia nurse network to help lead strategic change in this area of care at NHS Board level. In addition, around a further 100 Dementia Champions, drawn from the frontline of care, were trained and will graduate in early 2015, taking the overall number to 500 with a further 100 to be trained in 2016.

In August 2014 the Scottish Government’s response and action plan was published[63] following The Mental Welfare Commission’s critical report in June into specialist and continuing dementia NHS care settings[64]. This includes an initial round of NHS Board self-assessments, which will be submitted to, and assessed by, the Scottish Government in late 2014.

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES
The two HEAT access targets in Child and Adolescent Mental Health Services (CAMHS) and Psychological Therapies (access to specialist CAMHS treatment within 18 weeks from December 2014 and access to a psychological therapy within 18 weeks from December 2014) are driving improvement in mental health through service redesign, strong leadership and the hard work of clinicians and other staff.

Latest figures for the CAMHS access target show that in the quarter ending September 2014, just over 3,300 children and young people started treatment at Child and Adolescent Mental Health Services in Scotland, with 78 per cent seen within 18 weeks. Progress has also been seen in growing the workforce. Since 2009, the CAMHS workforce in NHSScotland has risen from 764.6 WTE in September 2009 to 936.4 WTE at the end of September 2014[65]. Data quality and collection continue to be amongst the challenges to delivery, emphasising the importance of investment in information systems and outcome measurement.

In 2002, the Scottish Government set a target of reducing the suicide rate in Scotland by 20 per cent by 2013. Since then the Scottish Government has worked with a range of partners, across sectors, to improve mental health services and the diagnosis of depression and mental health problems. More support is now available for those affected and much has been done both to improve safety for patients experiencing mental health problems and to tackle the stigma of mental ill-health. Over the period 2002-2013, suicide rates in Scotland have fallen by 19 per cent, demonstrating that suicide is preventable and that having the right support available can make a big difference[66].

DETECTING CANCER EARLY
The Detect Cancer Early (DCE) programme was launched in February 2012 to address the poor quality of life and poor survival rates resulting from late diagnosis of cancer. The sooner that cancer is diagnosed and treated, the better the survival outcomes and, in the case of advanced or incurable disease, increases the possibility of treatment that prolongs life or manages symptoms. The programme has successfully delivered four social marketing campaigns to help people identify the signs and symptoms of cancer earlier, encourage them to seek advice from their health professional, and equip them with information that allows them to make an informed choice about participating in cancer screening programmes.

As an example of the impact of the campaigns, following the breast awareness phase, there was a 50 per cent increase in the number of women attending their GP with breast symptoms compared to the previous year. The bowel screening campaign is influencing more people from the most deprived areas in Scotland to take up the invitation to screen (from 41.9 per cent to 43.6 per cent). Men in particular have increased from 39.6 per cent to 41.7 per cent. Also, there are indications of an increase in the volume of chest x-rays carried out, linked to the timing of the lung campaign[67].

One of these key change themes is ‘Reducing Child Poverty’. Pioneer sites working to improve the uptake of Healthy Start Vouchers are seeing an improvement, where better communication and enhanced documentation have led to pregnant women and young children receiving support to access healthy food and vitamins at critical times for them in terms of brain development for growing babies and children.This work has captured the imagination of other members of the Collaborative who have now formed themselves as ‘shadow sites’ to scale up and spread this important intervention. Thirteen of the CPPs are either working on or planning to work on better uptake of healthy start vouchers and vitamins and are working together to learn from each other to improve faster.

The Teenage Cancer Trust is being supported by the programme to provide cancer awareness in schools that will help maximise the awareness messages amongst families of teenagers and a new Primary Care initiative recognises the importance of the role of GPs in supporting informed uptake of screening. Healthcare Improvement Scotland (HIS) has published refreshed Scottish Referral Guidelines for Suspected Cancer[68] and education sessions for Primary Care professionals have been conducted in partnership with cancer charities. NHS Boards are being funded to take forward implementation plans to improve diagnostic and treatment capacity.

Already there have been encouraging improvements in data recording and staging.

EARLY YEARS
Through its active involvement in the Early Years Collaborative (EYC), led at local level by Community Planning Partnerships (CPPs), NHSScotland continues to make an important contribution to the Scottish Government’s aim of improving outcomes for children and young people, and the strategic objective that Scotland is the best place to grow up for our children.

The Early Years Collaborative is an outcomes-focused, multi-agency, quality improvement programme. A wide variety of agencies are involved including education, police, social work and the third sector as well as health.

Multi-agency CPP teams have worked together on a large variety of projects including: increasing the amount of physical activity undertaken by children in Primary 1; improving speech and language support for children at risk; maximising income for families by helping them take up the benefits to which they are entitled; and helping expectant mothers give up smoking. All of the projects are taken forward using the Model for Improvement[69] which underpins the EYC. This enables practitioners to reliably implement interventions for every child, every family, every time.

Our 2020 Workforce VisionWe 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.

WORKFORCE
Our workforce is vital to responding to the challenges that NHSScotland is facing. We are committed to all staff being empowered to influence the way they work, leaders who show by example and managers who have the skills to manage well – all held to account for what we do and how we do it. We want to see all staff being fairly treated, supported to do the best job that they can. Evidence shows staff who are motivated and valued deliver better quality care for patients.

To deliver this, in June 2013, we launched Everyone Matters: 2020 Workforce Vision and our shared values which were developed through extensive engagement and consultation with around 10,000 staff and key stakeholders, resulting in one of the largest consultations undertaken in NHSScotland.

We expect everyone to live by our shared values which are:

Care and compassion;

Dignity and respect;

Openness, honesty and responsibility; and

Quality and teamwork.

Our five priorities to deliver our 2020 Workforce Vision are:

Healthy organisational culture - creating a healthy organisational culture in which our values are embedded in everything we do, enabling a healthy, engaged and empowered workforce.

Sustainable workforce - ensuring that people are available to deliver the right care, in the right place, at the right time.

Capable workforce - ensuring that all staff have the skills needed to deliver safe, effective, person-centred care.

Integrated workforce - developing an integrated health and social care workforce across NHS Boards, local authorities and third party providers.

Effective leadership and management - leaders and managers lead by example.

The work taken forward in 2013/14 delivers on one or more of these priorities, supporting and delivering our vision that by 2020 everyone is able to live longer, healthier lives at home or in a homely setting.

2013 NHSScotland Staff Survey
The NHSScotland Staff Survey response rate was 28 per cent, 2 per cent higher than in 2010. The results have provided important feedback on progress to improve staff experience, but more importantly, where attention needs to be focused to do more. The Cabinet Secretary for Health and Wellbeing has been clear that NHS Boards have a duty to listen to what staff are saying, and to take action to address the issues which are of concern to them. Progress to address key issues is being monitored locally.

iMatter Staff Experience Continuous Improvement Model
In responding to the results of the 2013 Staff Survey, the Cabinet Secretary wrote to NHS Board Chairs setting out a number of commitments. These included the commitment to roll out the iMatter Staff Experience Continuous Improvement Model to all NHS Boards.

