In Scotland, change is coming, and quickly. At the last count, the Scottish Government was formulating, piloting or implementing 27 health reforms – ranging from integration of health and social care to a new clinical strategy.
But even before these official changes, Scotland’s health services were adapting to the enormous demands being placed upon them, particularly in some of Scotland’s more remote areas.
For example, in Grampian, the medical emergency department delivers out-of-hours care for the area's 500,000 residents, with 27 whole-time equivalent advanced nurse practitioners (ANPs) and paramedic practitioners working alongside GP colleagues. Every ANP in the service is either an independent prescriber or preparing to become one, and recruits are expected to have a minimum of five years' post-registration experience at senior staff nurse or charge nurse level.
They also have to obtain a master's degree from Robert Gordon University as well as completing British Association of Immediate Care training and passing objective structured clinical examination appraisal of their skills.
The service has been well received. One of the medical emergency department’s clinical supervisors, Dr Fiona McKay, said of the new roles: “We couldn’t manage without them...The ANPs are extremely proficient.”
On the Isle of Cumbrae, the out-of-hours service is provided by an ANP-led team operating from a base at the island’s Lady Margaret Hospital. Members of the local public reference group have said that they are very happy with the arrangements: “I have only heard good things about the way it’s working” said one, with another adding “It is a great improvement on what went before. Now there’s an appetite for more new things, like telemedicine.”
The awareness and discussion of these innovative services has sparked a wider consciousness about how services are being delivered, and a conversation around who has the potential and the capacity to deliver them in the future. The Scottish Government recently announced, for example, £3 million to train an additional 500 ANPs.
Those conversations chime with the main finding of the Nuffield Trust report Reshaping the workforce to deliver the care patients need – that expanding the skills of existing staff is one of the best ways to develop the NHS's workforce for the 21st century.
In Scotland there is growing recognition that multidisciplinary teams are the way forward in terms of delivering services that meet the demands being placed upon them, and providing quality patient care. But there is still some work to be done.
In June of last year, the RCN published a joint statement with the Academy of the Medical and Royal Colleges in Scotland which addressed the issue of sustainability in Scotland's NHS. The statement called for the barriers to collaborative team working to be removed and for professionals to be trusted and enabled to work to the top of their expertise.
I firmly believe that this multidisciplinary model is the only way to ensure that patients will always be able to see the right person, at the right time. But there are two very real public challenges in this.
First, we must address the fact that some patients expect to see a doctor when, in fact, a specialist nurse, a physiotherapist or a pharmacist is actually the health professional best placed to give them the care, advice and support that they require.
And second, we must tackle Scotland’s wider social ills, which have a huge impact on health and wellbeing services and the way in which people want and need to access them.
RCN Scotland’s Nursing at the Edge highlighted some of the most innovative and inspirational work of nurses in areas where health inequalities are marked, and those accessing services have chaotic lives which do not fit into the neat arrangements of appointments and set opening hours. But it also put forward six proposals which would help Scotland to make progress in tackling health inequalities.
One of those was related to staffing – and acknowledging the transformational impact that staff can have on those who access services. But what came through clearly is that it must be the right health professional, with the right skills, at the right time. And those professionals must have the time to invest in building trusting relationships.
Scotland must aim for a system where all staff have the time to invest fully in their patients, no matter their social circumstances. Clinical decision making is one element of care, but too often personal aspirations and outcomes are overlooked. And equally, clinicians must be open to new ways of working.
I have no doubt that Scotland has the potential to be a much healthier place, but unlocking that potential will not be easy. It will take a concerted effort from decision makers and all stakeholders, including the public.
But if Scotland fails to get these complex relationships – between professionals and patients; investment and innovation; output and outcomes – right, then I cannot see how services will be sustainable for generations to come: Scotland cannot afford to get this wrong.
On 8 June the RCN in Scotland launched Measuring success: principles for a new approach to improving health and wellbeing in Scotland. The paper puts forward nine principles for for addressing the targets culture in Scotland’s health and wellbeing system, and champions a move to measuring success by outcomes.
Please note that views expressed in guest blogs on the Nuffield Trust website are the authors' own.