Centralised and integrated NHS in balance part 2

2/2 - Read the first part of the article 

This ethos fed directly into the 2020 vision, which is seeing formal integration of health and social care services. “It was actually about older people and the way in which we must have more services delivered in community settings including the home. This is now the orthodoxy which underlines the whole integration agenda,” says Chisholm.

But although local authorities and territorial health boards across Scotland have submitted their plans to work together to the Scottish Government, and joint boards have been set up across the country, progress has been limited, and while there may be broad agreement of policy direction, the arguments centre on implementation.
Recent statistics revealed there has been no shift in the balance of care from hospitals to the community over the last three years despite the 2020 vision for the NHS where ‘everyone is able to live longer healthier lives at home, or in a homely setting’.  

FURTHER READING

Our prevention crisis - John Carnochan, James Mitchell and Jonathan Sher 

Scotland's Chief Medical Officer on what is better than a cure

Of the total £4.8bn spent on health and social care in 2013-14, £1.45bn was spent on unplanned admissions by people aged over 65 to hospital. 
Royal College of Nursing (RCN) Scotland Director, Theresa Fyffe, says the system is struggling to deliver the policy.
“This means a colossal £1.45 billion is being spent on older people ending up in hospital: while some of these cases will be genuine emergency admissions for things like strokes and falls, others could have been prevented if adequate care was in place at home and in communities,” she says.

For Chisholm, the challenges are not new. “One of the fundamental objectives and challenges Kerr outlined was trying to stop this ever-increasing stream of emergency admissions to the acute sector, and that’s the problem. That’s what hasn’t changed,” he says. 

Waiting times at A&E are now being published weekly as of this year, with the most recent showing that in April, 92.8 per cent of people were seen and subsequently admitted, transferred or discharged within four hours. This is still below the Scottish Government’s target of 95 per cent. Representatives from the Royal Colleges, the NHS and Integrated Joint Board Chief Officers met Robison last month to agree the latest in a number of action plans – an approach to improving unscheduled care on a sustainable basis. 
The Health Secretary said: “Addressing A&E performance cannot be seen in isolation, which is why we must look at the whole system, and these actions depend on a number of partners across the health and social care system working together.”

Last week a joint statement by the Royal Colleges in Scotland warned of “diificult decisions” ahead if the NHS is to be sustainable in the future.  It called for a genuine public debate on change, a new approach to targets, new ways of delivering care and improved inter-professional working.
Chair of the Academy of Medical Royal Colleges and Faculties Ian Ritchie, said: “What we require, urgently, is to develop new models of care which are fit for the future. And, given that it’s our members who will have to implement these new models of care, we are committed to working across our health service to make sure this happens.”
A principal Kerr recommendation was for Community Health Partnerships to have a clear agenda to work across barriers between primary and secondary care, and engage with social care partners to shift the balance of care, but there was “big disappointment” about their lack of engagement with GPs, according to Chisholm. “In terms of that constant stream of people into emergency services in hospital, it is GPs who are the key to that,” he says.

However, general practice faces a recruitment and retention crisis in Scotland. In April the Royal College of General Practitioners (RCGP) in Scotland predicted a shortfall of up to 900 GPs by 2020 due to population growth, while around 20 per cent of the current GP workforce is aged over 55 and likely to retire in the next five years. 

Dr Miles Mack, chairman of RCGP Scotland, said: “There is clearly a desperate need for all Scottish politicians to put general practice at the front of their thinking and announcements and to emulate the commitments for England that political leaders there have given regarding sourcing and funding a much larger GP workforce.”
In response the Scottish Government announced £7.6m of added value to the current GP contract, and pointed to the ongoing negotiations on the new contract, which is hoped to be in place by 2017.

Mack remains optimistic. “We’re looking toward a system of peer-led values,  [with] governance driven by small locality clusters of practices, which is going to be very different to what we’re doing. Actually, I think it could transform the way general practice is done, that we move away from looking at single diseases and actually have the opportunity to look at people in the full complexity of their lives, to provide the sort of professional input we want.” This will involve more collaborative working with the whole primary care team, he told Holyrood in February.
The Scottish Government is willing to consider the new model, he said, but “it all predicates on having the right resources to do this, unfortunately”.

Pharmacists, too, will play an increasing role. The Prescription for Excellence action plan, launched last year, will see pharmacy play a bigger part in care. Alex MacKinnon, director of the Royal Pharmaceutical Society in Scotland, told the Pharmacists’ Defence Association conference in Glasgow, March 2014, the status quo had not been an option. “Integration is about the co-ordination and continuity of care, not structure, process or systems,” he said. 

One area where integration has been practised since 2012 is NHS Highland, which adopted a lead agency model, rather than the combined board model adopted now in most other areas. NHS Highland chief executive Elaine Mead insists it has paid dividends.

“There is no question that it is facilitating a more collaborative approach, including driving up quality in care homes and care at home. Over time we will see more and more innovation to support. What will be one of the biggest requirements, and that is to make a step change increase in care at home capacity to support people to be independent for longer. Since integration, we are already seeing the age of people going into care homes increasing by some 18 months,” she says.

