Policy responses and statements

Name of organisation:

Scottish Executive: Healthcare Policy and Strategy Directorate

Name of policy document:

Better Health, Better Care: A Discussion Document

Deadline for response:

12 November 2007

Background: The Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon MSP, launched 'Better Health, Bettter Care: A Discussion Document'. This document initiates a nationwide discussion raising a series of questions about the actions which need to be taken over the next few years in order to improve patients' experience of care, further enhance the support provided for people with long term conditions and tackle health inequalities across Scotland.

In 2005, Building a Health Service Fit for the Future identified the challenges to health and wellbeing from an ageing population, persistent health inequalities and a growth in long term conditions. These factors are increasing demand for health and care services and changing the pattern of that demand, with a rise in emergency admissions and an increase in age related conditions such as dementia.

The report argued that the current model of healthcare, developed at a time when the main challenge had been to provide hospital based care for acute conditions, was not sustainable in the longer term. We needed a new and different response, formed against a background of rising public expectations, the potential of new technology to transform the quality and accessibility of services and pressures on our workforce as we compete to attract the best talent in a shrinking labour market. The challenges described in the report continue to face us and many of the required responses remain the same.

This document sought to open discussion about the Scottish Government's objectives and the best means to achieve them. It poses a series of questions to give consultees the chance to shape the action plan which will be published in December 2007. This will be a detailed plan, with a timetable for action for NHSScotland at national, regional and local leveal, as well as a series of commitments from key delivery partners.

COMMENTS ON
SCOTTISH EXECUTIVE HEALTHCARE POLICY AND STRATEGY DIRECTORATE
BETTER HEALTH, BETTER CARE: A DISCUSSION DOCUMENT

Summary of Key points

• Scotland must attract and retain excellent medical trainees to deliver a consultant-led healthcare workforce.  Consultant numbers must be increased to secure the highest possible quality of care for Scots.  Improved workforce planning is key.
• Investment in health education must be sustained.
• Policy initiatives must be evidenced-based and research activity targeted to fill the “evidence holes”.
• Centrally set performance targets must not distort clinical priorities or quality of care.
• All new initiatives must be piloted and evaluated before roll-out across Scotland.
• Care should be delivered locally whenever possible, but not at the expense of safety or quality.  The potential of e-health developments should be explored fully.
• Patients must be supported to take responsibility for their own health and the efficiency and effectiveness of their local services.
• Preventive policies must be expanded and investment balanced with that available for acute and chronic care.  Cross-government initiatives will be critical.

Introductory Comments

1. The Royal College of Physicians of Edinburgh welcomes the opportunity to respond to the new Scottish Government’s consultation on delivering improved health and health care for Scotland.  The College shares many of the high level aspirations within the document and recognises the need for priorities within a cash limited system; the opportunity costs of change will be critical.  Indeed, there is a strong signal within the document that levels of spending on health in Scotland may be curtailed after a period of significant growth.  It would have been useful to have indicative budgets for key Government proposals.  Also, the NHS desperately needs a period of stability to sustain health improvements and this should be kept in mind when determining priorities and timelines for change.

2. The College notes the key shifts anticipated within the consultation document, particularly those related to “doctor dependency”.  Doctors have been leading and supporting multi-disciplinary teams for many years, and clinical networks were well established across Scotland long before Managed Clinical Networks became a policy initiative.  That said, the College firmly supports moves towards preventive and long term conditions, provided that change is supported by evidence and shifts in resources do not undermine specialist or emergency services.

3. The following comments are offered from the particular perspective of hospital physicians, recognising the importance of working collaboratively with colleagues in the community, social services and voluntary sectors.

   Improving the patient’s experience of care

4. The College considers that swift (24 hour) access to trained medical staff for diagnostic opinion and treatment would have the largest impact on patients’ experiences of care and outcomes.  This applies equally to access to general practice, access by general practice to diagnostic services and access to acute units for urgent assessment and treatment.  Doctors need time to deliver patient-centred care and, while Scotland continues to be “under doctored” by comparison with other western health systems1, access problems will remain and quality improvements will be limited.  The College believes that increasing the number of trained doctors will be welcomed by patients and is key to delivering improved patient experiences.

5. The College endorses the need for a strong evidence base to support major service change. Providing evidence in support of new proposals is critical to achieving “buy in” from patients and health care professionals.  Where there is little or no evidence, new proposals must be piloted and/or research commissioned before final decisions are taken.  Funding for social and health related research should be channelled to support these evidence “holes”.

