Around 50 members attended the meeting at the Hilton Dunblane Hydro. This report is compiled from notes taken during the meeting, is for information only and does not constitute formal minutes. Consequently, I take no responsibility for any inaccuracies, errors or omissions. Opinions expressed within the notes are those of members and have been included for completeness. However, this does not necessarily mean I agree with them.
Gerry Marr opened the meeting with a reaffirmation that this was the start of the NHS in Scotland modernisation process - the plan covered a 5-10 year period.
The members were split into groups to discuss a tabled paper describing a model of different health care stages. It had been decided that the word 'heirarchy', although used in the model to describe the stages, was not really accurate. The groups were to discuss the model, and then how it might be applied to areas such as Mental Health, Care of The Elderly, Children's Services, Stroke, Cancer and Coronary Care. Below are some of the comments made by the various groups on each of these areas.
It was thought that the model was a little narrow, and that a broader journey was required. Far greater professional and public input was required to improve it. The aim is a smooth journey through care, but health and well being should be emphasised. There is an opportunity for radical changes, but there need to be explicit incentives for change. A 'care-manager' or similar was required to act as a travel agent and guide the patient into the most appropriate type of care. There should be multiple entry points into the service, and organisational barriers such as local authority or health boundaries should be broken down or blended to allow closer working. Patient ownership of their health information was proposed, and then they could make decisions on with whom to share that information.
Skill mix and team working are important, as is the institution and support of a robust communication process involving everyone. Smart cards might be one answer, used by all parts of the service e.g. GP / dentist / pharmacist / OP clinic. There are medico-legal issues too. Many practitioners don't focus properly on the patient as they are too busy watching their backs and covering themselves. There is a need to recognise the time and resources required for implementation of guidelines.
For all of this, there needs to be a realistic assessment of the resources required and increased involvement of the public and patients.
Community Health and Well Being
Local Services Advisory Group - (multidisciplinary inc. IM&T)
Education & Training - professionals & patients
Protocols, Standards & SIGN
Acute Stroke Unit
To allow this to work effectively and efficiently there must be collaboration not competition and -
There was discussion on opening up professional boundaries, extending prescribing rights and 999 prioritisation. There must also be documentation of contributions to patient care.
There should be an increased emphasis on education and support in the community to remove the stigma and increase understanding of mental health. Improved multidisciplinary involvement was also necessary. Speed of access to services was important, to prevent a drama becoming a crisis. However, although entry to the system was important, there is also a need to manage patients out of the system too.
Proper assessment should be available to allow access to the most relevant service, be it primary, secondary or tertiary care.
Education was important at all stages, and it should be comprehensive and started as early as possible. It was important to recognise that the child and parent are a unit and should be treated as such, although the relative importance of the two will change over time. From the child's birth, the influence of the parent will gradually reduce and the influence of the child will increase until the child reaches adulthood. There needs to be more help and support for tertiary referrals with appropriate speed and level of referral. There must be a solution for children in care and those with mental health problems who often fall through the current cracks in the system. The roles of health visitors, school nurses and the voluntary sector should not be ignored. It is also necessary to be in accord with the increasing Children's Rights framework.
Age and need should both be considered. There is likely to be gravitation from secondary to tertiary care as fewer numbers of centres exist. The challenge is to make these centres more local. The move from generalisation to specialisation can be considered as "de-skilling", as practitioners are expert in only one field.
Care of the Elderly
There should be a multidisciplinary team working across primary, secondary and tertiary care. It should not be a matter of where, but how the service is delivered, and is it effective? The hospital at home concept needs more evidence for the effectiveness of outreach rehabilitation. It is necessary for the elderly to demand health, not expect illness. The West Dunbartonshire 75th birthday card scheme was discussed. Here, people receive a birthday card on their 75th birthday detailing the services available to them and asking them to contact a named individual if they have any problems. The service should aim at crisis prevention rather than crisis management. The division between nursing homes and residential homes should be scrapped and replaced by 'care homes'. There should be some sort of 'flagging' process which notes if a person accesses various parts of the system and indicates if they might be 'at risk'. Discharge delays and bed blocking are usually down to problems between health and social care - there are blocks in the system which could be removed by commonalising the budgets for both.
In prevention, there should be a consistent resource informing and educating local communities. The goals must be achievable and realistic. In self-care, the messages must be repeated and be consistent and accessible. Too often there are conflicting messages from different health professionals. "Drink more orange juice - it's good for you" from one "Drink less orange juice - the acid attacks your teeth" from another. Taxation could be extended to things like Irn-Bru
Again specialisation is leading to de-skilling in this area. Many practitioners now practise defensively to avoid possible lawsuits. What is the definition of 'minor trauma'? This is an added complication to the patients journey unless they are educated as to the appropriateness of the type of care provided at each stage and at different centres e.g. Trauma centre / casualty / ACAD / GP surgery. The public can only use the services effectively if they have the knowledge, or someone who does.
There should be a strong emphasis on primary and secondary prevention with, for example, an annual health check for everyone. There should be support for a nationwide improvement in acute stroke treatment , with an explicit statement in the plan and increased investment in stroke units and rehabilitation units.
There are major education issues for the community and well being area. Screening was suggested, but would require to be worked out more fully.
Within secondary care, it will be necessary to plan for discharge from day 1, working with primary care. There must be close liaison between the acute stroke unit and the rehab unit with, preferably, the same people involved in both.
Once the patient is discharged follow up is important. This may be where the intermediate care level comes in.
Minister for Health Susan Deacon was present for the reporting back of each of the groups and noted that agreeing the principles was excellent, but there was a need to transfer it into practice. There should be a change from being the 'Gatekeepers of the NHS' to being the 'Gateways to the NHS'. There is a need for the right information in the right form at the right time. The process did not have a beginning, middle and end. Continuous improvement and development were the goals, with a new way of taking decisions and formulating policies for the Government in Scotland.
The afternoon sessions built on the morning by asking how the plan could be implemented, what blocks had to be overcome and how best to overcome them. Time for reporting back was limited, but all the details were taken away for consideration.
How do we develop financial regimes and ensure flow of funds to provide resources that enable rather than obstruct?
Increasing access to IT
Managing people effectively
Communication, the quality of the communication and the degree of caring inherent in that communication are all important.
It is a difficult task. It is necessary to get people on board with the goals, purposes and values of the NHSiS.
Identify and break down professional barriers
Principles of teamwork -
There needs to be an overall approach, and the Clinical Standards Board are the key to a lot of it. It has to be done so that an individual service looks at itself critically. External audit should praise when things are going right and disseminate good practices. An agreed plan of action is required, and a need to simplify Trust financial structures to free up some people and time. There should be an increase in centralisation and central control.
Secretary for Scotland
Guild of Healthcare Pharmacists