The iMatter Model was successfully developed and piloted in four NHS Boards – NHS Tayside, NHS Dumfries and Galloway, NHS Forth Valley and NHS National Waiting Times Centre. The Model will enable Boards to have more accurate information about staff experience throughout their organisation, and see where improvements are being made, year on year, and where further interventions may be required. It will encourage teams to take action and make improvements, which will contribute to better performance and higher standards of patient care. Implementation will take place across all Boards on a phased basis, beginning in 2014/15.

Staff Governance Monitoring
Achieving the Staff Governance Standard is essential to achieve continuous improvements in service quality. In November 2013, a revised Staff Governance Standard Monitoring Framework[70] was introduced. This is used by all levels within each NHS Board to help each year to review progress in implementing the five strands of Staff Governance and to identify issues requiring attention through the Staff Governance Action Plan.

National Confidential Alert Line for NHSScotland Staff
A new pilot National Confidential Alert Line for NHSScotland was launched to ensure staff are supported in raising concerns and know how to do so. Launched in April 2013, this confidential service provides a safe space for staff to discuss their concerns with legally-trained staff. Where appropriate, these concerns can be passed to the relevant regulatory or scrutiny body. Further information, including the number and type of calls received and the interim evaluation of the service is available on the Scottish Government website71. Following the conclusion of the successful pilot, the Cabinet Secretary announced that the National Confidential Alert Line would continue for a further two years from August 2014.

Youth Employment
As part of the Scottish Government’s Making Young People Your Business campaign, all NHS Boards have been asked to provide a range of employment-related opportunities for young people aged 16-24. Over 5,000 opportunities, ranging from Modern Apprentices to work experience, have been offered over the two years to March 31 2014. The Cabinet Secretary has since announced that NHS Boards are being asked to deliver a national target of 500 new Modern Apprenticeships across NHSScotland over the coming three years to August 2017.

NHS Pay and Conditions
The recommendations of the NHS Pay Review Bodies for 2014/15 was implemented in full. This meant that all NHS staff groups in Scotland covered by the remits of these bodies received a 1 per cent pay increase from 1 April 2014, while staff earning under £21,000 also received an additional sum to increase their pay by £300 in total. Work with the British Dental Association and NHS Employers in Scotland delivered a new terms and conditions package for salaried dentists.

NHS Boards already have met the Scottish Government target of reducing senior management posts by 25 per cent by 1 April 2015. The latest figures show that the overall reduction in senior management in the first four years of the target (financial years 2010/11-2013/14) has been 386.2 WTE (down 29.3 per cent), exceeding the target by 4.3 percentage points72. Work is continuing with all stakeholders on the implementation of statutory changes to the pension scheme in 2015 and the related Working Longer Review.

Sustainability and Seven Day Services
In October 2013, the Cabinet Secretary for Health and Wellbeing shared his vision for the NHS in Scotland to provide a genuine sustainable, seven day service where required. While NHSScotland already provides round-the-clock care, more is required to remove variation in the way care is delivered, particularly at the weekend. This is not about routine operations being carried out at midnight or on Sunday afternoons but about giving patients the best possible care and access to the services they need to move through the system, including being discharged from hospital, regardless of the day of the week.

Phase one of the programme is focusing on the services that people need most out of hours and at weekends and which have the greatest benefit for patient outcomes. It is also taking forward specific work to support delivery of sustainable seven day services in remote and rural areas. A taskforce is leading this work and will identify the key steps needed to provide a sustainable seven day service. The initial report is due by the end of 2014.

Workforce Planning
Recommendations aimed at strengthening workforce planning within NHS Boards were set out in the report Pan Scotland Workforce Planning Assessment and Recommendations[73] produced under the auspices of the National Workforce Planning Forum. Discussions about how to implement these recommendations made good progress and in the coming year will help each NHS Board to use its workforce more intelligently; taking account not only of numbers but of a broader range of influences on staff, and ensuring workforce planning reflects the need to deliver high quality services within an integrated context.

Medical Revalidation
Revalidation is the process by which doctors demonstrate that their skills, knowledge and competencies are up to date and that they remain fit to practise. It is a UK legal requirement that all licensed doctors revalidate every five years and is an important component in the governance of medical staff. The aim is to give the public confidence that doctors are performing well and are aware of the latest developments in their medical specialty and that the doctor is being regularly checked by their employer and the GMC. It also helps doctors reflect on how they can improve their practice and how they interact with patients. The process has been implemented in Scotland and subject to external review by Healthcare Improvement Scotland (HIS). In the last year, 90 per cent of doctors in NHSScotland had an appraisal undertaken.

INNOVATION
New technologies and different service models will be important in realising our 2020 Vision. The Route Map to the 2020 Vision for Health and Social Care built on Health and Wealth In Scotland: A Statement of Intent for Innovation In Health[74], making a commitment to ‘increase our investment in new innovations which both increase the quality of care, and reduce costs and simultaneously provide growth in the Scottish economy’.

The challenge is not only to encourage inventive ideas, but also to make sure that these ideas are adopted and spread. It was on this basis that the Scottish Government made £2 million available to allow all NHS Boards to have electronic whiteboards on wards so that clinical teams can get and update all the information they need about a patient in a readily usable way.

Innovation by its very nature is often about longer-term change, but during 2013/14 there were clear signs of momentum behind the drive to increase investment in innovations.

A new service in West Lothian now offers people over 75 in an emergency a choice of not being admitted to hospital. Following a GP referral, a member of the Rapid Elderly Assessment and Care Team (REACT) will arrange to see the person in their home on the same day to undertake an initial assessment. Thereafter, the team can provide hospital-level support and therapy interventions within a person’s own home.

Innovation has also been making a difference not just for individual patients but for whole communities. Living It Up has enlisted local communities to help design and develop ways in which local services can be connected digitally. Living It Up has started in five areas and aims by 2015 to provide services for 55,000 people (most of whom are over 50), supporting them to use familiar technology to be better connected to what matters to them and to keep them healthy and independent at home.

Innovations using digital technology are also being developed for those with specific illnesses. My Diabetes, My Way is the NHSScotland interactive website helping people manage their diabetes and look out for the signs of Hypoglycaemia – providing access to their own test results, clinic letters and treatment plan, and a variety of high quality multimedia resources.

The United4Health programme, operating across 14 regions throughout Europe, commenced in Scotland in 2013 for three years. The programme will trial a range of digital health monitoring solutions using familiar technologies to support home-based health monitoring of patients living with diabetes, respiratory disease and heart failure as an alternative to hospital care.

Touch Bionics, a Scottish company spun out of the NHSScotland, launched the first powered prosthetic hand to have five independently powered fingers that open and close around objects in a natural and anatomically-correct way. During 2013, working with the company through the joint NHSScotland-industry Health Innovation Partnership for Medical Technologies, arrangements were put in place both for patients in Scotland to benefit from this innovative technology and for its benefits to be evaluated.

