THE vast majority of Scotland’s population will be completely unaware that a London-based think tank, the Nuffield Trust, published a report last week which suggested that health services elsewhere in the UK could learn from the integration and focus on quality and safety that has been put at the heart of care in the NHS in Scotland.

Most of the few articles written about the report, called Learning From Scotland’s NHS, focused largely on the challenges faced; that money is going to be really tight in the coming years and that the political divide between the Scottish Government and the opposition parties inhibits the making of difficult decisions. These are both true, and are indeed covered in the report, but they are hardly the dominant theme – which praised our innovation and relentless drive towards quality improvement and safety.

I saw this approach emerge in Scotland because I had the honour to lead the project group which developed the national Breast Cancer Standards for Scotland. Scotland already had an international reputation for the study of population health and many aspects of data collection and the registration of cancer patients but, at that time, many hospitals did not routinely collect audit data to help improve their services.

That all started to change in 1999, immediately after devolution. I remember being asked by Lord Naren Patel, who was setting up the Clinical Standards Board for Scotland – now called Health Improvement Scotland, to develop a set of clinical standards for breast cancer units. I remember thinking: “Wow, someone is actually going to listen to frontline clinicians.”

The aim was to ensure that services were of high quality right across Scotland and not just for patients treated in prestigious academic centres. I was honoured to work with colleagues from all over Scotland representing all the clinical disciplines involved in treating breast cancer, and with patients who had walked that journey and could therefore ensure we focused on things that were important to them.

We used the evidence-based Scottish Intercollegiate Guidelines Network (SIGN) guidelines for the diagnosis and treatment of breast cancer to select the most important clinical measures which would improve survival and reduce recurrence. We also promoted service aspects, such as the provision of breast care nurses, to provide support and information to patients.

A major difference from performance measures used elsewhere in the UK was that we did not seek to create league tables. It isn’t helpful for a patient to know that there is a great hospital 300 miles away – the aim is to ensure we bring her local unit up to a high standard as that is where she is likely to be treated. We therefore set target levels for each standard which meant every single unit could aspire to achieving them.

On the first round of visits we found that many units didn’t even collect audit data but that quickly changed and by 2003 we started to have comparable performance data for all the breast cancer units in Scotland. Just reviewing your own team’s performance data tends to highlight previously unrecognised weaknesses, which the team can then set about improving, but the performance of all units are also compared and discussed at the annual Scottish Breast Cancer Networks Conference. While units failing a standard or lagging behind others will be challenged, the reasons will be explored and clinicians from other units will share their experience and expertise to suggest practical solutions. This is one major advantage of not having a fragmented system like that which exists in England, where private providers are in competition for contracts and therefore simply would not co-operate in comparative audit in this way.

This is the crux of the difference in Scotland’s approach to performance audits. In England, market competition and financial incentives are used to set performance targets when commissioning a service, while a threatening regulatory approach is taken by the Care Quality Commission when judging it.

In contrast, the aim in Scotland is to encourage co-operative working by staff, patients and teams to improve clinical quality and safety.

Health Improvement Scotland has been criticised in the past for covering both the regulatory and improvement roles but the Nuffield Report found that this is a more successful approach in improving the quality of care for patients.

If you look at the performance of Scottish breast cancer units over the last 15 years you would see all teams have improved against key measures such as pre-operative diagnosis – which allows patients to be involved in planning their treatment – the availability of breast reconstruction for mastectomy patients or the appropriate use of new drugs and surgical techniques. Apart from breast screening services, such audit data is not currently collected nationally for breast cancer treatment in England, indeed there only appear to be three tumour types audited currently.

I remember being rather surprised, as a member of Westminster’s health select committee, when I realised the primary goal of England’s “NHS Improvement” did NOT appear to be about clinical standards but rather about balancing the books.

As well as gradually setting performance standards for common cancers, and indeed other conditions, Scotland was the first country to have a nationwide Patient Safety Programme. This was introduced in 2005 with a particular focus on reducing the risk of mistakes for patients undergoing surgery. The approach was quite radical and sought to learn from the aviation industry. Each operating list now starts with “the huddle” where all patients on a list are discussed to ensure any problems or risks are considered in advance and any special equipment is prepared and available. Staff introduce themselves to ensure everyone knows who’s who and first names are used to reduce any barriers between the theatre orderly who might spot something is wrong but feel too intimidated to raise it with the professor who is operating. For older surgeons, this took a bit of getting used to – but there is no doubt it ensures everyone is prepared for the more difficult cases and the patient safety programme has already reduced hospital mortality.

As well as rigorous checks of patient ID, consent form, skin marking and any x-rays and pathology results, there is a “time-out” taken by the whole theatre team for a final “pre-flight”

check to ensure the right operation is carried out on the right patient for the right reason. While the first phase of the patient safety programme was in surgical departments, it quickly spread throughout all hospital departments and primary care. The fact that such changes where brought about in the actual behaviour of clinicians, rather than remaining as a protocol in a folder, is the biggest advance in NHS Scotland over the last 15 years.

Quality improvement has made its way into the DNA of front-line staff – and that’s where it should be.