The NHSScotland Quality Strategy reflects the shared ambitions of everyone in Scotland whether a patient, a carer, or whether working for NHSScotland in a community, primary or acute care setting. This is to create high quality person-centred, clinically effective and safe healthcare services and to be recognised as being world-leading in our approach. Many of the things we are already doing in primary care, in health improvement, in hospitals and in other healthcare environments are the right things, so the Quality Strategy can build on a strong foundation. However, we also need to focus on some new things, to do some things differently, and to reflect the changing cultures, expectations, needs and context for healthcare service delivery so that future generations can also enjoy the same high-quality healthcare services.
Pursuing this ambition for the NHS in Scotland will ensure that we simultaneously maximise our shared responsibly for contributing to the wider Purpose of the Scottish Government to create sustainable economic growth and opportunities for everyone in Scotland to flourish. The Quality Strategy will have a direct and positive impact on these goals through the improvements it will support in ensuring everyone in Scotland can expect to live longer healthier lives, to participate more productively both economically and socially, and through the increased effectiveness and efficiency of the NHS, there will be a resultant increase in productivity of the health sector in Scotland – a significant and direct contribution to economic growth.
The aim is for everyone in Scotland to work together to ensure better health and higher quality healthcare services which are flexible and reactive to each individual circumstance. The Scottish Government wants to ensure:
- Caring and compassionate staff and services
- Clear communication and explanation about conditions and treatment
- Effective collaboration between clinicians, patients and others
- A clean care environment
- Continuity of care
- Clinical excellence
To do this, the Scottish Government will continue to pursue the health improving activities NHSScotland is already undertaking in partnership with other bodies through the implementation of our health improvement strategies, including Equally Well. It will focus on making the changes and supporting the shift in culture required to one which is personcentred and focussed on clinical excellence and patient safety, supported by an optimum balance between continuous improvement and performance management.
The Scottish Government will do this by setting out a number of key drivers and priority areas for action across NHSScotland. It will begin the process of implementation by agreeing the specific interventions required to make progress in each of these areas.
COMMENTS ON SCOTTISH GOVERNMENT
THE HEALTHCARE QUALITY STRATEGY FOR SCOTLAND: DRAFT STRATEGY DOCUMENT
The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on its draft strategy document on The Healthcare Quality Strategy for Scotland.
The College welcomes the emphasis on building a national quality infrastructure, adopting a systematic approach to measuring and improving quality and reducing the number of “initiatives”. The emphasis on integrating quality measures with existing HEAT and other targets is also welcome, as is the recognition that the balance of performance management should shift from activity to patient safety and quality of care.
The document would benefit from being referenced to the evidence cited in support of the chosen direction of travel, for example, cross referencing to progress reports for the Scottish Patient Safety Programme (SPSP) to support the endorsements of Don Berwick.
The following comments reflect a secondary care perspective and raise a number of issues for the hospital service, given the current emphasis within the strategy document on evidence and experience from primary and community care:
A new emphasis on standards in clinical care will be necessary to support the development of robust audit and outcomes data. The College has a strong track record in this respect and welcomes the opportunity to contribute using the expertise within our professional clinical networks.
The College supports the emphasis on developing effective clinical data systems to measure and monitor quality and looks forward to contributing to the various work streams that will progress this work. Physicians are committed to improving the quality of clinical data in Scotland, which can be inaccurate and damages confidence in the output. The definition of and methodology for deriving quality measures will be critical to the success of the strategy and in securing the confidence of patients and doctors.
There will be a need to establish a well resourced audit infrastructure across Scotland to allow clinical teams to undertake clinical effectiveness work in support of local quality improvement projects. Participation in relevant clinical effectiveness projects is also a key component of specialist recertification for all consultants, and the College welcomes the synergy in this aspect of the Quality Strategy. Time will have to be created in consultant job plans for this essential work.
A strategy for audit in physicianly medicine has been a high priority for the College for many years, and it has proved difficult to get agreement to fund pilots to begin this essential work. The College welcomes the opportunity to make progress through the proposed Healthcare Quality Strategy.
The College notes the references to including CARE measures in clinical appraisal and revalidation of doctors, and understands that these were developed by and for Primary Care and that there is limited evidence of their direct application to Secondary Care. The College is aware of one published study in a single UK hospital outpatient facility, a related study with consultant anaesthetists and some work in Germany and would be keen to hear of other evidence demonstrating the validity of this approach in Secondary Care (1,2,3,4).
The College notes the move towards a trained doctor service and agrees there is significant evidence in support of clinical quality improvement resulting from rapid access to senior clinical opinion, particularly for the sickest patients and those presenting as emergencies(5). Similarly, evidence is emerging that supports the cost effectiveness of consultant delivered care.
Effective workforce planning will be critical to secure a sustainable consultant delivered service, particularly given the emerging quality issues of patient continuity and outpatient capacity resulting from the European Working Time Regulations (EWTR) changes. A recent survey undertaken by the Scottish Academy shows that over 70% of Scottish Consultants believe that the EWTR has had a negative impact on patient safety with many qualitative statements citing poor continuity of care and rota gaps as the main drivers.
Finally, the College looks forward to working with colleagues across NHS Scotland on the development and delivery of the Quality Strategy as part of the Quality Alliance.
References
1. S.W. Mercer, D.J. Hatch, A. Murray, D.J. Murphy, K.W. Eva. Capturing patients' views on communication with anaesthetists: the CARE Measure. Clinical Governance, 2008 vol 13, issue 2, 128-137
2. Mercer SW, McConnachie A, Maxwell M, Heaney D and Watt GCM. Relevance and practical Use of the Consultation and Relational Empathy (CARE) Measure in general practice. Family Practice 2005; 22: 328-334.
3. Mercer SW, Murphy DJ. Validity and reliability of the Care Measure in secondary care. Clinical Governance, 2008 vol 13 issue 4, 269-283.
4. Neumann M, Wirtz M, Bollschweiler E, Mercer SW, Warm M, Wolf J, Pfaff H. Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ Couns. 2007 Dec;69(1-3):63-75. Epub 2007 Sep 11.
5. NCEPOD Report; Deaths in acute hospitals: Caring to the End? 2009