« Previous | Contents | Next »
Listen
Health in Scotland 2002
CHAPTER 6
ASSURING THE FUTURE
Quality Assurance and Improvement
Early in 2002, a consultation paper proposed the amalgamation of a number of the organisations involved in the quality improvement agenda. Numerous constructive comments and suggestions from individuals and organisations were received in response. On 1 January 2003 NHS Quality Improvement Scotland (NHS QIS), a new Special Health Board, came into existence.
This process of reorganisation, however, did not prevent the continuation during 2002 of significant activity by the organisations concerned.
Clinical Resource and Audit Group (CRAG)
The Clinical Outcomes Working Group of CRAG published its ninth Clinical Outcome Indicators Report in July 2002. This included indicators on survival after admission for hip fracture, myocardial infarction and Stroke, survival from lung cancer, mortality after elective surgery and emergency readmission. There were also groups of indicators on primary care prescribing and immunisation and on alcohol problems.
The Clinical Effectiveness Programme Sub-group of CRAG continued to develop new national clinical effectiveness programmes and projects. There are established programmes of work in Reproductive Health and in Primary Care. In addition, the group maintains a constantly changing portfolio of 25 to 30 individual national projects covering a wide range of topic areas and including co-ordinated groups of projects in cancer, children's health and mental health.
During 2002, the CRAG Implementation Sub-group funded and supported locally organised conferences on Stroke (hosted by Borders NHS Board), Information Management and Technology (hosted by Grampian University Hospitals NHS Trust), Dental Services for Children (hosted by Greater Glasgow Primary Care Trust) and co-hosted the Guideline Implementation Conference with SIGN in Edinburgh. Conferences planned for early 2003 include integrated care pathways, coronary heart disease, clinical governance and communicating with patients. CRAG also carries out surveys monitoring specific NHS Scotland activity, manages a national network of clinical effectiveness contacts and provides funds to Boards for training to support clinical effectiveness.
Health Technology Board for Scotland (HTBS)
HTBS issued three comprehensive assessments during 2002. The first was the report on the Organisation of Services for Diabetic Retinopathy Screening, followed by Positron Emission Tomography (PET) Imaging in Cancer Management and finally a report on Prevention of Relapse in Alcohol Dependence.
HTBS provided comment for NHSScotland on a wide range of NICE Technology Appraisal Guidance and supported and facilitated the work of the Scottish Medicines Consortium and its New Drugs Committee.
Clinical Standards Board for Scotland (CSBS)
CSBS published both a national overview and local reports on NHSScotland's performance against its standards for breast cancer, colorectal cancer, lung cancer, ovarian cancer and schizophrenia in 2002. It also published the findings of the first review of performance across NHSScotland against its Generic Clinical Governance Standards and an interim report on HAI.
Standards were finalised, following consultation, on older people in acute care, renal services, diabetes, breast and cervical screening, HAI, cleaning services and specialist palliative care. Peer review visits were undertaken in relation to renal standards, cleaning services - by Audit Scotland - and infection control.
Draft standards were issued for consultation during 2002 on a wide range of new topics: post mortem and organ retention, vascular services, anaesthesia, community hospitals and food, fluid and nutritional care. Draft standards are being developed for primary care dentistry, Stroke services, maternity services and screening in pregnancy and of the newborn.
CSBS seeks to ensure that the primary care component of the patient journey is included in all its standards and review processes. It endorsed the Royal College of General Practitioners' Practice Accreditation Scheme as the most appropriate methodology for quality assurance in general medical practice. The aim is for all practices to achieve this or, in one area, a similar
local scheme by the end of 2004. CSBS published the results of a survey of progress in September 2002.
NHS Quality Improvement Scotland (NHS QIS)
The amalgamation of HTBS, CSBS, CRAG, SHAS and the Nursing and Midwifery Practice Development Unit in one organisation, NHS QIS, will facilitate co-ordination of work programmes, rationalise review visits and allow an increasingly systematic approach to quality improvement and assurance in Scotland. SIGN will retain its status as an independent body but will work closely with NHS QIS as its commissioning body.
Work on patient safety will be further developed by NHS QIS with the National Patient Safety Agency. A consultation paper on this issued at the end of 2002. NHS QIS also has a new remit to investigate cases of serious service failure. NHS QIS will support NHSScotland in its clinical governance responsibility of delivering safe and effective clinical care and will provide an external quality assurance mechanism to ensure it is doing so.
Scottish Intercollegiate Guidelines Network (SIGN)
During 2002 SIGN published new evidence based clinical guidelines on cardiac rehabilitation, safe sedation of children undergoing diagnostic or therapeutic procedures, community management of lower respiratory tract infection in adults, post natal depression and puerperal psychosis and investigation of post menopausal bleeding. They also revised and updated four earlier guidelines.
