Health and Social Care Alliance
First Minister Nicola Sturgeon
27 October 2015
The Scottish Government sees the Health and Social Care Alliance as a very important partner. There’s many different ways in which we work in partnership.
One very good example is the Self Management Impact Fund which is run by the Alliance, with financial support from the Scottish Government, has helped almost 100 projects over the last three years, and reached more than 20,000 people.
You’re also currently working with us on the national conversation. It’s an exercise we have initiated to create a space for people’s voices to be heard. We want to hear the voices of health and social care professionals, the third sector, but also people who rely on our health and social care services about how we equip the NHS for future given the challenges it faces; about how we, working together, create a healthier and happier country. The Alliance is organising events across Scotland as part of that conversation and facilitating so many people to have the opportunity to feed into that.
This Health and Social Care Academy is another important initiative – bringing people from different sectors together to drive change in health and social care. It is an honour to give the Academy’s inaugural lecture tonight.
This is also an important time to deliver this lecture. As all of you know – since most of you are heavily involved - we are in the process of moving towards the integration of health and social care by next March. That’s a process in which the Alliance is playing a lead role.
This is therefore an appropriate time to set out the Government’s basic vision for health and social care – to create wellbeing and to make sure we support all of the different factors in Scottish society that add up to the wellbeing of our population.
Integration is a very important part of that, but not the only part. I’m going to set out some of the steps we will take to ensure that hospital care is as quick, effective and expert and specialist as possible; that as much care as possible is provided at home or in a homely setting; and that people receive care that prioritises not the needs of the system that provides the cares, but the needs of them as individuals and how it promotes their wellbeing as individuals.
But I want to start with a very basic point but a point that perhaps doesn’t get stressed enough in the culture and climate we live in where all of us, with no exception, are always quick to point out the things that are not perfect or that are not going well; we sometimes forget to celebrate success.
In recent years health and social care services in Scotland, in what has been a very challenging financial climate, have performed better than ever before.
Public satisfaction levels with NHS services are at record levels. They have increased by 20 percentage points in the last 8 years. Satisfaction with GP services has also increased.
The NHS in Scotland employs 10,000 more staff than it did back in 2007. And as a result, more people are being treated more effectively, more quickly and more safely than they were back then.
As a result of our patient safety programme that was implemented across the NHS – an area in which Scotland didn’t just lead the UK but in many respects led the world and attracted enormous international recognition for. Because of that programme, mortality rates in our hospitals have fallen by more than a seventh in the last 8 years.
That’s a pretty impressive record. More to do of course but nevertheless, real progress.
In 2007 when I first became Health Secretary, the waiting time target for inpatient and day-case treatment was 18 weeks, and 85% of patients were seen within that time. Today, the target is tougher at 12 weeks, and that target today is being met for 95% of patients.
So, the target’s got tougher and the performance of the NHS against that target has improved.
We can also point to things like free prescriptions are benefiting households across the country. Adults on low or moderate incomes – less than £16,000 a year – no longer have to consider, as was the case in the days of prescription charges, whether to ration their use of medicines.
We have also retained free personal and nursing care - a policy which now benefits nearly 80,000 people across the country. Crucially, we have increased the proportion of that care being delivered at home, rather than in a care home or hospital. We are now moving at pace towards the integration of health and social care.
Now, I’m standing here citing all of these achievements standing here as First Minister and a former Health Secretary as if they’re achievements form the Government – they’re not. They are achievements that depend on the efforts of tens of thousands of people across the NHS, in primary care, social care and the third sector, and we should never forget the contribution the third sector makes. This is an opportunity tonight for me to pay tribute to and thank sincerely, on behalf of the Government, everybody who works across the country delivering health and social care services.
These achievements are achievements we should be proud of and be prepared to celebrate, but none of them should make us rest on our laurels. Despite everything that we have achieved, we know that we need to do far more and we know there are headwinds coming in the other direction that are making it more difficult for us. So, we must keep looking at how we do better; how we reform; how we equip health and social care services to deliver even better in the future.
