Basic and Clinical Environmental Approaches in Landscape Planning
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We recently announced an increase of in GP specialty training places and an enhancement of the GP returners scheme to encourage GP s who are not currently working in NHSScotland back into the service. In addition we are working with our universities on a number of actions that will increase the number of medical undergraduates and broaden the range of people entering medical education to ensure that all of our young people have the opportunity to develop their skills through a career in NHSScotland.
As demand for health services increases, we need to ensure future models of service delivery and workforce configuration are optimal. Ensuring a sustainable workforce means maximising the contribution of all healthcare professions, so that our staff work at the top of their professional capability, but without adding to a loss of continuity of care or increasing the complexity of care. It means further investment in a mixed economy workforce, and crucially, it means transforming roles so they are of more direct benefit to Scotland's NHS patients in different healthcare settings.
For example, further training allows experienced nurses to deliver advanced practice; pharmacists with extended roles can provide care, especially for patients with long-term conditions; allied health professionals can develop increased skills to deliver professional care autonomously; and physician associates are a recent and welcome addition to multidisciplinary clinical teams.
The primary care workforce is the one which we most need to develop and grow in order to achieve the capacity and workforce transformation that is required, and specific reference is made to that later in this chapter. Our ultimate aim remains to have sufficient numbers of the right staff in the right location with appropriate skills, delivering patient care of the highest possible quality.
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Much excellent healthcare is already delivered by multidisciplinary teams. This has been shown to be highly productive and delivers safe and effective care with improved outcomes for patients. We will continue to build on this model going forward. The number of GP vacancies within independent contractor practices is difficult to define precisely, though ISD collects data on numbers of GP s, and the biennial Primary Care Workforce Survey is underway.
There is however considerable evidence of a significant recruitment challenge in general practice across Scotland, with some areas finding it more difficult to recruit than others. This has had multiple impacts, including a number of practices relinquishing their contracts, requiring Health Boards to deliver a directly managed GP service for a period of time until new arrangements are put in place.
The sustainability of the GP workforce continues to be affected by the existing short-fall in GP numbers, the trend towards flexible working, the high proportion of GP s over the age of 55 who are likely to retire in the next five years and the fact that GP specialty training places are difficult to fill. These issues are common across the whole UK. The Scottish Government is taking measures to increase the supply of newly trained GP s, with the recent announcement of an extra GP training posts across Scotland from August This potential increase in capacity is accompanied by renegotiation of the GMS GP contract due to be implemented from April which will provide a role and career structure that is more attractive.
Concerted action is also needed to make GP careers more attractive, and there are a number of actions which are being considered or are already in train to address this. These include giving medical students the opportunity to spend more of their training in primary and community care settings, presenting a more positive view of general practice, and extending the range of career opportunities for GP s. Such opportunities include the new one year GP fellowship to provide them with the enhanced skills to work in the new community-based models.
The renegotiation of the GP contract is a key enabler to increase the attractiveness of the profession, removing bureaucracy and enabling GP s to spend more time on the type of patient care that provides the greatest benefits to patients, whilst providing higher levels of job satisfaction to the doctors.
For the future, general practice will require a different approach. The role of the GP will evolve to be the expert medical generalist, working with larger teams, and supported by a wider multi-professional team able to deliver much greater clinical care, working in a way that utilises their particular skills. The impact of the clinical team will be enhanced by collaborative working with social care staff, and increasingly by signposting patients to third sector organisations that provide significant community-based support for patients.
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The development of the wider primary care team will be trialled in a number of areas through new ways of working. Important issues to be determined by the trialling of newer models will include how continuity of care for patients can be optimised in wider teams, and how the increased range of professionals can be integrated to work with the existing practice-based structure of primary care.
It will be important for primary care professionals to be prepared to offer some basic training to relevant social care staff, with particular emphasis on what developments with a client should prompt contact with a healthcare professional. The provision of an appropriate level of support for patients in the community aiming to help rehabilitation and re-enablement requires a continuing expansion of the primary care workforce. This will be a central role of the newly formed Integration Joint Boards.
However, given the resource constraints, it is likely that a shift from investing in hospital care will be required, with a more significant move to investment in primary and community care. Healthcare will increasingly be delivered by teams of professionals united by common professional values, with effective clinical leadership. Recognising the current and future challenges in recruitment of highly skilled staff, we need to continue planning of training and recruitment for all types of clinicians to ensure that we can have the capacity to deliver the services that will be required in the future.
Enhanced capacity has to be planned early to deliver the health and social care workforce that will be required in the future, particularly given that training for some professionals takes years. A new GP contract must provide a professionally satisfying career path to attract a greater proportion of doctors into primary care. However, increasing the numbers of staff alone will be insufficient. We have the potential to deliver care in different, and potentially better ways, by fully utilising the many skills found across the wide range of disciplines supported in some settings by innovative use of digital technology.
NHSScotland has already invested significantly in a mixed economy workforce and recognises the benefit of new roles in the healthcare setting but also recognises the need to do more. The workforce challenges we describe are not exclusive to NHSScotland and dealing with them requires action by individuals, Health Boards and other bodies and Government. This should reflect our particular circumstances and build on our well established models of collaboration and partnership working.
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This is a clinical strategy which provides the rationale for change in the delivery of high quality and sustainable clinical services. To be successful it must also be underpinned by a sustainable financial strategy, with a primary focus on the value of healthcare services. Value-based healthcare is an established approach to improving healthcare systems across the world - the central argument is that higher value healthcare is not necessarily provided by higher inputs. What matters more is that care is provided early in disease to prevent progression avoiding the added patient burden of more intensive interventions , it is provided safely to avoid harm, it is proportionate to the patient's needs avoiding the waste of providing outcomes that are not relevant to the patient , it is provided consistently and reliably avoiding unwarranted variation.
