To help us plan and prioritise our work, we have a clear focus on the priorities of the Cabinet Secretary for Health and Sport, together with the framework for a quality management system, to describe some of the main activities we are carrying out in 2019–2020 to help make care better.
The Cabinet Secretary has set out four priorities for focusing the work of the NHS:

• Mental health
• Access and waiting times improvement
• Governance, and
• Increasing the pace of integration of health and social care.

To help us support the Cabinet Secretary, our five strategic priorities as set out in our strategy Making Care Better highlight the specific ways that we can make the biggest difference through our expertise as one organisation and have enabled us to focus to the delivery of our work in a cohesive way across the organisation.

These also provide the foundation for how we will approach our work using the quality management system. Below we describe some of our work and how this approach will work in practice. Many of our individual programmes and projects support more than one of our strategic priorities and, as highlighted below, there are some activities that we are required to carry out by legislation.

Integration of health and social care services

We are already carrying out a wide range of activities designed to help achieve the ambition of an effective integrated health and social care system across Scotland. This includes, for example, work focusing on the care of older people to maximise the impact of whole system planning and service provision. Essential characteristics of an integrated health and social care system include:

• a stronger focus on involving people, their communities and their carers in the delivery and design of their care
• delivering care closer to where people live, and
• to try and prevent illnesses and problems before they become more serious.

Community-based care services

As part of our efforts to support the development of stronger community-based services, we are working to develop a more holistic, organisation-wide approach to our work on older people. We are leading improvement work focusing on supporting early identification of older people with frailty or long term conditions (such as chronic obstructive pulmonary disease) to live well in their community for longer. We are also helping to enable people at the end of their lives to have a better experience of care and die in their place of choice, which is normally in the community.

We are working as part of the Adult Social Care Reform Programme to support key initiatives, including support to implement the Carers Act, develop Community Led Support hubs across several Health and Social Care Partnerships in Scotland, and support work to develop the community and social care market. This is being developed alongside Health and Social Care Partnerships and other national organisations, as well as ensuring all of our work considers the opportunities of choice and control for people in their communities.

We bring together evidence and publish guidance about aspects of care delivered in community settings. For example, during 2019–2020 we are publishing guidelines on: the diagnosis and management of asthma; the pharmacological and non-pharmacological management of dementia, and: prevention, early recognition and treatment of type 2 diabetes. We are also building an informal evidence base of outcomes based commissioning and opportunities for self-directed support.

To help alleviate pressures in hospital settings is to improve outcomes and experience for frail people who present to unscheduled acute care services, by rapidly and reliably identifying frailty at the front door. By delivering early comprehensive geriatric assessment within 24 hours, we help ensure people experience well-coordinated care attuned to their needs with the focus on support at home or in a homely setting. This will support system changes that result in improved flow, reduction in avoidable admissions and a reduction in length of stay.

We are continuing to work with the Care Inspectorate to deliver our programmes of joint inspections of health and social care services, which focus on services for children and young people – and services for older people.

Helping to deliver change

We fund and support strategic and targeted approaches to building a sustainable infrastructure for quality within NHS boards and Health and Social Care Partnerships. This includes, for example, generic support and coaching in quality improvement as well as support for specific, locally determined improvement programmes. Alongside this, we have a programme that provides support with whole system redesign to health and social care organisations. An integral part of this is promoting the involvement of people and their carers who use services in the design process, to ensure that the right services are designed based on their needs.

We will continue to build on our work within primary care and deliver targeted improvement support to optimise care and service redesign across primary care in Scotland. This work includes GP Cluster support and supporting improvement work within Integration Authorities as they develop new service models for primary care. We are also beginning a new programme of work on external quality assurance of primary care services.

We are using the quality management system to consider our work on supporting the integration of health and social care services. An area where we could have a stronger focus is the quality assurance of community-based health services. We already have some plans to increase our work in this area and, during 2019–2020. 