I want to highlight two reasons for that. The first is inequality. Here in the New Town of Edinburgh, the average male life expectancy is 84. Four miles away, in Greendykes and Niddrie Mains, the average male life expectancy falls to 58. That’s shocking.
Now, Scotland is not unique in having unacceptable levels of inequality but no society can ever be comfortable when there are such stark differences in the life chances that people have.
That’s one of the reasons why health promotion – encouraging healthier lifestyles – is such an integral part of our approach to healthcare. One of the things I’m proudest of as Health Secretary, not started by me but we continued it, was integrating into our whole approach to health, health improvement and tackling ill-health and inequality.
At a broad level, we want to see health benefits and we hope to see health benefits from our efforts to tackle poverty and improve support for parents when children are in their early years. And more specifically, it’s why we attach such huge importance to the work that we’ve done and was done by previous administrations to reduce smoking, tackle alcohol misuse and promote a healthier diet.
So, inequalities is the first reason why we cannot rest on our laurels. The second reason is demographic change. Describing it as a headwind coming in the other direction is too negative a way to describe demographic change – it’s actually a thoroughly good thing that more people are living longer. But nevertheless is does present challenges across our society but particularly for our health and social care services.
Just to illustrate this point and not me telling you anything you don’t already know, but some of these statistics are worth repeating because they do bring into sharp focus some of the challenges that we’re dealing with now and some of the challenges we’re dealing with in the years to come.
By 2037, the number of people in Scotland aged 75 or over is projected to increase by 360,000 – that’s more than the population of Aberdeen and Dundee put together.
That’s something to be celebrated but it presents real issues for us in how we design and deliver health and social care services because as the population ages, it stands to reason the demand on the health service in particular grows and the nature, complexity and acuity of that demand grows as well.
It’s also the case that it’s not just the role of health and care services to look after people in a very strict literal sense – it’s also the role of these services to try and make sure they’re helping people not just live longer, but live longer in a happy, fulfilling, meaningful way as well. We don’t just get more years, we get more life in people’s years as well.
That’s is why we need to make sure that those services are promoting wider wellbeing because the longer people can participate fully in their communities - meet their friends; play a part in family life; and volunteer or even work – the better it is for all of us. And to enable that to happen, we need to rethink the way in which health and social care services work.
So I want to focus this evening on how we’re doing that. And I want to look in particular at three trends which will be increasingly significant in the years ahead.
I want to start by talking briefly about the implications of demographic change for hospital care and elective surgery, since that’s a very important part of the wider picture. Then I want to speak in more detail about the importance of health and social care integration. And finally, I want to look at primary care services – which of course will be crucial to the success of integration but also crucial in a wider sense because primary care is still the first and only contact people have with the health service. Therefore, the steps we’re taking to transform primary care will be an important part of our overall approach.
Much of the thrust of what we’re trying to do is keep people out of hospital where we can and avoid hospital admissions where we can. But, we’ve got to recognise that we will still require to provide appropriate hospital care for people who need it when they need it.
One consequence of an ageing population is that demand for elective surgery – surgery which isn’t immediate, or life-saving, but which can make an enormous difference to people’s quality of life - is increasing dramatically. If you take just three of the most common elective procedures - hip replacements, knee replacements and cataract removals - demand for them has increased by almost 50% since 2005, from 38,000 procedures a year to 57,000. That trend is going to continue and is going to accelerate.
We have to make sure that we equip the health service to deal with it and the health service has done a great job so far in dealing with that. Ten years ago, people would often wait years for procedures like these - the vast majority are seen within 18 weeks of referral. The median wait for hip and knee replacements has more than halved since 2005. For cataract removals, the reduction is 45%. In fact for almost all of the most common types of elective procedure, Scotland has the shortest waiting times anywhere in the UK.
One reason has been the decision, which was taken by a previous administration so credit where it is due, to use the Golden Jubilee hospital at Clydebank as a specialist centre. It currently deals with 20,000 procedures a year.
But the continuing increase in demand is invariably causing pressures. As a result, we’re starting to see waiting times rise again. The trend is very gradual at the moment, but we need to act now to reverse it.