Looking ahead, there are various issues that will specifically impact on the health resources available:. This all requires to be delivered within the context of the toughest public expenditure conditions we have faced. This strategy is primarily about improving the value delivered by, and from, health services. Improving value by providing reliable care that is proportionate to need, is safe, effective, person centred and sustainable will increase value for patients, and is likely to stabilise costs. Evidence shows that the relationship between healthcare expenditure and health outcomes is non-linear.
If it were, any additional euro spent on healthcare would result in a corresponding improvement in the population's health status measured, for instance, in terms of healthy life expectancy.
In reality, the greater the expenditure, the lower the marginal improvement in health status as a result of its increase. Countries also vary significantly in their ability to translate a similar level of resources into health outcomes. International comparisons show that the same amount of per capita healthcare expenditure can be associated with very different health outcomes even after taking into account the differences in lifestyle and socio-economic realities among countries.
It is not only how much money is spent, but also how it is spent, that determines a country's health status.
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Present budget constraints should therefore be used as an opportunity to improve the value and effectiveness of healthcare spending. The pace of change as a result of medical advances is considerable. It is not just the change in the actual treatment that will alter the services that we can offer, it is change in the way that services are delivered, and challenges to accepted practice. For example, 10 years ago it was considered normal and acceptable for patients to remain in hospital for up to 10 days after hip replacement.
Since then, work has been done to reduce the physiological impact of anaesthesia and operation, and speed recovery. Progressive work has shown that better outcomes can be obtained with a concerted effort to reduce length of stay, and it is now not unusual for patients to be discharged within 48 hours of hip replacement. Likewise there has been a continuing increase in the amount of day-case surgery, and, especially in gynaecology, a significant move to provide traditional day-case care in outpatient clinics - improving the service to patients, maintaining or improving outcomes and providing a higher value service at less cost.
Scientific advances will continue to provide the means to improve outcomes, but many of these advances will come with considerable cost and complexity, and may require more total resource than the treatments they displace. We will need to ensure that we have a health service that assesses improvements in outcomes against increases in resource input, and is as efficient as possible, otherwise our ability to invest in future treatments may be constrained. There is evidence that some advances are only very slowly taken up across the Health Service.
This natural conservatism with respect to new treatments can have benefits as there are examples of treatments that have been withdrawn after early experience has revealed previously unsuspected safety issues or unpredicted harms. However we need to ensure that new advances are taken up promptly across the whole of Scotland, especially if they result in significant increases in the value of treatment to patients, and improved outcomes, or reduced costs.
The role that Healthcare Improvement Scotland has taken in this respect has ensured that cost-effective and proportionate use is made of new technology for example, the consortium formed to advise on the use of the novel anti-coagulant agents but there are further opportunities to improve decision making and treatments. In summary, we need to ensure that any new developments in Scotland deliver proportionate improvement in value in relation to their costs.
That value should always be related to patient experience and outcomes. We should focus as much on different and better ways of delivering current services as we should on new technology and medicines.
Medical and technical advances can be marginal in their impact; service improvement can be transformational. We require a continuing national approach to support service improvements - as has been seen with the increased understanding of improvement science with the Scottish Patient Safety Programme.
We require to support widespread clinical leadership - from multiple professions - to ensure that we have a Health Service that is rapidly able to adapt to changing technology, and better ways of delivering current services. Scotland has a population of just over five million, and covers a vast area, much of which is sparsely populated. A significant proportion of areas are remote from centres of significant population and thus physical access to services.
Rural populations continue to grow at a faster rate than the rest of Scotland and have higher levels of older people, which increases demand for core services. Furthermore many rural households suffer from deprivation with "extreme fuel poor" rates around double of those elsewhere in Scotland.
The co-ordination and delivery of health and social care in remote and rural areas presents very significant challenges. There are insufficient populations to sustain specialist hospital services and distances and limited public transport links to acute hospital care can result in long travel times. This can lead to difficulties in providing high quality emergency care - issues which have been significantly addressed by the establishment of the flight based medical retrieval services.
There are other key ingredients to the provision of effective emergency care - the ability of well-trained local clinicians suitably equipped to respond rapidly to emergencies, and the ability to transport selected patients rapidly to definitive care. Due to the low rate of emergencies in sparsely populated remote locations, clinicians there may infrequently be called upon to provide emergency care, leading to reduction of any skills that have been acquired.
For this reason, it is necessary to consider further development of remote clinician support from specialists so advice can be obtained rapidly via phone or internet, given the much broader range of skills required of clinicians in rural areas.
go here This may augment the broad range of service initiatives that are found across rural Scotland - often based on local solutions using local resources and skilled healthcare professionals. A number of innovative ways of delivering healthcare in rural areas are being developed and tested with Scottish Government support. Working with NHS Boards we are developing networks between rural and urban hospitals. These networks will support doctors working in rural areas to maintain and develop their skills - ensuring that patients receive safe care.
In some areas this will involve rotating staff between rural and urban hospitals to ensure that we continue to provide services close to communities. This work has already delivered early success in supporting the delivery of general surgical services in Fort William's Belford Hospital. Working with NHS Highland, a network between Caithness General Hospital and Raigmore Hospital in Inverness is being put in place which will involve rotating staff between the two hospitals.
This will support the delivery of the majority of surgical care and all out-patient care close to the community in Wick. The Scottish Government is also supporting an enhanced training programme for GP s who will be able to support the general medical services delivered in Caithness General. This programme has explored new healthcare approaches to tackle challenges of primary care delivery in rural and remote areas.