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Why do we need to change?
People want a health service which listens, communicates and values them throughout their journey of care. Greater continuity of care, better information and improved access are key to achieving this.
The NHS delivers high quality care and people value it, but there are weaknesses in the system.
For too long, people have been made to fit services rather than services being made to fit people. Too many people wait too long for treatment and care. As people move from one part of the care system to another there are too many delays and too little communication. Homeless people and drug users have even more need to access services but are excluded by their life circumstances or their lifestyle.
"He needs to feel like a person, not just a set of symptoms. It's very frustrating to go from one specialist to another ...... not realising that one thing affects the other."
This situation will not be changed overnight. A combination of investment and reform is necessary to bring about sustained improvement. There must be changes both to systems and to culture. Many parts of the NHS in Scotland are already demonstrating how this can be achieved. We want to build upon this, to share best practice and to accelerate the pace of improvement and change across the country.
Investment is part of the solution. Tackling equipment and staff shortages must be a priority both nationally and locally. But money alone will not improve the patient's journey through the care system. Reducing bureaucracy, removing unnecessary demarcations and improving communications - both between different parts of the NHS and with patients themselves - is key.
Some of the changes which patients want to see do not require major investment or significant changes to services. They require the NHS to listen and to respond.
"The baby clinic is held from 2.30 to 3.30, but that's the same time I have to pick up my older kids from school. If they could just hold the baby clinic in the morning then I could do both."
"PEOPLE REQUIRE THE NHS TO LISTEN AND TO RESPOND"
Most people are likely to feel vulnerable and anxious about their health and welfare from time to time. But even when they are ill or low, people form very clear impressions of the quality of the service they are getting. People want:
44% of people we asked thought it should be easier to get a GP appointment.
32% of those visiting their GP Surgery said they wanted more time with their doctor or nurse.
NHS staff and their representative bodies echoed these themes. There is an appetite for change among both patients and staff. Now is the time to bring about that change.
"At least I can get to the GP. My husband never goes. The only time the surgery is open is when he is at work and there is no way he would take time off to go to the doctor unless he was really ill. Why can't you go to the doctor in the evening or at the weekend? They have a Saturday morning surgery but that is only for emergencies."
Improving the patient's journey
Extending access, reducing waiting and improving the way the NHS responds to the needs of patients must be a key priority for every part of the NHS. Investment must be matched with reform to deliver change. Each local NHS Board will be required to demonstrate to the Scottish Executive and to local communities how it is using resources to improve service delivery.
The NHS at every level must work to transform the patient's experience: from first contact through primary care, out-patient clinics, in-patient stay if necessary, and back home.
This means looking at each service from the patient's point of view, making best use of the skills of all members of the healthcare team, adopting a 'whole system' approach and challenging traditional ways of working to improve the speed, responsiveness and quality of care.
"WE WILL WORK NOW TO MAKEGOOD PRACTICE THE NORM"
"The different professionals should work together, to get an idea of the whole person."
People suffering from complex chronic diseases need care from many different specialists. This often means that patients have to attend many different primary care and hospital appointments.
"Over a 12-month period I not only attended hospital three times a week for dialysis treatment and had a further 31 separate out-patient clinic appointments with other doctors for tests in diabetes, hypertension, ophthalmology, ENT, cardiology, dermatology and chest disease. I've had more than 180 separate appointments in a year."
Change can be achieved, as our 44 National Health Redesign Demonstration Pilot Projects are showing.
IT'S HAPPENING ALREADY...
In the Highland Health Board area, redesign of the Colorectal Cancer Service led to the introduction of a one-stop clinic. The time people have to wait for diagnosis or staging has dropped from 19 weeks to 4. The number of visits that people have to make to hospital has been cut from four to one. As a result, 50% of patients can be reassured and discharged on their first visit.
We will work now to make good practice the norm. Successes in one part of Scotland must be rolled out across the country.
Information and communications technology
The effective use of information and communications technology has the potential to transform the patient's experience and is doing so in many parts of the country.
We are investing £50 million over this year and the next two years specifically for this purpose.
Over the next few years, we will speed up this work. We want to see integrated patient records in GP practices and health centres, electronic transmission of prescriptions between GPs and pharmacists, all primary care staff connected to NHSnet, and electronic clinical communications (ECCI) to support booking ofin-patient appointments from the GP surgery, faster test results, protocol-based referrals and timely discharge information.
Harnessing information management and technology to improve people's experience of public services is at the heart of the Executive's work towards a digital Scotland.
On a typical day in the NHS in Scotland:
People receive care and services from over 130,000 staff, including:
Illness is no respecter of the time of day or the day of the week. It strikes those who are remote from population centres just as it does those in our cities. So the challenge is to provide excellent services all round the clock and all across the country. Technology and teamwork are key to achieving this.