That’s why one of the decisions we’ve taken is to repeat and replicate the success of the Golden Jubilee across the country. We’ve pledged over the next 5 years to invest £200 million to develop 5 more centres like the Golden Jubilee in Aberdeen, Dundee, Edinburgh, Inverness and Livingston.
So anybody waiting for a knee or hip replacement will know that their treatment isn't going to be delayed because their ward or their surgeon is needed for an emergency. They’ll go to a dedicated ward which provides expert, scheduled, specialist care.
Those five centres are a good example of one trend we will see. Some types of treatment – and elective procedures are a good example – increasingly benefit from a limited number of specialised centres.
However for most care, people want to be, and deserve to be, be treated as close to their home as possible.
Apart from anything else, it’s better for them. The best way of promoting people’s wellbeing is to help them to live as independently as possible, and wherever that is possible that means living independently in their own homes.
In order to do that, care services need to be as well-coordinated and seamless as possible.
That’s why the integration of health and social care is so important. I don’t think it is any exaggeration at all to say that integration of health and social care is one of, if not the most significant healthcare reforms in Scotland since the establishment of the NHS back in the 1940s.
I am very grateful to the work that I know is being undertaken by councils, health boards, professional organisations and third sector bodies who are currently working on integration. It represents a major change for some of you and how you go about your day to day work. It won’t always be easy – but it is essential if we’re going to provide the best possible services for the future.
The reason for that is that integration responds to the reality of how people now need to experience care.
As the number of older people in the population increases, many will have long-term conditions which need managing. Those conditions are often quite complex. For someone with multimorbidities – they could have emphysema together with Type-2 diabetes, or any combination of conditions - they may not need frequent visits to hospital or to their GP. Often, the vast majority of their care should be available at home – led by an experienced professional such as a community nurse.
Integration is intended to make it easier for that experienced professional to bring in other expertise when necessary; whether that’s hospital services, physiotherapy or third sector help - for example from befriending services.
It means that we want to take down the administrative barriers that often, in the past, have affected the type and nature of care and support people get. We need to make sure that everybody in the system, whatever they do in the system, is co-operating to provide the care a person needs, when they need it and the form that they need it.
It is essential that everybody – whether they’re a GP, a community nurse or a hospital clinician – is working together for that common purpose.
The crucial point is that the individual being supported is at the heart of the process. It’s not about individuals fitting in to how we make the systems work ; it’s about us making the systems work to support the individual.
We know that is hugely beneficial to individuals. It helps people self-manage. That can be fundamental to people’s wellbeing. It gives them a greater sense of independence and self-esteem, while still providing them with expert support when they need it. By encouraging self-management, we want to support people to be well, rather than treating them for being ill.
Health and care integration will also be better for unpaid carers. There are more than three quarters of a million unpaid carers in Scotland; it has been estimated that 3 in 5 people will become a carer at some point in their lives.
We’re already doing a great deal to improve support for carers. As we get the powers to do it, we intend to increase Carers Allowance, but integration I think will also help make sure that because services will be more effectively integrated, that will bring further benefits for carers.
All of these benefits I think fundamentally are benefits for the individual. But they do have benefits for the system as well.
Here’s another statistic that many of you will be aware of that illustrates the benefits of better, more joined up, more integrated care in people’s own homes can bring.
At the moment, 2% of the population in Scotland account for 75% of bed use associated with unplanned hospital admissions. Often, those 2% are the people who will benefit most from having services work more effectively together to make sure that their care is delivered where and when they need it.
If we can make sure that a significant proportion of those unplanned admissions coming from that tiny proportion of the population are instead scheduled admissions or avoided admissions altogether because the care at home is better, then we don’t just benefit the individual – we’ll have massive benefits and cost savings for the system as well.
These are the reasons why integration is so important. First and foremost because it’s about providing the care that people need in the way they need it when they need it. But let’s also recognise there are massive gains for the health and social care system to be realised as well.
Primary care services will be crucial to the success of integration. But we also know that primary care is essential to the confident that people have in the health service as a whole.
Primary care is the way in which most people first experience the health service and it’s often for many people the only way in which people experience the health service. Services have improved in recent years. 86% of people are satisfied with the care they receive from their GP.