Across Scotland there are many innovations being taken forward through the third sector drawing upon its agility, different perspectives, direct knowledge of people’s needs and links to local communities.

Loneliness is common amongst older men and is associated with significant health problems such as high blood pressure. Drawing on Change Fund[75] money, five organisations in Aberdeen have launched a befriending service to help people aged 55 plus overcome isolation.

RESEARCH
Research is a substantial contributor to effective care, providing insight into new ways of working and enabling new techniques and technologies to be tested out in a safe and controlled environment and, importantly, have their perceived benefits properly evaluated. The Chief Scientist Office (CSO) of the Scottish Government supports a substantial portfolio of research benefiting NHSScotland and patients.

Two of these CSO-funded research studies were awarded prizes by the Royal College of General Practitioners this year in recognition of the quality of their ground-breaking work. In cancer research, Dr Peter Murchie and colleagues at the University of Aberdeen found that GPs can effectively perform biopsies to test for melanoma without leading to poorer long term outcomes for patients. They demonstrated that patients who have their initial diagnostic excision biopsy in Primary Care experience fewer subsequent hospital admissions and fewer days in hospital. Dr Hillary Pinnock and her team at the University of Edinburgh were also recognised for their work on the effectiveness of telemonitoring – when integrated into existing clinical services – on hospital admission for Chronic Obstructive Pulmonary Disease.

Other recently-published or funded CSO studies on diabetes have developed techniques to allow clinicians to estimate a patient’s three-year risk of developing type 2 diabetes according to their blood glucose level and, in a study that if successful would transform the quality of life of type-1 diabetic patients, will assess the efficacy and safety of co-transplanting Mesenchymal Stromal cells with Pancreatic islets with a view to restoring hypoglycaemic awareness and in some cases reduce or eliminate insulin dependence.

CSO also supports the development of non-research innovations through Scottish Health Innovations Ltd (SHIL), a not-for-profit company owned by Scottish Ministers and NHS Boards.

E-HEALTH
Primary and secondary care organisations rely more than ever on secure, resilient and reliable information, communication and technology systems in order to deliver safe, effective and person-centred services. Health and care workers require access to the right information 24 hours a day, seven days a week wherever they need it to inform their decisions and ensure the best possible care is given to each individual.

During 2013/14, work to deliver improved outcomes has included:

Increasing the level of clinical information available online to healthcare professionals;

Increasing the capacity of patients to order prescriptions and book appointments online; and

Agreeing an Information Sharing Strategic Framework[76] that provides guidance and protocols for sharing information across health and social care.

Over the last year, the Key Information Summary (KIS) has been introduced which supports people with long term conditions and those most likely to require additional care at the weekend or out-of-hours. The KIS is a rich information resource for healthcare professionals and provides almost fully up-to-date information extracted from the general practice record, including details such as current medications, adverse reactions and allergies, anticipatory care plans, carer details, and particular wishes the patient wants recorded. This development was implemented in all GP Practices across Scotland over a three-month period and there are now over 110,000 KIS records – already helping people with complex needs to be cared for at home.

Improving the Health of the Population

Scoring goals and transforming lives.

Glenn’s Story

Die-hard Hibs fan Glenn, weighed 25 stone in 2002 when he was diagnosed with dangerously high blood pressure and put on medication. He began to diet and quickly lost six stone, but then found it difficult to make further progress. The turning point came when Glenn signed up for Football Fans in Training (FFIT) at his beloved Easter Road stadium.

Initially apprehensive about joining a course where he didn’t know anyone, Glenn soon found he was making friends – and progress. “The coaches really helped us to get to grips with what we were trying to do”, he says. “And if anyone was feeling down, the group as a whole tried to encourage that person.”

Glenn made great progress, and kept up the momentum after completing the programme. Now he’s maintaining a healthy weight on the BMI scale, he’s been able to come off the hypertension medications, and his replica Hibs top is an ‘M’ rather than the ‘XXXL’ he was wearing three years ago. Even wife Linda has become fitter, initially losing a couple of stone by adopting Glen’s healthier eating habits, and then joining him on vigorous walks.

FFIT began in 2010 as a unique collaboration between the SPFL Trust and 16 of Scotland’s professional football clubs, with academic input from five leading universities. FFIT incorporates some of the latest scientific approaches to exercise and diet, delivered typically through an initial 12-week programme at professional club grounds all over the country.

While most weight management programmes are attended largely by women, FFIT‘s success has been in reaching men who might otherwise find it difficult to maintain interest and commitment. So far, more than 2,000 men have attended FFIT, with continued growth expected.

The Scottish Government has been a major backer from the beginning, providing funds to set up and maintain the scheme, as well as a budget for the FFIT Tournament in June 2014. NHSScotland is working to increase the number of GPs referring patients to the scheme, and a number of local NHS Boards across the country are supporting the programme.

The FFIT programme has attracted a number of prestigious awards and award nominations. In 2012, FFIT received the Community Wide Programme Award from the Physical Activity and Health Alliance. It also received a European Professional Football League (EPFL) 2011 Best Practice Award for Social Responsibility, and in 2011, received the Herald Society’s Health Provider of the Year Award.

“The motivation comes from being part of a team and wearing the club badge. Getting to train at Easter Road has been absolutely great….I can’t think of an aspect of my life which hasn’t changed.”

Glenn, Hibs fan and FFIT success story

NHSScotland has a vital role in improving and maintaining the good health of the people of Scotland, and in reducing health inequalities. This is central to the aim for NHSScotland to become a world-leader in terms of healthcare quality, and to the wider Scottish Government objectives to support people to live longer, healthier lives, and to reduce inequality through early intervention and anticipatory care.

While Scotland’s health is improving, with year on year improvements, it is improving more slowly than comparable European countries. From the middle of the last century, Scotland’s health has dropped below that of its neighbours and the rate of improvement of health in the poorer areas of Scotland is significantly slower that in more affluent areas.

The origins of health inequalities are complex and they are to be found in the many interactions between social, economic, educational and environmental determinants. During its most recent review of progress in delivering Equally Well[77], the Ministerial Task Force on Health Inequalities recognised the continued need for concerted action across this range of determinants. The specific focus of the Task Force on this occasion was to consider how better health might be supported within Scotland’s communities through considering the role of Community Planning Partnerships, the recommendations of the Christie Commission on the Future Delivery of Public Services[78],and how aspects of ‘place’ impact on health.

The Task Force heard evidence that while the health of Scotland was improving, it was doing so more slowly than other European countries. It heard that conventional approaches to the problem that involve attempts to modify the health-related behaviours of poorer people have failed. It heard that the level of deaths in the 15-44 age group was contributing significantly to the relatively poor position of Scotland’s health in a European context. It also heard that despite many similarities, Glasgow and the West of Scotland were experiencing many more deaths than comparable cities and regions in the UK. Evidence was presented that showed that people’s immediate environment plays an important role in their health and wellbeing.