The introduction of GP out-of-hours co-ops in many parts of Scotland has improved access to services in many areas. The NHS Helpline has been extended and is being used by a growing number of people seeking information and advice over the phone.
We want to build on these developments to ensure that people across Scotland can get access to services, advice and support any time of the day or day of the week.
This new service, developed jointly with health professionals and those who will use it, will provide people across Scotland with the support and reassurance of 24-hour access to advice about symptoms or to the care they need. The first NHS24 pilots will be launched in 2001.
Public attention on the NHS often focuses on what goes on in hospitals. Yet 90% of contacts with the NHS begin and end with primary care - GPs, health visitors or other community-based health professionals - with only a small proportion of people needing hospital care. Effective and timely provision of community-based care can also play a major role in avoiding unnecessary or inappropriate hospital admissions.
IT'S HAPPENING ALREADY...
The City of Aberdeen Rapid Response Team provides intense short-term help to older people when their need is greatest. It has a dedicated joint budget from the Local Authority and the NHS to purchase simple equipment and adaptations and install them quickly. It can also purchase services, including access to independent home care providers.
The team includes a social worker/care manager, home care organiser, district nurse, physiotherapist, occupational therapists, and one occupational therapy technician/assistant. It has access to a dedicated budget for equipment and services including those provided by independent care providers.
This service, which handles about 60 cases a month, helps people go home from hospital earlier.
"ILLNESS IS NO RESPECTER OF THE TIME OF DAY OR THE DAY OF THE WEEK"
We want to see a fundamental change in the quality and accessibility of people's contact with the NHS. This means greater flexibility in both thinking and working. For example, traditionally, GPs have been seen as 'gatekeepers' to the NHS. In future, we want to provide people with 'gateways' to the NHS. Making best use of the skills of the whole healthcare team is key.
There are over 1,100 community pharmacists in Scotland. We can promote better access by making better use of pharmacists and pharmacies. Model schemes for pharmaceutical care in the community are already in place for palliative care, older people and people with mental ill health. We want to build on these.
There are many other community-based services including those provided by dental practitioners, optometrists, physiotherapists, speech therapists, occupational therapists, chiropodists and others and those provided by Local Authority care services. Making best use of the skills of all these professionals is key to providing patients with a more accessible, more responsive service.
We will work to make better use of the whole healthcare team, expanding the role of nurses and freeing up GPs to spend more time with those who really need their clinical skills. People's desire to spend longer with the nurse or doctor came through strongly in what people said to us.
"A good GP takes time to look at you, talk to you, take your mind off what's bothering you."
"He doesn't even look up, he's writing a prescription before you're through the door."
"The time the doctor spends with you, that makes all the difference. It makes you feel like a human being."
We will support patients in caring for themselves, give people better information and advice, streamline information management and develop the whole team approach at LHCC and practice level. For example:
IT'S HAPPENING ALREADY...
In Lanarkshire, more than 25% of all male deaths are men under 54. Younger men are increasingly at risk due to their lifestyle choices and are less likely to access routine health services for advice.
In January 2000, Coatbridge Local Healthcare Co-operative (LHCC) started a men-only evening clinic lasting three hours a week and offering open access, drop-in facilities, lifestyle checks, health examinations and education. The clinic has been widely and imaginatively advertised and staff numbers have doubled to cope with demand.
The clinic has reached a significant number of people with potentially serious conditions. Around 28 men, aged between 27 and 79, have attended on each occasion. A quarter had not seen their GP in the last 5 years. Heart disease, diabetes, high blood pressure and mental ill health were among the problems identified.
Our aim is to take the NHS to people rather than just people to the NHS. This is consistent with our desire to promote health in a range of settings.
In many parts of the country, the NHS is offering services outside traditional times and settings and is going to where people are - in the workplace, in schools and in community centres. We will encourage this approach.
"OUR AIM IS TO TAKE THE NHS TO THE PEOPLE RATHER THAN JUST PEOPLE TO THE NHS "
IT'S HAPPENING ALREADY...
Lanarkshire Workplace Assessment Service (LWAS) is a service specialising in promoting health, safety and wellbeing amongst small and medium sized enterprises (SMEs) in Lanarkshire. A team of two specialists, a Health and Safety Adviser and Health Promotion Adviser - visits the workplace where they offer a free and confidential assessment concerning health and safety, occupational health and health promotion. This gives people who work in smaller companies access to occupational health services which companies could not otherwise afford.
Providing health services to sparse populations dispersed over many hundreds of miles of land and sea is one of the distinctive features of the NHS in Scotland. The need for effective partnerships with other agencies, the flexible use of all members of the healthcare team, the creative use of modern technology and the need for effective patient transport are even more vital in rural Scotland.
We recognise that services can and must be organised differently in rural Scotland as distinct from urban Scotland. We will continue to work with the NHS and with professional bodies to ensure that the needs of rural Scotland are addressed effectively.