SIGN worked with the British Thoracic Society on a joint revised asthma guideline, published early in 2003. SIGN and the National Institute for Clinical Excellence (NICE) indicated an intention to work together in making their programmes more complementary and work has started on a joint revision of lung cancer guidelines. A successful symposium on implementation was held in November and over 100 healthcare workers received training in critical appraisal skills at introductory or advanced level. SIGN has also developed a Web based development tool as part of its contribution to the AGREE International Collaboration.
A CSO funded research project looking at the use of a consensus methodology in guideline development was undertaken. A project developing the role of patients in guideline development is also nearing completion and has already resulted in changes to SIGN methodology. SIGN has also developed a Web based development tool.
Workforce Planning and Development
The staff of NHSScotland are the key to the delivery of services to patients and their families and are vital agents of change. The health workforce, at over 130,000, is the biggest in Scotland. To sustain advances in patient care, it is essential to have the right staff, with the right skills, in the right place at the right time.
Future Practice - the report of the review of the Scottish medical workforce - made clear that service pressures and demands continue to apply not only to the medical profession but right across the whole NHSScotland workforce. Its firm conclusion was that the service as a whole will only survive with change.
There are many drivers of change. The negotiation of new pay systems offers more than an opportunity to make technical changes to terms and conditions: the proposed consultants' contract and the 'Agenda for Change' proposals for other NHS employees offer important opportunities to promote reform in a way that benefits staff and the service. The proposed new GMS contract can be expected to set the pace for wide-ranging reform of primary care services, not least by focusing on the quality outcomes that can be delivered by GP practices.
Shortening the hours worked by doctors and other staff to bring about safer practice, to the benefit of both patients and staff, places increased pressure on the NHS at a time when activity levels are increasing. The New Deal for Junior Doctors has challenged service planners for some time and the European Working Time Directive will increase the pressures. The challenges of achieving compliance must be met imaginatively and by taking a whole-systems approach with staff being considered together.
In the future, services will need to be delivered by integrated teams with complementary skills. Traditional approaches are not sustainable and, in the face of the pressure for reform, some established practices need to be revisited. Some of this is already happening and examples of new ways of working include
Early intervention teams in A&E
The NHS24 Nurse advice line
Clinical and self care advice from Community Pharmacists
Increased use of Nurse Specialists in general practice and hospital care
GPs working in A&E departments
Nursing staff in A&E assessing older people to prevent unnecessary admissions
Expanded roles for Ambulance staff
Direct referrals to Physiotherapists
Nurse led/Technician led/Physiotherapist-led clinics and interventions
2002 saw the start of a step change in how to plan and develop the workforce. The foundations were laid in the SE's response to the Scottish Integrated Workforce Planning Group's landmark report
Planning Together which mapped out the way ahead. The key conclusions were that service planning and workforce planning needed to proceed in tandem and that it was necessary to take a more holistic look at workforce solutions than has often been the norm in the past.
A conference in April 2002 took the ideas further forward and in August
Working for Health -The Workforce Development Action Plan for NHSScotland was published, setting out the various actions that are now being taken forward.
Overseeing the work and setting strategic direction is the newly-established National Workforce Committee, which will advise on the future size and shape of the workforce and on the recruitment, retention, training and development programmes that will be needed to respond to the challenges of the future. The Committee is serviced by a new National Workforce Unit within the SEHD and will draw on work at a regional tier. The task of building capacity in the regions was started at three well-attended regional workforce conventions in the autumn and the momentum generated must be sustained so that workforce issues remain a strategic priority.
This commitment to a more integrated approach to workforce planning means that there is a need to address key issues including
Recruitment and retention
Skill mix
Retraining the existing workforce
Career pathways
Career progression
Job satisfaction, including flexibility
Continuous professional development and lifelong learning.
The new Centre for Change and Innovation will be helping to set the pace for much of this agenda. NES also has a key part to play in promoting change: for example, this year the SEHD released 2,500,000 for educational provision for nurses who come into contact with children requiring emergency care in remote and rural areas of Scotland. NES has brought together practitioners, managers and educationalists to produce the curricular guidelines.
Several developments have taken place over the past year to strengthen the public health workforce.
Nursing for Health recommended devising new educational programmes to bring together health visiting and school nursing to prepare a flexible workforce of public health nurses. It also proposed the introduction of new LHCC-based public health practitioners of whom there are currently 84 in post, in almost every LHCC in Scotland.
Specialist training in public health for doctors is being unified by NES as a single Scottish scheme, from the current four separate regional programmes, to ensure consistency and quality of training of the future public health consultants and Directors of Public Health.
The speciality of Health Promotion comprises a diverse workforce, tackling a wide range of influences on health. Their contribution to public health was included in a review by PHIS, commissioned to make recommendations to maximise the contribution of health promotion to improving health in Scotland. The final recommendations and action plan will promote progress by further integrating the public health workforce within the NHS and with other organisations involved in health improvement.
The SEHD and NHSScotland are gearing up for one of the biggest change programmes in the NHS's history - a programme within which NHS staff will play a central role in an unprecedented way.
« Previous | Contents | Next »