The Task Force re-iterated its view that it was not solely the responsibility of the NHS in Scotland to resolve the problems arising from health inequalities. All parts of local and national government, and the wider public and voluntary sectors, have a significant part to play in achieving the reduction in inequalities.

The Task Force identified the need to make further progress in adopting approaches which are asset-based, co-produced and person-centred, to bring about effective and sustained change. There is strong evidence of the effectiveness of this distinctive Scottish approach to government and delivery of public services. Partnership working between the public sector, third sector, business and local communities is essential. Community planning has a critical role to play in making public service reform happen at local level. It provides the foundation for partnership working between NHSScotland and its partners in local authorities and other public bodies alongside their local communities. Greater levels of integration are increasing the focus on prevention and securing continuous improvement in service delivery.

For most Community Planning Partnerships, one development priority has been to give effect to the Agreement on Joint Working on Community Planning and Resourcing[79], which was published alongside the Scottish Government Draft Budget for 2014/15, so that partners work together to deploy resources towards joint priorities as set out in their Single Outcome Agreement. The forthcoming Community Empowerment Bill will create new opportunities for people and communities to co-produce services around their needs – supporting them to build and use their own assets, including their skills and networks.

Preventable, lifestyle-related illnesses including many cancers, heart disease, type 2 diabetes, arthritis and dementia are not an inevitable feature of life. They are the unintended, long-term consequences of sometimes poor lifestyle choices, compounded by the fact that many people lack the support needed to make important and truly beneficial changes to their health.

The impact on health of physical activity, smoking cessation and sensible alcohol consumption in preventing the onset of disease is unequivocal. It is well understood that simply warning people about the detriments of physical inactivity and smoking, for example, does not necessarily translate into them making healthier choices. However, health improvement advice that is followed through by further one-to-one or group support, tailored to the individual’s needs and circumstances, is more likely to have a significant and lasting effect. Glen’s story of his involvement with Football Fans in Training and resulting health benefits is just one example of the work underway within our communities and NHSScotland that reach out to tackle real people in their everyday lives and sometimes by harnessing what interests them.

GPs in the most deprived communities too often have to deal with patients (one in five consultations) whose primary concern may be a non-medical issue but one which is impacting adversely on their lives.

The Link Worker Programme, delivered in partnership with the Health and Social Care Alliance and the Deep End General Practitioners, aims to explore how the Primary Care team can support people to live well in their community.

While GPs and health professionals manage the patients’ medical issues, the Link Worker assists by helping deal with other issues that are causing them concern including debt, social isolation and stress, poor housing and fuel poverty issues. This can ensure that people receive the right support and minimise the demand on GP services and other NHS services. The current Link Worker programme is made up of two inter-related interventions: the provision of a practice-attached Link Workers (seven in Glasgow and two in Dundee) and the development by the practice team of a link approach.

ALCOHOL BRIEF INTERVENTIONS
Alcohol-related harm has an impact not only on the individual but on families and communities. Alcohol Brief Interventions (ABIs) play an important preventative role in tackling this, as one component of a wider strategic approach to tackling alcohol misuse.

The ABI programme has focused delivery on three priority settings: Primary Care, Accident & Emergency and antenatal services. In 2013/14, 104,356 ABIs were carried out, exceeding the target of 61,081 by 71 per cent[80]. In order to support the long term aim of embedding ABI delivery into routine practice, the target will continue into 2014/15 for a final year.

Consideration is also being given to how a better service can be provided in Primary Care settings that contributes to building social capital. If people feel better supported to live well within their community and to self-manage, they are more likely to avoid reaching crisis point which can mean ending up in hospital.

SMOKING
Tobacco remains the primary preventable cause of ill health and premature death. Each year in Scotland, it is associated with over 13,000 deaths (around a quarter of all deaths in Scotland every year) and 56,000 hospital admissions[81]. Annual costs to NHSScotland associated with tobacco-related illness are estimated to exceed £300 million and may be higher than £500 million[82].

Reducing the number of people who take up smoking, supporting those who do smoke to quit and protecting people from second-hand smoke have long been clear public health priorities.

On 27 March 2013, the Scottish Government’s latest Tobacco Control Strategy, Creating a Tobacco-free Generation[83], was published. This reaffirmed the vision for a tobacco-free Scotland and set a world-leading target to achieve this by 2034. This will mean that a child born in 2013 will become an adult in a Scotland that is largely devoid of tobacco-use with all the health, social and economic benefits that entails. This is a challenging target and achieving it will require a determined effort to support people to choose not to smoke. The strategy sets out a package of measures to progress along this journey over the next five years.

Part of this journey will be to help people who smoke to quit the habit. Between 2011 and 2014, NHS Boards exceeded the Scottish Government target to help people quit tobacco for at least one month with 124,734 quits compared to a target of 80,000. Even more encouraging are the numbers in our most deprived communities. In these areas a target was set for 48,000 people to quit for at least a month. The actual figure achieved was 70,162[84]. To build on the success of our one month target, NHS Boards are now working towards a new target of supporting people in our poorest areas to quit smoking for at least three months. This is a challenge but it is known that tobacco use is much more common in poorer communities. The latest statistics show that smoking rates in the 20 per cent least deprived areas are now around 11 per cent compared to around 39 per cent in our most deprived areas[85].

It’s not just the people who smoke who are affected by the health impact of tobacco. Second-hand smoke also affects children who are exposed to it. Recent Scottish research shows that harmful chemicals from tobacco can linger in a room for up to five hours. The harmful toxins will pass still from room to room, and be breathed in by others. The recently-launched campaign, Take it Right Outside, takes a message to smokers – particularly parents – that, if they must smoke, they should go outside and close the door.

Help continues to be provided for those who want to quit. GPs provide expert advice and will direct people to a range of local services on their doorstep. Pharmacists have, for many, become a convenient front-line smoking cessation service which can provide smoking cessation products to help people quit with ongoing advice and follow-up support. Further information and advice is also provided through services such as Smokeline (0800 84 84 84) or at www.canstopsmoking.com or www.rightoutside.org.

PHYSICAL ACTIVITY
Physical inactivity results in around 2,500 premature deaths in Scotland each year and the costs to NHSScotland have been calculated at around £94.1 million annually[86]. It is generally agreed that, with regular physical activity, mortality can be reduced by 30 per cent, and a risk reduction for many chronic diseases of around 20-40 per cent can be seen[87]. In addition, regular physical activity can help prevent obesity and many associated health complications, while improving physical and mental health outcomes.

In 2014, Scotland was presented with an opportunity to inspire people to be more physically active through hosting the XX Commonwealth Games and The Ryder Cup. A 10-year Physical Activity Implementation Plan A More Active Scotland – Building a Legacy from the Commonwealth Games[88] was launched in February 2014 to help achieve lasting change and by the time of the Opening Ceremony, over 50 national Legacy 2014 Programmes and over 80 Supporting Legacy 2014 Projects were already in place encouraging people to be active and connected in their communities.