The board is also looking to innovate how it distributes its workforce across a large geographic area, she says. “We are seeking to build multi-professional community teams working to deliver high quality health and social care to scattered communities using all modern methods of communication and rotational models. Our workforce is ageing and we are struggling to recruit GPs and other professionals, and this will also drive radical new ways of how we organise our services. We will not be able to do this on our own and so we are going to have to join forces with communities and partners in much more progressive ways.” 

Meanwhile at the other end of the country, NHS Borders is also looking to work more closely with partners. Interim chief executive Jane Davidson says:  “NHS Borders is currently undertaking a clinical services review entitled ‘Health in your Hands’ to consider what needs to change to achieve the vision of everyone being able to live longer, healthier lives at home, or in a homely setting, and with seamless provision of service across health and social care.

“The way in which the review is conducted will put mutuality at the heart of the services that we offer and [we] recognise that the people who own the NHS, our communities, should be seen as co-owners rather than service users. “Throughout the process we will be making considerable efforts to engage patients, carers, staff and the public, and our expectation is the outcomes of any service reviews will emphasise the need for new models of care that reflect a more active role for patients as partners in their treatment and care.”

At Westminster, the Queen’s Speech revealed a commitment to a “truly seven-days a week NHS” which will see an increase of £8bn a year in health spend south of the border. Prime Minister David Cameron said the funding would pay for an increase in the number of GPs and faster access to new drugs and treatments in NHS England.

This will lead to an increase in the Scottish Government’s budget of hundreds of millions of pounds, which could be spent on the NHS. The idea of seven-day services has also been explored in Scotland, as evidence points to weekend patients having poorer outcomes and longer stays in hospital.

But how much will seven-day services cost? “Everyone supports it in principle,” says Chisholm. “You would need to have more consultants on the weekend, more diagnostic services. That could come out of the week, there might be an argument for evening out, I don’t know. But if you’re doing that as additional then that’s quite a financial challenge.”

The wider challenges to the Scottish Government and health boards are not just financial, however.  The Scottish Public Health Observatory (ScotPHO) has released a fully revised and updated edition of the Health and Wellbeing Profiles for Scotland, which includes several new indicators to give comparative pictures of health and wellbeing in Scotland. 
Although the profiles paint a positive picture over time – life expectancy is rising and mortality rates among working-age adults is falling – Scotland still lags behind the rest of the UK and most Western European nations. 

There is also a large variation between areas of the country. In 2011-13, for example, all-cause mortality amongst 15-44 year olds varied from 66 per 100,000 population in East Dunbartonshire to 148 per 100,000 population in Dundee City. 

Looking at NHS Boards, the lowest mortality rate was seen in NHS Grampian (81 per 100,000 population) and the highest was in Greater Glasgow & Clyde (122 per 100,000 population).
Speaking about publication of the report, Gerry McCartney, head of the ScotPHO at NHS Health Scotland, said the figures could help health boards, local authorities and smaller communities compare their profiles and plan for the future. “Our profiling tool facilitates comparison between a wide range of areas in Scotland and enables trends and inequalities in the key outcomes across health, employment, income and behaviours to be exposed. We hope these statistics will be helpful to a wide range of people who are interested in health and social outcomes at local level and be used to support planning decisions,” he said.  

For NHS Health Scotland, investment in service delivery will be less cost-effective than prevention.
Neil Craig, Health Economics expert at NHS Health Scotland, said:  “In general, interventions which use taxation, regulation and legislation to reduce income inequalities and reduce exposure to unhealthy products such as tobacco are the best investments. [They are] cost-effective and most likely to reduce inequalities. This offers a potential ‘win-win’ scenario – the policy works, pressure on public services is relieved slightly, and we tackle health inequalities in a cost-effective way.”

Innovation, too, will play a role in reshaping care in the future. At the new Glasgow ‘super hospital’, a new teaching and learning centre will be run by the University of Glasgow. 
Robert Calderwood, Chief Executive of NHS Greater Glasgow & Clyde, said the new facility would “cement the bond” between the health board and the university.
The £25m facility will be operational from July and will comprise three floors jointly developed by the university and the NHS devoted to learning and teaching facilities, including a 500-seat auditorium, as well as social and public spaces, conference and teaching spaces, a learning resources centre, clinical skills facility and a teaching laboratory.
Industry will also be accommodated, with the top floor home to the Stratified Medicine Scotland Innovation Centre, bioinformatics company Aridhia and a number of incubator units, to provide an environment to drive innovation in precision medicine.

Professor Anna Dominiczak, Head of the College of Medical, Veterinary and Life Sciences, at Glasgow University, said: “The new teaching and learning centre will provide unrivalled facilities for medical students and NHS professionals alike, as well as an excellent base for industry and the Stratified Medicine Scotland Innovation Centre.
“Our ‘triple helix’ partnership with the NHS and industry is helping to put Glasgow at the forefront of patient care and research.”

But for Craig, the focus must remain on prevention. “Investment in prevention within and beyond the healthcare system is a good buy. Although financial savings from prevention are sometimes hard to measure and hard to achieve, prevention has the potential to help reconcile the high demands on public services, squeezed resources and [the] Scottish Government’s goal of reducing health inequalities and achieving a fairer healthier Scotland.”