Mental health

The Scottish Government’s Programme for Government for 2018–2019 sets out a clear priority for transforming services across Scotland for people with mental ill health – including children and young people.

Through the mental health access collaborative, we are working with frontline teams to develop and deliver improvements to services across a range of mental health supports and settings.

Alongside this we have an established quality improvement safety programme focused on reducing harm in mental health settings, which is addressing issues such as the safe prescribing of medicines, self-harm, and the use of restraint and seclusion.

We are working with NHS boards and Health and Social Care Partnerships to support them to develop robust plans to improve access to mental health services which are informed by the data, the evidence about what works, and service user and staff insights.

In January 2019 we published new guidance which supports and challenges all mental health care practitioners to move away from the traditional practice of enhanced observation and work instead towards a framework of proactive, responsive, personalised care and treatment which puts the patient firmly at its centre. This is a significant change in practice which will require work to embed the new approaches. We are currently awaiting the outcome of a proposal to Scottish Government to extend the Improving Observation Practice programme for a further two years to enable us to support NHS boards to embed this new way of working into business as usual practice. 

Children and young people with mental ill health

We are already working to ensure that people with mental ill health who need to access psychological therapies get the right help when they need it, and to improve access to mental health services for children and young people. As well as reducing waiting times, our work in this area is focused on enabling improvements to the quality of care more broadly.

Other new areas of work include the translation of established safety principles into perinatal and infant mental health and children and young people’s services. We are also supporting work to ensure services take an evidence-based approach to early intervention when people have a first episode of psychosis.

We continue to develop methodology which supports local integrated teams, including young people, social care, education, police and community organisations to design preventative pathways for young people’s mental health.

During 2019–2020 we are developing a guideline on the care provided for people with eating disorders and we anticipate this will help improve existing services and, where necessary, with the redesign of services. We are also working with Scottish Government colleagues on a Suicide Learning Reporting System to ensure we are maximising the opportunities for scale and spread of learning and best practice from our assurance work.

The majority of our work on mental health contributes to the quality planning and quality improvement components of the quality management system. We are now exploring options for how we can consolidate our work, this includes developing how we support frontline services carry out quality control of mental health services, and how we strengthen collaborative working across the different functions of Healthcare Improvement Scotland. 

Access to care

We are currently working with Scottish Government and NES to design a programme to help improve access to services and waiting times. This programme will seek to embed the key elements for ensuring a sustained reduction in waiting times over the medium and longer terms.
The Cabinet Secretary has recently asked for a new programme of Quality Improvement work to support the delivery of the Waiting Times Improvement Plan (WTIP). Healthcare Improvement Scotland, NES and the Scottish Government are working together with key colleagues across Scotland to complete the detailed design of this work with the aim of starting delivery from April 2019.

This work will support the deployment of quality improvement expertise against the challenge of delivering sustainable improvements in waiting times whilst maintaining or improving the quality of care. It will do this by:

• strengthening the use of quality improvement within existing access improvement programmes.
• supporting leaders to create the conditions for quality improvement to be successfully applied to waiting time challenges
• supporting the accelerated implementation of locally redesigned pathways of care, and
• increasing quality improvement capacity and capability.

We are aligning and integrating this new programme of work with existing and proposed improvement work within HIS, including using our expertise in the development of evidence-based advice, standards and guidance to add significant value to this priority area of work as well as using our quality management system approach to support oversight and design of this work.
This is an area we are investing in further, recognising that some of our existing programmes and projects help with access to services; our work on access to mental health services, delivering reliable safe care through the Scottish Patient Safety Programme (SPSP) and in supporting people to live well in community settings. 

Governance of the quality of care

Across Healthcare Improvement Scotland, we carry out a wide range of activities that are designed to help strengthen local governance arrangements for the quality of care. This is continuing in 2019–2020 and beyond.
Our external quality assurance work continues to include a focus on the robustness of NHS boards’ governance structures, and their systems and processes to support staff to consistently deliver safe, effective, compassionate and person-centred care. As part of this, there is an ongoing programme of NHS board reviews which look at the quality of care provided, with a particular focus on outcomes and the effectiveness of leadership.