NHSScotland, along with many workforces across Scotland, has taken part in the Fit in 14 physical activity campaign which encourages staff to take small, simple steps towards a more active lifestyle. In addition, work is continuing to make the promotion of physical activity a routine part of clinical care.

HEALTH PROMOTING HEALTH SERVICE
An NHSScotland which places health improvement at its core is a strongly held ambition and is beginning to be realised through Health Promoting Health Service[89] in hospital settings. In addition to working in local communities to improve health, NHSScotland is also being challenged to ensure it is doing everything it can to promote health within NHS settings.

Antenatal Alcohol Brief Intervention Service in NHS Ayrshire and Arran

The Antenatal Alcohol Brief Intervention (ABI) Service aims to improve the health of future generations by providing the best possible start for babies in Ayrshire, as well as improving the health of their mothers. The service was designed to effectively screen all pregnant women for alcohol use, deliver an ABI as appropriate, raise awareness of the potential harmful effects of using alcohol during pregnancy and to signpost to other services when necessary. So far, all community midwives have been ABI trained and the focus is now on offering ABI training sessions for hospital-based staff.

Yvonne, one pregnant mother, acknowledged heavily binge drinking in early pregnancy and, following an ABI by the Midwife, a home visit was arranged. She planned to abstain for the remainder of her pregnancy due to the potential harmful effects, but could not guarantee that she could do it alone. Referral was made to a local Alcohol Counselling Service where she attended for one-to-one sessions. She remained alcohol free and support remained in place for her in the immediate postnatal period. This was a very positive outcome that Yvonne feels was due to the midwife raising the issue of alcohol at the booking appointment.

Historically, health promotion activity has tended to fall within the Public Health sphere and has been focused on activity outside of hospitals. Secondary care settings, however, offer the chance to engage with patients when they may be highly motivated to make changes that will positively impact on their health and wellbeing. Many hospital patients have multiple long term conditions and there are significant opportunities to support them to make healthier choices. NHSScotland has a substantial workforce and, with many patient interactions, hospital settings can be exemplars in promoting healthy lifestyle choices.

Promotion of healthier choices amongst patients, staff and visitors has been increasingly evident in the last year. There has been a rise in the number of patients referred to smoking cessation support from secondary settings and a substantial increase in the conversations between patients and health professionals on the benefits of physical activity. Improvements in the hospital environment are also clear, with healthier food choices on offer to staff, patients and visitors, and action is being taken to eradicate smoking on NHSScotland premises by March 2015.

Securing Value and Financial Sustainability

Serving up efficiency and quality – a new catering information system for Fife and beyond.

Saffron’s Story

Soft facilities like catering, cleaning and laundry are major expenditures for every hospital, and their quality can have a significant influence on the patient experience. So any improvement in their management can have a big impact on overall performance.

As part of an ongoing strategic review across NHSScotland, a new Catering Information System has been developed and tested at Queen Margaret Hospital in Dunfermline. A bespoke software application, produced and owned by NHSScotland and NHS Health Facilities Scotland, now covers stock, meal production numbers, purchase data, labour costs and wastage. The system also helps manage non-patient retail catering to review margins and profitability.

“The key improvement is that we now know exactly where we are, from day to day and even hour to hour.”

The new system means the team can see the big picture, all the time. Where previously they may have relied on guesswork, they’re now equipped with the precise numbers they need to review all aspects of performance on a daily basis.

“There was some resistance from staff at first, as they’d been doing it ‘their’ way for a long time. But when they realised that the savings were enough to pay the salaries of two full-time cooks, they soon got on board.”

Getting used to the new software was straightforward – it was implemented in less than a week – and although there was a little resistance from staff at first, the clear benefits of saving time on storekeeping and clerical work were obvious. With accurate information available in the kitchen itself, cooks have even begun to compete for ‘spot-on’, waste-free production.

Over the first year, savings have amounted to £40,000 on an investment of £10,400 – roughly a four to one return. That’s made up of a reduction in wastage from about 30 per cent to under eight per cent, an increase in retail profit margin, better demand accuracy, and release of resources.

Following success in Fife the pilot has been extended to NHS Borders, NHS Lanarkshire, NHS Tayside, NHS Shetland and NHS Orkney. Now the Catering Information System is being migrated to a web-based platform, which will provide yet more flexibility, accuracy and efficiency in years to come.

“The old attitude of ‘it was 200 beef stews last week, so we’ll have 200 beef stews this week’ has gone. We’re responding to patient choice and preference, and providing more choice with less waste.”

Saffron Moir, Assistant Catering Manager, NHS Fife.

“It’s great to know that the money we’re saving is going back into patient care.”

Saffron Moir, Assistant Catering Manager, NHS Fife.

For the sixth year in a row, all NHS Boards have met their financial targets. This means that they have stayed within the budgets allocated to them. This serves to demonstrate the robust financial planning and management undertaken by NHS Boards and the Scottish Government Health and Social Care Directorates.

For 2013/14, health recorded an underspend of £4 million on an overall budget of £11.8 billion which demonstrates that the totality of the budget was used to provide services and invest in infrastructure, thus securing good value in the use of public funds.

In 2013/14, of the total £11.8 billion health budget, the majority of this budget – £9.1 billion – was distributed to NHS Boards at the start of the year. A further £0.4 billion was spent on infrastructure, while the remaining £2.2 billion was directed towards priority areas (in the main through allocations to NHS Boards). Chart Ten shows how both resource and capital funds are distributed and spent.

CAPITAL
The following infrastructure investment took place in 2013/14:

£230 million of investment as part of the progression of the £842 million New South Glasgow Hospitals Project, which continues on time and on budget and is due to open in the summer of 2015; and

Completion of the £23 million Aberdeen Health and Care Village, the first hub project to be delivered through the Scottish Government’s innovative pipeline of revenue-financed major acute and community health infrastructure. Total investment delivered through the Non Profit Distributing (NPD) and hub programmes during 2013/14 was an estimated £32 million.

Other completed projects during 2013/14 include community health infrastructure across Scotland, including the Vale Centre for Health and Care in Alexandria, the new Glenwood Health Centre in Glenrothes, the Westerhailes Healthy Living Centre and the new Possilpark Health Centre.

RESOURCE
The majority of the resource budget (80.6 per cent) is allocated to NHS Boards and forms their baseline budgets. The remaining 19.4 per cent is held centrally to support national initiatives and target specific priorities. Chart Eleven outlines these target areas. The Scottish Government is committed to ensuring that this remaining funding is allocated to NHS Boards as early in the financial year as possible.

EFFICIENCY SAVINGS
In order to continue to secure value for the public and ensure the future sustainability of the NHS in Scotland, NHS Territorial Boards and Special Boards that deliver direct patient care are required to deliver planned savings each year which they retain in order to reinvest in services. Special NHS Boards that do not provide direct patient care return their savings in order that they are recycled into the overall funding available to support patient care. Over the past five years, NHSScotland has successfully reinvested over £1.5 billion of savings – £275 million in 2013/14 alone – allowing NHS Boards to direct this money towards improving the quality of services.

