The meeting was opened by the Health Minister, Malcolm Chisholm, saying that everyone was agreed that change was necessary but asking what change was needed. The Executive needs to know the drivers for change. The review of management and decision making was still a work in progress. Collaboration and integration were wanted and frontline staff were essential in achieving this.

Dick Manson from SEHD then presented the latest output from the various subgroups working on the project. The aim was for people centred, better integrated care, mainly delivered in local communities. This involved

• empowering self care
• redesigned pathways of care
• holistic care, breaking down traditional barriers

• primary and secondary care
• NHS and social care
• innovation and traditional methods

As technology and telemedicine improves, more care is shifted from the tip of the triangle towards the base.

Patients want to be able to access all the different areas of the NHS without hitting all the barriers which currently exist. Movement between the different areas shown above should be a smooth, seamless transition rather than the current situation of all referrals being made through medical staff.

How does this translate into the Service?

There was then an update on how the various subgroups had progressed.

The main message is that wholesale change is not necessary. There should be absolute clarity on accountability and the Board should remain strategic.

It is necessary to reduce the number of different systems in use by boards and trusts and there should be standard NHS systems based around the Boards rather than the trusts. IT investment is the key to redesign and having one single patient record.

The Minister then chaired a session where attendees raised the issues they felt important. He stressed it was not all about abolishing trusts and asked whether we wanted them to go at all. The general theme was integration, but what would the integrated NHS look like.

There was concern about professionalism being replaced by less skilled staff following a step by step approach without having the proper background and knowledge to think beyond what was written down in their instructions.

There should be a stronger emphasis on people/patient centred services and a shift of control to people and communities. But how should this be achieved and how does it relate to accountability in NHS boards. Is there a downside/risk to patient involvement in service design and delivery?

There was speculation that the current primary care trust role might become redundant.

One size will not fit all.

Evidence of good practice should be used, but there is the problem of promulgating the good practices and having them adopted. I raised the issue of 28 day dispensing as an example of this (see my Secretary for Scotland report for September 2002 Council meeting). We should be learning from success to generate reform.

There must be a commitment at local level for service redesign, facilitated by the centre. There must also be local systems to improve and develop patient centred services. This may involve reconfiguration of existing services.

What will be the impact of the Working Time regulations? Emergency care must be considered here.

There was a suggestion for one health board and 15 branches.

Appropriate personnel should be used to improve the capacity of the community for appropriate health/social care e.g. MacMillan nurses and Red Cross volunteers.

Use should be made of computer data to create informed (virtual?) clinical communities.

The service must be honest with the public about service rationalisation and the reasons for it. There should also be honesty and openness between the professions and the health sectors.

The voluntary sector should be seen as a key partner in achieving the vision.

There is a problem of initiatives falling into the 'abyss' after the initial launch.

There should be a balance between specialism and generalism. Specialist services, which serve to isolate smaller professions, can inhibit cross fertilisation of skills.

We must reinforce the effect of health efforts on the economy and the wider determinants of health and health improvement e.g. education.

Cost effectiveness and value for money must co-ordinate the initiatives.

The meeting then split up for group discussions. In a change from previous practice, the groupings reflected the interest areas of the main participants. One group comprised voluntary organisations, local authorities, carers and the public, another NHS managers, another various professions and the last comprised medical staff.

Services could be improved by listening to carers and patients. There should be widening of workforce development and education. There should be more integration of health and social care. Also important are access to services; the quality of the service when accessed; and respect for the individual. One stop shops aren't as important as the quality of care. There is great potential for NHS24 and voluntary groups to improve the information available. Wider aspects such as housing, education and transport must not be excluded.

Trusts have served a useful function to create a local focus and local loyalty. Primary care offers a lot of opportunities for change as they consist more of people and services rather than the buildings and plant of acute trusts. A housing association type structure was a possibility. Large psychiatric services should be on acute sites. Acute trusts should be about putting together complicated packages of care and there should be a matrix of care. The momentum for integration will increase over the next few years and it will be necessary to emphasis what it means to the whole service. The service needs to be more evidence based and agreed protocols should be central to processes e.g. detailing what is expected from each of the partners

The triangle shown at the start of the session should have another layer above it - illness prevention and promotion of a healthy lifestyle.

The NHS should also make it easier for people to keep healthy e.g. healthier eating, and this responsibility should probably lie with the LHCCs. Integration must not be dilution and we must be specific about the levels of integration. Extreme caution should be exercised in assuming that new roles can be adopted to solve capacity issues. There are dangers inherent in having generic workers -

• the loss of clinical / professional identity
• the potential for loss of skills and expertise.

What can be done is to get rid of the nonsense existing in current practice - the artificial barriers where all referrals between health professionals need to go through a GP. Members of the group challenged the service to ask them how they would integrate their services fully and what government could do to facilitate / enable that to happen.

This group was ambivalent about trusts being abolished. Reconfiguration of services across Scotland was not going to go away and must be considered in the redesign and modernisation agenda. There was concern about consultant workload. There was also the possibility of expanding the role of secondary care consultants in primary care. However, proper facilities would be required for this. There should be better planning of services at local / regional / national levels, but there are problems with politics at each of these levels.

One more meeting is planned before Christmas.

COLIN RODDEN
Secretary for Scotland
Guild of Healthcare Pharmacists
4.11.02