We are leading a national programme to improve the quality of nursing care through the development of indicators and tools to improve and assure the robust and reliable delivery of nursing and midwifery care across NHS boards. We are also supporting the introduction of new legislation to implement the necessary workforce tools and to monitor the provision of safe staffing in our healthcare facilities. 

Inspections and reviews

Throughout 2019–2020 we are continuing to carry out inspections and reviews of hospital based services. These are designed to support improvements in care by highlighting where care is good and where the quality of care should be better. We are currently reviewing our programmes of hospital-based inspections (which focus on the care of older people, and safety and cleanliness) to take a more holistic approach to these reviews.

We are continuing to embed the Health and Social Care Standards and to ensure that the underpinning principles are reflected in the design and delivery of care. The standards underpin our quality of care approach and support improvements in the quality of services across health and social care.

We are developing our own approach to how we consider, and where necessary respond to, potentially serious concerns about the quality of care that our organisation is made aware of. This is also designed to help strengthen the effectiveness of governance mechanisms within NHS boards. We report publicly on how NHS boards have responded to concerns about quality of care (including their governance mechanisms), as well as on the quality of care itself.

One of the ways in which potentially serious concerns about the quality of care are brought to our attention is through our intelligence sharing work with other national agencies. This work is also designed to help strengthen the effectiveness of governance within NHS boards, by considering data and intelligence information from seven national agencies and discussing this with individual NHS boards.

During 2019–2020 we are setting up a programme of work to support NHS boards and Health and Social Care Partnerships to put in place quality management systems. We are now considering opportunities for additional support we can provide for NHS boards and Health and Social Care Partnerships to help them plan and improve their local governance mechanisms (namely the quality planning and quality improvement elements of the quality management system). 

Ensuring the effective engagement of individuals in the design and provision of their care

Through our Scottish Health Council local office network we are continuing our work to enable local communities to participate in the planning, development, and delivery of services. As part of this work with local communities, individuals and the third sector, we use equalities monitoring data to understand how well we are ‘reaching’ different parts of the community.

We have a legal duty to help reduce health inequalities, and to involve service users, carers, and the public in our work. Throughout 2019–2020 we are further developing how, for work carried out across Healthcare Improvement Scotland, we assess the anticipated impact on health inequalities. We are also continuing to produce and promote evidence that helps NHS boards and policy makers address health inequalities.

Helping build knowledge and share learning is also one of the aims of our international learning exchange which, through QI Connect (a series of interactive WebEx sessions), provides an opportunity for colleagues across health and social care to learn from international leaders in the fields of improvement, innovation and integration.

We are also incorporating the Scottish Approach to service design within our improvement work, which aims to empower and support the people of Scotland to actively participate in the definition, design and delivery of their public services.
 
Statutory duties to safeguard the public and to provide high quality care

There are a number of activities that we are required to carry out by law. These include:

• providing a single point of advice for Scotland on the clinical and cost effectiveness of new and existing health and care technologies that are likely to have significant implications for people’s care
• providing a single point of advice for Scotland on the clinical and cost effectiveness of all new medicines, with the aim of reducing variation in availability of medicines across Scotland
• maintaining and publishing the register of controlled drugs’ accountable officers in Scotland, and providing external quality assurance of the governance arrangements for the safe management of controlled drugs
• providing advice and support to NHS boards on involving patients and communities in service change processes
• helping to improve the quality and accuracy of death certificates, and giving public assurance around the death certification process
• regulating independent healthcare services, with the aim of ensuring that independent clinics, hospitals (including private psychiatric hospitals) and hospices are maintaining high standards of care, and
• carrying out regulatory inspections to ensure safe care for patients, carers and staff who are exposed to medical ionising radiation (X-rays and nuclear medicine, and treatments such as radiotherapy) in any NHS or independent service.