Across Scottish Government health policy, the priority is to deliver improved quality and safer care whilst ensuring that the NHS is sustainable and delivers value for the public purse. Prudent management of scarce resources, avoiding duplication and removing unnecessary and harmful variation across and within areas is the key component of this approach. NHS Boards have made significant progress with both Territorial and Special NHS Boards continuing to deliver financial balance and savings goals while improving the quality of their services.

The Scottish Government offers a wide range of support to NHS Boards in this. In particular, the Quality and Efficiency Support Team (QuEST) delivers 10 specialist, focused programmes across a range of clinical and non-clinical areas including procurement, facilities, whole system patient flow and mental health. Between them, these programmes have supported NHS Boards to test, spread and embed their own innovative good practice as evidenced by almost 200 examples collected to date.

The Scottish Government’s approach to improving the efficiency of health services has been set out in its 2020 Framework for Quality, Efficiency and Value[90] which includes many examples of improvement. Saffron’s story of the new catering information system for Fife and beyond is one of the many projects in QuEST’s Facilities Programme.

Territorial NHS Boards achieve their savings for reinvestment across a wide range of areas including service redesign, prescribing, procurement and facilities management. Boards also deliver programmes leading to gains in productivity, freeing up staff time and resources that enable them to avoid additional costs. While these savings are not as immediately obvious, they are critical to ensuring that resources are managed effectively and the quality of patient outcomes and experience is improved.

NHS Greater Glasgow and Clyde, supported by QuEST, has made significant improvements in its waiting times for Child and Adolescent Mental Health Services. Using tools and techniques that can improve quality and efficiency, they have reduced the longest wait for these services from 113 weeks to less than 26 in three years and are on track to achieve the 18-week target by December 2014[91].

Support services have an important role in the services provided by NHSScotland and many of the initiatives that lead to improved quality and efficiency are in this area. In the procurement of goods and services, NHSScotland has been working hard to ensure that best value is achieved through its purchasing practice. Special NHS Boards often procure services on behalf of the whole of NHSScotland so it is imperative that they are as effective as possible in this area. NHS Education for Scotland implemented a much smarter approach to procurement and has delivered savings initially of £300,000, with a further £430,000 that will be achieved recurrently. The staff involved have also been freed up to carry out their specialised work as they no longer have to manage procurement activity alongside their own roles.

After staffing, prescribing makes up the second largest part of the NHSScotland budget. NHS Boards have been delivering large savings across their drug budgets for many years but there are still efficiencies to be made, many of them flowing from improvements in the quality of prescribing.

Many patients, particularly those who are older, are on multiple drugs, some of them used to counteract the side-effects of other medicines. The Scottish Government published guidance on the management of this issue – known as polypharmacy – in 2013 and a number of NHS Boards have used them to deliver significant improvements in the quality of pharmaceutical care for patients that have also reduced the cost of drugs.

Two patients with complex needs in Fife required specialist treatment that could only be provided outside Scotland with significant associated cost. This was clearly not best for the patients who had to be away from their families and made management of their wellbeing more difficult. By redeveloping some unused estate into a state-of-the-art facility for these two patients, NHS Fife achieved massive improvements in the social and therapeutic quality of life for the patients, while also delivering savings of £320,000 a year to be reinvested in care.

NHS Lothian carried out a review of 602 patients across 24 GP Practices and subsequently made the following changes:

659 medicines were stopped (this includes 150 high-risk medicines stopped);

169 medicines doses were reduced;

26 medicines doses were increased;

91 new medicines were started; and

166 medicines were switched, for example, to formulary choices and/or safer and more cost effective alternatives.

The average number of medicines per patient before the review was 11.4 and after review was 10.5, a reduction of 0.9 across Lothian.

In total, immediate savings of almost £40,000 and cost avoidance of over £16,000 were achieved[92]. The activity is ongoing with a full cohort of almost 3,000 patients and the projected savings and cost avoidance will reach almost £250,000 a year. More importantly, many patients will be receiving more appropriate and, in many cases, safer drugs than before that will have a major impact on their quality of life.

The NHSScotland estate (buildings and facilities) is one of its biggest assets. As NHS Boards have redeveloped and redesigned their services to provide better quality care, some buildings and facilities have become surplus to requirements. In such cases, plans are required to find innovative uses for them or, where appropriate, building and land may be sold off to provide the best deal for the public purse. Often, by thinking differently about how to use these resources, NHS Boards can develop services that have an enormously beneficial impact on patients and which can also be more cost-effective.

In addition to this, the Scottish Government, along with Chairs and Chief Executives of NHS Boards, have agreed to develop a programme of work under the heading of ‘Once for Scotland’ to spread and implement good practice more widely across NHSScotland. Where an intervention is proven to meet the ‘Quality, Efficiency and Value’ test and can deliver significant gains for the service and its users, the programme will support its adoption by NHS Boards across the whole of Scotland.

Appendices

HEAT Target Performance 2013/14

Health Improvement

HEAT Targets Due for Delivery in 2013/14
Target | Outcome
Reduce suicide rate between 2002 and 2013 by 20 per cent. | The suicide rate for 2011-13 was 14.0 per 100,000, compared with 14.3 per 100,000 in 2010-12. Between 2000-02 and 2011-13 there has been an overall downward trend of 19.5 per cent in suicide rates.
At least 60 per cent of 3- and 4-year-old children in each Scottish Index of Multiple Deprivation (SIMD) quintile to receive at least two applications of fluoride varnish (FV) per year by March 2014. | For the year ending March 2013, the worst-performing age/quintile combination at the national level was 10 per cent.
To achieve 14,910 completed Child Healthy Weight Interventions over the three years ending March 2014. | For the three years ending March 2014 the number of completed Child Healthy Weight Interventions was 16,820.
NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40 per cent most-deprived within-Board SIMD areas over the three years ending March 2014. | From April 2011 to March 2014, NHSScotland smoking cessation services reported 70,162 successful quit attempts (at one month post quit) in the 40 per cent most-deprived within-Board SIMD areas.

HEAT Targets Due in Future Years
Target | Latest Results
To increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung cancer by 25 per cent by 2014/15. | In Scotland, there was a 4.7 per cent increase in the percentage of people diagnosed at stage 1 for breast, colorectal and lung cancer (combined) between the baseline of 2010/11 and 2012/13.
NHSScotland to deliver universal smoking cessation services to achieve at least 12,000 successful quits, at 12 weeks post quit, in the 40 per cent most deprived within-Board SIMD areas (60 per cent for island health boards) over one year ending March 2015. | Work is underway to develop the data source for reporting on target progress.
At least 80 per cent of pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours. | For the year ending March 2013, the worst-performing SIMD quintile at the national level was 74.6 per cent.