6. E-health provides opportunities to improve the patient experience with remote access to specialist care through video linked consultations, rapid access to electronic patient records and improved communication between hospital and community based teams. Investment in a comprehensive infrastructure across Scotland will be essential for all patients and practitioners and will bring particular benefit in remote and rural areas.  These benefits must extend to medical education and development, supporting the ongoing training of all healthcare professionals.  Investment is required in hardware, support staff and training.

7. Public education is also key to many of the proposals, including supporting patients to participate in decisions about their healthcare, to have higher expectations of health services and to take greater responsibility for their own health.  The College believes that an appreciation of the costs of healthcare and support for patients to use services effectively would also bring benefit.

8. Giving local people a sense of ownership of their local healthcare services is critical, but the College is not convinced that direct elections to Health Boards will necessarily achieve this aim.  Health Boards need access to specific expertise to take informed decisions in line with local preferences.  If elections are to deliver this level of expertise, the job specifications and candidate credentials must be laid out clearly to support the election of capable officers.  The delivery of health at a local level must not become further politicised.

9. The College supports the commitment to improve the transport infrastructure to deliver safe access times for patients across Scotland and would be interested to understand more about the cost effectiveness data underpinning this proposal, particularly given the potential for clash with environmental targets.

10. The creation of outcome targets to improve patient care could be complemented by broader structure and process targets eg target nursing levels for wards may be a useful indicator to patients and inform their expectations.

11. The commitment to capture the views of staff is to be applauded as the delivery problems of the NHS are well understood by frontline staff, many of whom are committed to their resolution and have innovative ideas for change.

    Best Value

12. The College is concerned about the perception that “expensive doctors” do not represent best value.  Fully trained doctors use their knowledge and skill to manage uncertainty and take decisions safely and quickly.  Delivering care through trained doctors maintains standards and supports patient outcomes.  The College is unaware of cost effectiveness data that suggest otherwise. 

13. Scotland must continue to train young doctors to secure its future workforce.  The market for doctors is global and, when implementing MMC, the Scottish Government must ensure that training opportunities attract excellent trainees to Scotland. 

14. The College welcomes the introduction of new roles to improve patient care and would be keen to participate in the ongoing training and development of physicians assistants and nurse/midwifery/AHP consultants in specialist medical areas.  Indeed, many senior nurses and AHPs attend College education events with their medical colleagues.  Their role is complementary to that of doctors and supports a patient centred system of care within carefully defined areas.  The College currently offers e–Associateship at no cost to physicians assistants and will extend membership to other related groups. 

15. Workforce planning is hugely complex and cannot be achieved effectively without expert input from the clinical staff who understand the roles, responsibilities and optimum workloads of doctors in the different specialties.  The College has access to detailed (annual) census data on the working profile of hospital physicians and will play a key role in workforce planning2.  The most recent census data demonstrates that most physicians in Scotland work well in excess of the sessions within their job plans.  This may not be sustainable in the future as the demand for flexible training and working increases.

16. Planners must recognise the difference between major and minor illnesses when designing and costing local services.  The oft quoted statistic that 90% of healthcare interventions happen at home must recognise that the minority of urgent and emergency patients require rapid access to acute and often highly technical care.  Patients expect to benefit from innovative, technical advances in medical practice, and many of these will continue to be delivered through (centralised) specialist units.  This must be considered when shifting resources from hospital to community based care.

17. The move towards locally based care is intuitively attractive, preferred by many patients and may limit travel in line with other environmental targets.  However, this should not be achieved at the expense of quality or outcomes for patients.  All proposals to move care from hospital to community must be evidenced based, allowing local Health Boards to take informed decisions.  There cannot be a standard model across Scotland, given the differences in population distribution and geography.  Also the cost impact of delivering some specialist care in the community must be considered in a cash-limited system, given that community provision can be very expensive.

18. The move towards greater joint working between health and social services is strongly supported, as the quality of care for individual patients has been compromised by different working cultures and budget protectionism.  The voluntary sector has a great deal to contribute and should be brought into local service partnerships.

    Taking Responsibility

19. The College welcomes the creation of a Minister for Public Health, given Scotland’s record as the “sick (wo)man” of Europe.  The major health challenges facing Scotland come from smoking, obesity and alcohol abuse and will present a major test for the new cross-department focus of the Scottish Government.  Reorganising the provision of health services will have little impact on Scotland’s health if levels of alcohol consumption and eating habits do not change.  The passive smoking legislation has had a major impact, but tobacco continues to damage health and still features large in the inequalities debate.