We’re working hard to try and address some of the concerns that GPs have had in recent years – for example by making a commitment to remove the Quality and Outcomes Framework, and moving to three year contracts rather than annual ones. We’re currently working closely with the BMA on the new contract for 2017.
But we also know that the workload on GPs is growing. They are dealing with more patients and an increasingly complex caseload.
So we need to ensure that GP-led services adapt in a way which meets the needs of their communities, and which also meets their needs as professionals and as individuals.
That means that GPs should be at the heart of teams who will be able to meet a wide range of health needs. The model which is already used in quite a few health centres across the country - where GP services work with or are located alongside psychiatrists, paediatricians, pharmacists and many other specialists. That’s the future for primary care. We have already committed to expand this community hub model across the country.
We’re providing an additional £60 million for transforming primary care. £20 million of that allows GPs to trial new ways of working, so that we can learn from successful initiatives in different parts of the country.
For example Lothian Headroom is working in areas of deprivation to tackle alcohol misuse, promote employability and take other steps to improve people’s wellbeing. That’s the sort of work which can make a big difference in tackling the inequalities I mentioned earlier.
In other areas, different approaches are being tried. For example West Lochaber is using telehealth facilities to improve consultation services on the Small Isles.
We have also allocated £16 million to recruit 140 pharmacists who can work directly with GPs. It means that pharmacists with advanced clinical skills can support the care of patients with long term conditions – something which benefits those patients, while enabling GPs to spend less of their time with those patients and more of their time with patients who do need their direct input.
That’s our vision for GP-led community services. But of course delivering that depends on us doing more to recruit and then retain general practitioners. So today I can confirm two important initiatives to help us achieve our ambitions for primary care.
The first relates to retention. We know that in the last 5 years more than 250 people under the age of 50 have stopped being a GP. Often that will be for personal reasons – for example if they become parents, or carers themselves.
Many of those GPs will become able to return to practice after a few years. So we will invest in a programme to increase the effectiveness of our existing GP returners’ scheme. After all, training a GP costs approximately £500,000. It makes overwhelming sense to encourage people who have already been trained, and already have experience, back into practice.
They can make a big difference – even by working on a part time basis.
Our second initiative relates to initial training and recruitment. Currently we offer approximately 300 specialist GP training posts each year. People take up those posts after they’ve already done at least 7 years of medical school and foundation training.
We know that we’ll need more students in the future. That’s partly to meet a growing demand for services, and partly because of changing working patterns. People who graduate are increasingly likely to become part-time GPs rather than full-time ones.
We’re already doing more to encourage people to choose GP training – for example by increasing medical students’ exposure to primary care when they are undergraduates.
And I can confirm today a further important step. We are increasing the number of training places for GPs by 33% - from 300 to 400.
That change will take place next year, meaning that from 2019 onwards, we will see additional GPs available to work in the community. That’s an important commitment towards ensuring that we have the skilled practitioners patients need, working in integrated services, delivering our vision for the health service of the future.
What we are trying to do as we reshape and reform the health and social care services to make them fit for the future is making sure that that whole approach, not just about treating people when they’re ill but also about promoting people’s wellbeing, is hugely important.
As people live longer lives we need to help them to live as fully and as happily as possible. That requires integrated care that helps people to remain independent rather than becoming institutionalised. It involves supporting people to live at home for as long as possible. And it means enabling people to contribute to their communities for as long as possible.
These various initiatives I’ve outlined tonight, from making sure our elective services are fit for purpose, to ensuring the integration of health and social care, through to making sure we have primary care services that are in the shape that we need them to be supported by the skilled practitioners we need in them - it all adds up to the picture of the health and social care service that we are seeking to deliver.
If we do that then we’ll have a health and social care service that is as fit for the future as the one we enjoy today.
I know that the Health and Social Care Alliance will continue to be a key partner to us as we take this work forward. But all of you as practitioners in different parts of the system that we’re seeking to integrate; as service users; as representatives of the third sector – if we’re going to deliver on this vision and the practical steps we need to take to deliver it, then it will involve all of us working together supported by Government.