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SBC describes changes at different levels across health and social care – all of which are intended to bring about improvements in health and wellbeing and better service outcomes by providing care which is earlier in the course of a disease, a quicker diagnosis and a treatment process tailored more closely to each person’s needs and is delivered closer to home.
The demographic profile of Scotland’s population is changing; there will be a significant increase in the number of older and very old people who may have several long-term conditions. Long-term conditions will be one of the main challenges facing the NHS and its partners. At the same time we must respond better to the needs of vulnerable people and those that are isolated socially or geographically and who have real difficulty in accessing services.
SBC is an evolutionary process with no fixed end point. Services and care must continually adapt to the changing needs and aspirations of individuals and their families. This requires careful service redesign with the full involvement of patients, users, carers, professionals and staff to ensure that services, care and support are fit for current and future purpose. Most importantly, it requires effective workforce planning and the better use of people, facilities, technology and information systems as well as recognising and implementing proven innovations.
The need to adopt this approach to service planning and delivery, based on outcomes and care pathways, has been widely acknowledged across organisations, professional groups and political parties for some time. Significant improvements in relation to mental health services and care for people with physical and/or learning disabilities have already taken place through shifts in the balance of care. We must build on this experience and ensure that we continue to improve and not reduce quality and safety in the community. We are not changing for the sake of it – not every change is necessarily an improvement but at the same time there can be no improvement without change. Measurement of the level of improvement will underpin the whole process of shifting the balance of care.
By increasing the rate of health improvement in deprived communities by enhancing anticipatory care; moving away from services focused on acute conditions towards systematic and personalised, bespoke support for people; developing continuous, integrated care rather than disconnected, episodic care. This means shifting our view of individuals as passive recipients of care towards full partners in improving their health and managing their conditions. This will include supported self-care and, where appropriate, using innovative tele-health and tele-care solutions that enable people to take greater control of their conditions and their lives.
Providing more care and treatment in the community requires professionals and staff to develop their skills, expertise and roles within a team. This means moving away from the ‘independence’ of individual practices and professionals towards extended primary and community care teams that make better use of generalist and specialist expertise across community and hospital services. Partnership working between organisations and between professionals will be critical to the effective delivery of new models of care, based on agreement about outcomes and care pathways. This means we need to develop community-based, multi-agency approaches to the delivery of integrated care.
There are opportunities to improve access to care and treatment through changes in the location of services; providing a wider range of diagnostic procedures and specialist services in communities. We expect to see changes in acute hospital activity as we develop the community infrastructure (including more joint premises). This will allow services to be delivered in a way that is convenient and makes sense to service users and will enable us to get a better balance between planned and unscheduled care. These local community-based services will require improvements in infrastructure, technology, information systems and workforce capacity