20. The College, through various national committees and work streams, continues to call for lower drink-drive limits, more active policing of age limits for purchasing alcohol and cigarettes, limiting advertising, increasing cigarette pack sizes, and using tax levers to increase the price of alcohol and tobacco.  These legislative initiatives would contribute significantly to alcohol and tobacco consumption levels.  The College, as a member of these organisations, supports the detailed responses provided by ASH Scotland and the Scottish Coalition on Tobacco (SCOT), and has not reproduced their evidence within this document.  The College is also an active member of the Scottish Health Action on Alcohol Problems (SHAAP) which is co-ordinating action to combat alcohol related harm.

21. The food manufacturing and retail sectors must be engaged in simple labelling schemes and pricing incentives for healthier options.  Education is vital but alone will achieve little. The recently announced pilot of free school meals in Scotland requires careful cost-benefit evaluation in the short and longer term to assess impact and cost effectiveness.

22. Exercise should be encouraged as a lifestyle change, making walking and cycling safer and easier and the norm when the weather permits. The recent announcement of Glasgow’s success in the 2014 Commonwealth Games provides an excellent platform to stimulate a more active lifestyle for Scots but the focus should not be only on sport, which will not appeal to some sections of Scottish society.  Investment in sport should be balanced against other initiatives including safer alternate transport.  Government must deliver consistent policies across departments to support a healthy approach that is compatible with modern living.  The NHS as a major employer in Scotland should set an example by ensuring all NHS staff have access to exercise facilities at the workplace for use during lunch breaks and before and after work.

    Tackling Health Inequalities

23. Prioritising the needs of the multiply disadvantaged is crucial if Scotland is to improve its health status.  The College agrees that health planners must be supported to deliver local services that target and deliver healthcare to disadvantaged and vulnerable groups.  To be effective, health interventions must integrate with the actions of other agencies requiring effective coordination at both national and local level.  Tackling the problems of continued smoking, excessive alcohol consumption and obesity should be a priority.

    Anticipatory Care and Long Term Conditions

24. Clearly, preventive care and screening offer much but, again, it is essential to apply the evidence base and be assured of the cost effectiveness of each new screening and immunisation campaign.

25. Patients with long term conditions must be supported to take an active role in their ongoing health care, in partnership with locally based health care professionals and with rapid access to appropriate care to prevent a crisis admission to an acute hospital bed. Emergency admission levels remain high, and this must be addressed before resources are transferred from acute hospital services to support long term care closer to home3.

26. As the population ages, family based carers need support, respite and advice to allow patients to remain well in their own homes.  The voluntary sector could have a major role in providing locally based support.  It is important that the routine provision of community-based care for older people must not create an unintended barrier to acute care when necessary.

27. The College is concerned about whether the abolition of prescription charges will deliver cost-effective and improved access to healthcare.  Older people and most long-term patients are already exempt, as are other vulnerable groups.  Indeed, the abolition of prescription charges may encourage over-prescribing or waste of prescribed medication through non-compliance. The impact of this policy change must be kept under careful review.

    Continuous Improvement in Healthcare

28. Clinicians have long been concerned about the impact of waiting time guarantees on clinical priorities, particularly if this becomes a firm guarantee.  The College is concerned that targets generally can skew priorities and reduce quality of care in other areas, for example, increased boarding of patients due to pressure of acute admissions.

29. A focus on competences and training is essential to sustain a safe and effective workforce. Workforce planning must take account of the time spent by clinicians training and assessing junior colleagues and the time required for their own continuous professional development and revalidation.  Investment in trainers is essential, and hospital study leave budgets must not be frozen towards the year end as has happened previously at times of financial stress.

30. An organisational culture of safety results from highly trained staff working in a supportive environment, where time is available for adequate supervision of junior colleagues and team working is valued.  Stressed doctors as a result of inadequate staffing levels retire early, become unwell and are at risk of errors.  Investment in high profile safety initiatives will fail unless supported by adequate staffing numbers and appropriate training.

References

1. Health Data. Paris. Organisation for Economic Cooperation and Development, 2005.

2. Census of Consultant Physicians in the UK, 2006 Data and Commentary. Federation of the Royal Colleges of Physicians of the UK. 2007.

3. ISD Scotland. The System of Unscheduled Care in Scotland: variation in the level of emergency inpatient admission by GP Practice. 2007.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[12 November 2007]