We are already investing £2 million a year in the Remote and Rural Areas Resource Initiative (RARARI), which is implementing 14 projects this year. The proposals in Fair Shares for All will enhance those resources allowing faster roll-out of RARARI successes.
Telemedicine ('medicine at a distance') is a rapidly developing field with great potential to improve access to high quality care irrespective of distance. This is particularly important given Scotland's geography.
IT'S HAPPENING ALREADY...
A Telemedicine link between the Western Isles Hospital in Stornoway and the Dermatology Department at the Raigmore Hospital in Inverness has reduced the need for patients to travel to the mainland and has reduced waiting lists.
A joined-up approach
Many people and organisations contribute to the development of health and to the delivery of health services. The quality, speed and responsiveness of the patient's journey is determined by how effectively these different people and organisations work together. A patient-centred approach means thinking first about the needs of the person and thinking second about who can best meet those needs.
It is not just the NHS which provides health care services. Local Authorities, voluntary organisations, independent providers and community health groups all have key roles to play. We expect the NHS to adopt a holistic approach to the delivery of healthcare and to work closely with a range of others to meet local needs effectively.
In particular, we will expect the NHS to give renewed support to local voluntary organisations where these are best placed to meet local need.
Access to hospital care
Our approach is to provide care at home where possible, in hospital where needed. A growing amount of treatment and care can now be delivered outside the traditional hospital setting.
Many of our current hospital buildings are outdated and inflexible. Many are in the wrong place to meet current population needs. We need to change the configuration of hospital services. Buildings and bed numbers must be right_but they are only a part of the picture. The aim must be to provide individuals and communities with access to the range of health services they need.
Advances in medicine such as keyhole surgery have meant dramatic reductions in the proportion of treatments which require a stay in hospital and in
length of the hospital stays. For example, over 60% of all non-emergency surgery is now performed as day cases, and the average stay in hospital for an acute operation dropped from ten days in 1981 to six days in 1999. The average stay of a woman in maternity hospital is now 2.8 days compared to 4.1 days nine years ago.
Achieving the right balance between hospital and community based health services is key. This balance will vary across the country reflecting the different needs of local populations and the existing pattern of services.
Eight new major hospital developments are now being built across Scotland and will be completed by 2003. We are also committed to creating a new generation of Walk in/Walk out Hospitals. These will deal only with planned treatment and not emergencies, benefiting patients through ease of access and speedy diagnosis and treatment.
"ACHIEVING THE RIGHT BALANCE BETWEEN HOSPITAL AND COMMUNITY BASED HEALTH SERVICES IS KEY"
Good transport links help people get access to the right care in the right place at the right time. This applies in both emergency and routine situations. The Scottish Ambulance Service is currently undertaking a wide review of its operations which will be completed in 2002. This review will help to ensure that both Patient Transport Services and emergency ambulance services are provided effectively across Scotland. It will also evaluate the case for introducing priority-based dispatch.
"If the Council can arrange transport at the right time every day for travel to the Day Centre why can't the NHS do the same for hospital visits twice a year?"
Ambulance paramedics play a key role in delivering emergency and often life-saving treatment and care. Investment in and development of their skills means that many patients can get urgent treatment as soon as they are attended to and before their arrival at hospital. Increasingly, it is the ambulance response time not the time taken to arrive at hospital which matters.
Public transport and transport links are also vital. We expect the NHS to work closely with Local Authorities and with local transport providers to ensure patient transport needs are met effectively. The NHS should work co-operatively with these other organisations to ensure that patient-friendly and environmentally-friendly transport schemes are in place.
Minimising delays and reducing the time patients have to wait for treatment and care must be a major priority for the NHS in Scotland.
Many of the changes taking place in the NHS in Scotland are already delivering results:
" THERE ARE NOW 200 ONE-STOP CLINICS ACROSS SCOTLAND OFFERING FAST DIAGNOSIS AND TREATMENT FOR SPECIFIC CONDITIONS"
But more needs to be done. Too many people still wait too long for treatment. And too many people experience delays between different stages of their diagnosis, treatment and care. In addition, too many people are still being cared for in an inappropriate setting.
Our objective is to improve and speed up the patient's whole journey of care - not just one part of it. This requires action on a number of fronts. Many of the measures elsewhere in this Plan will contribute to this goal. Many parts of the NHS in Scotland are already delivering improvements.
We want to ensure that fresh impetus is given to the drive to reduce waiting. There must be a clear, comprehensive and transparent picture of performance in the NHS across Scotland. This will assist the NHS locally to benchmark its performance against others and will enable the public to see how their local NHS is performing.
We want to ensure that older people are discharged from hospital as soon as proper arrangements are in place for their care at home or in their local communities. Currently about 10% of hospital beds are occupied by patients who are clinically ready to be discharged.
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