Efficiency and Governance

HEAT Targets Due for Delivery in 2013/14
Target | Outcome
NHS Boards are required to operate within their Revenue Resource Limit (RRL), their Capital Resource Limit (CRL) and meet their Cash Requirement. | All NHS Boards met their 2013/14 financial targets.
NHSScotland to reduce energy-based carbon dioxide (CO2) emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009. | Between 2009/10 and 2013/14, NHSScotland secured a 3.6 per cent reduction in carbon dioxide (CO2) emissions and a 3.4 per cent reduction in energy consumption.

Access to Services

HEAT Targets Due for Delivery in 2013/14
Target | Latest Results
Eligible patients will commence IVF treatment within 12 months by 31 March 2015. | Waiting times data for IVF treatment commencement is at an early stage of development. The initial estimates from data at this early stage indicate that for the quarter ending September 2014, around 71 per cent of eligible patients were screened for IVF treatment within 365 days.
Deliver faster access to mental health services by delivering 18 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from December 2014; and 18 weeks referral to treatment for Psychological Therapies from December 2014. | During the quarter ending June 2014, 82.9 per cent of children and young people were seen within 18 weeks for CAMHS services. During the quarter ending June 2014, 81.9 per cent of people were seen within 18 weeks for Psychological Therapies.
95 per cent of patients will wait less than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment by year ending September 2014. | The percentage of patients waiting less than 4 hours for the year ending September 2014 was 93.4 per cent.

Treatment Appropriate to Individuals

HEAT Targets Due for Delivery in 2013/14
Target | Outcome
To support shifting the balance of care, NHS Boards will achieve agreed reductions in the rates of attendance at A&E between 2009/10 and 2013/14. | In the year ending March 2014, the number of unplanned A&E attendances per 100,000 population was 2,116.

HEAT Targets Due in Future Years

Target
Latest Results

Further reduce Healthcare Associated Infections so that by March 2015 NHS Boards’ Staphylococcus aureus bacteraemia (including MRSA) cases are 0.24 or less per 1,000 acute occupied bed days; and the rate of Clostridium difficile infections in patients aged 15 and over is 0.32 cases or less per 1,000 total occupied bed days.
For the year ending June 2014, the rate of Staphylococcus aureus bacteraemia (including MRSA) cases across NHSScotland was 0.31 per 1,000 acute occupied bed days.
For the year ending June 2014, the rate of identifications of Clostridium difficile infections across NHSScotland was 0.34 per 1,000 occupied bed days among patients aged 15 and over.

No people will wait more than 14 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2015.
There were 587 people waiting over 14 days to be discharged from hospital in October 2014.

To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a Link Worker, including the building of a person-centred support plan.
Data systems and definitions are currently under development.

Reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population by at least 12 per cent between 2009/10 and 2014/15.
There was a 13.7 per cent decrease in the rate of occupied bed days for patients aged 75+ who were admitted in 2013/14 compared with the target baseline. There were 5,420 bed days per 1,000 population in 2009/10 compared to 4,677 in 2013/14.

Territorial NHS Boards

NHS Ayrshire and Arran | www.nhsaaa.net
NHS Borders | www.nhsborders.scot.nhs.uk
NHS Dumfries and Galloway | www.nhsdg.scot.nhs.uk
NHS Fife | www.nhsfife.org
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.org.uk
NHS Lothian | www.nhslothian.scot.nhs.uk
NHS Orkney | www.ohb.scot.nhs.uk
NHS Shetland | www.shb.scot.nhs.uk
NHS Tayside | www.nhstayside.scot.nhs.uk
NHS Western Isles | www.wihb.scot.nhs.uk

Special NHS Boards

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

Healthcare Improvement Scotland

Healthcare Improvement Scotland (HIS)
www.healthcareimprovementscotland.org

Footnotes

1 The Route Map to the 2020 Vision for Health and Social Care can be found at: www.scotland.gov.uk/Topics/Health/Policy/Quality-Strategy/routemap2020vision

2 The Healthcare Quality Strategy for Scotland, Scottish Government, May 2010

3 O’Loughlin J et al. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. American journal of epidemiology, 1993, 137:342-54

4 National Records of Scotland: Vital Events, Deaths: Age Standardised Death Rates

5 ISD Scotland: Annual Heart Disease Statistics Update/Annual Stroke Statistics Update

6 ISD Scotland: Detect Cancer Early Staging Data

7 National Records of Scotland/Scottish Public Health Observatory: Suicide: Scottish Trends

8 ISD Scotland: Births in Scottish Hospitals (Annual Update)

9 ISD Scotland: Dental Statistics: National Dental Inspection Programme (NDIP)

10 ISD Scotland: Child Healthy Weight Intervention Statistics 2013/14

11 Scottish Government: Scottish Health Survey, 2013 Annual Report

12 ISD Scotland: NHS Smoking Cessation Service Statistics

13 Scottish Government: Scottish Household Survey, 2013 Annual Report

14 ISD Scotland: SALSUS Annual Report 2013

15 ISD Scotland: Alcohol Brief Interventions 2013/14

16 Scottish Government: Scottish Health Survey, 2013 Annual Report

17 ISD Scotland: NHS Waiting Times, 18 Weeks Referral-to-Treatment

18 ISD Scotland: NHS Waiting Times, Stage of Treatment

19 ISD Scotland: NHS Waiting Times, Cancer Waiting Times

20 ISD Scotland: Drug and Alcohol Treatment Waiting Times

21 Nuffield Trust: Four Health Systems of the UK, How do they compare?

22 ISD:Scotland: Hospital Standardised Mortality Ratios: Quarterly Statistics

23 Health Protection Scotland: Clostridium difficile Quarterly Report

24 Health Protection Scotland: SAB Quarterly Report

25 Scottish Government: Scottish Inpatient Patient Survey 2014

26 Scottish Government: Health and Care Experience Survey 2013/14

27 Scottish Government: Scottish Maternity Care Survey 2013

28 ISD Scotland: Emergency Department Activity and Waiting Times

29 ISD Scotland: Delayed Discharges in NHSScotland

30 ISD Scotland: Acute Hospital Activity and NHS Beds Activity

31 Scottish Inpatient Patient Experience Survey 2014 Volume 1: National Results, Scottish Government, August 2014

32 Health and Care Experience Survey 2013/14 Volume 1: National Results, Scottish Government, May 2014

33 Having a Baby in Scotland 2013: Women’s Experiences of Maternity Care, Scottish Government, January 2014

34 The Patient Opinion website can be found at: www.patientopinion.org.uk

35 Further information on the People Powered Health and Wellbeing Programme can be found at: www.alliance-scotland.org.uk/what-we-do/projects/people-powered-health-and-wellbeing

36 Delivering Better Services for People with Long-term Conditions. Building the House of Care. Angela Coulter, Sue Roberts, Anna Dixon, October 2013

37 Making it Easy: A Health Literacy Action Plan for Scotland, Scottish Government, June 2014

38 Further information on the Health Literacy Place can be found at: http://www.knowledge.scot.nhs.uk/healthliteracy

39 Valuing Carers 2011, Calculating the Value of Carers Support, Carers UK/University of Leeds www.carersuk.org/scotland/news/facts-and-figures

40 Caring Together. The Carers Strategy for Scotland 2010-2015, Scottish Government and COSLA, July 2010

41 Health and Care Experience Survey 2013/14 Volume 1: National Results, Scottish Government, May 2014

42 Equal Partners in Care (EPiC): Core Principles for Working with Carers and Young Carers, NHS Education for Scotland and Scottish Social Services Council, 2013

43 Self-Directed Support: A National Strategy for Scotland, Scottish Government, Nov 2010

44 CEL 19 (2013) Next steps for acute adult safety: patient safety essentials and safety priorities, Scottish Government, September 2013 www.sehd.scot.nhs.uk/mels/CEL2013_19.pdf

45 The Annual Scottish Intensive Care HAI Prevalence Report can be found at: (www.scottishintensivecare.org.uk/uploads/2014-08-23-11-43-31-2014HAISurveillanceReport-59491.pdf)

46 Source: www.isdscotland.org/Health-Topics/Quality-Indicators/HSMR

47 A Rapid Review of the Safety and Quality of Care for Acute Adult Patients in NHS Lanarkshire, Healthcare Improvement Scotland, December 2013

48 The Healthcare Associated Infection (HAI) Delivery Plan April 2011 and Beyond, Scottish Government, August 2012

49 The NHSScotland National Cleaning Services Specification, Health Facilities Scotland, July 2014

50 “Quarterly Scottish Staphylococcus aureus bacteraemia Surveillance Report, April – June 2014, Health Protection Scotland (HPS), October 2014 and Quarterly Scottish Clostridium difficile Infection (CDI) Surveillance Report, April – June 2014, Health Protection Scotland (HPS), October 2014

51 Antibacterial Primary Care Prescribing Indicators Report 2013-14, Health Protection Scotland (HPS) and Information Services Division (ISD), October 2014

52 The Healthcare Environment Inspectorate Annual Report 2012/13, Healthcare Environment Inspectorate, February 2014

53 Report on the Review of the Methodology and Process for the Inspection of the Care of Older People in Acute Hospitals, Healthcare Improvement Scotland, November 2013

54 Prescription for Excellence: A Vision and Action Plan for the right pharmaceutical care through integrated partnerships and innovation, Scottish Government, September 2013

55 National Unscheduled Care Action Plan April 2013 to April 2016, Scottish Government, February 2013

56 ISD Scotland: A&E Datamart

57 Many Conditions, One Life: Living Well with Multiple Conditions – a new Action Plan to improve care and support for people living with multiple conditions in Scotland can be found on the Joint Improvement Team website at: www.jitscotland.org.uk/resource/many-conditions-one-life-living-well-multiple-conditions

58 Information from Key Information Summary (KIS) system: a Scotland-wide NHS system. (Information correct as of September 29, 2014). Further information on KIS can be found at: www.nhs24.com/Explained/MyInfoNHS24/WhatisKIS

59 Thistle is a Scottish charity that supports people with disabilities and health conditions

60 Scotland National Dementia Strategy 2013-2016, Scottish Government, June 2013

61 Promoting Excellence: A framework for all health and social services staff working with people with dementia, their families and carers, Scottish Government, 2011

62 Further information on the national action plan can be found at: www.scotland.gov.uk/topics/health/services/mental-health/dementia

63 The Scottish Government response to the Mental Welfare Commission Report “Dignity and Respect: dementia and continuing care visits” Scottish Government, August 2014

64 Mental Welfare Commission of Scotland Visit Report, Dignity and Respect: Dementia Continuing Care Visits, Mental Welfare Commission of Scotland, April 2013

65 ISD Scotland: CAMHS Workforce

66 Scottish Public Health Observatory 2014, www.scotpho.org.uk/health-wellbeing-and-disease/suicide/key-points

67 Management data

68 Scottish Referral Guidelines for Suspected Cancer, Healthcare Improvement Scotland, August 2014

69 Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

70 CEL 26 (2013) Staff Governance Standard Monitoring Framework for 2013/14, Scottish Government, November 2013 www.staffgovernance.scot.nhs.uk/monitoring-employee-experience/staff-governance-standard-monitoring

71 NHSScotland Confidential Alert Line – Six month interim evaluation www.scotland.gov.uk/Topics/Health/NHS-Workforce/Employee-Experience/NHS-staff-alert-line/AlertLineSixMonthEvalu

72 25 per cent Reduction in Senior Management Posts Target – National Progress Towards 25 per cent Reduction as at 31st March 2014, Scottish Government, August 2014

73 Pan Scotland Workforce Planning Assessment and Recommendations – Final, National Workforce Planning Forum, March 2014

74 Health and Wealth in Scotland: A Statement of Intent for Innovation In Health, Scottish Government, June 2012

75 Further information on the Change Fund can be found at: www.scotland.gov.uk/Topics/Health/Support-Social-Care/Support/Older-People/ReshapingCare

76 Further information on the Information Sharing Strategic Framework can be found at: www.scotland.gov.uk/Publications/2013/12/1004/2

77 Report of the Ministerial Task Force on Health Inequalities (2013), Scottish Government, March 2014

78 Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie, Scottish Government, June 2011

79 Agreement on Joint Working on Community Planning and Resourcing, Scottish Government and COSLA, September 2013

80 ISD Scotland: Alcohol Brief Interventions 2013-14: Official Statistics publication 2014

81 ScotPHO Smoking Ready Reckoner 2011

82 ScotPHO Smoking Ready Reckoner 2011

83 Scottish Government Tobacco Strategy: Creating a Tobacco-Free Generation – A Tobacco Control Strategy for Scotland, Scottish Government, March 2013

84 ISD Scotland: NHS Smoking Cessation Service Statistics (Scotland) 1st April 2011 to 31st March 2014

85 Scotland’s People Annual Report: Results from 2013 Scottish Household Survey, Scottish Government, August 2914

86 Costing the Burden of Ill Health Related to Physical Inactivity for Scotland, commissioned by NHS Health Scotland, August 2012

87 Start active, stay active, Chief Medical Officers of England, Scotland, Wales and Northern Ireland, 2011

88 A More Active Scotland – Building a Legacy from the Commonwealth Games, Scottish Government, February 2014

89 Further information on Health Promoting Health Service can be found at: www.knowledge.scot.nhs.uk/home/portals-and-topics/health-improvement/hphs.aspx

90 2020 Framework for Quality, Efficiency and Value, Scottish Government, www.qihub.scot.nhs.uk/media/607430/2020framework_12062014_final.pdf

91 Further information, including data source, can be found on the QuEST website at: www.qihub.scot.nhs.uk/knowledge-centre/case-studies.aspx

92 Further information, including data source, can be found on the QuEST website at: www.qihub.scot.nhs.uk/knowledge-centre/case-studies.aspx