Health and Community Care
To improve the health and the quality of life of the people of Scotland and to deliver integrated health and community care services making sure there is support and protection for those members of society who are in greatest need.
Objectives and Targets
Working across Scottish Executive Departments and with other delivery partners to improve the health of everyone in Scotland and reduce the health gap between people living in the most affluent and most deprived communities.
Reduce the mortality rates for those aged under 75, between 1995 and 2010 by health improvement action to tackle diet, physical activity, smoking and alcohol consumption, by action to ensure early detection and improved access to treatment and care. We will reduce deaths due to cancer by 20%; coronary heart disease by 60%; and stroke by 50% by 2010.
Reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15%, by 2008. (The range of indicators has been selected from the 23 recommended indicators of health inequality. For adults - coronary heart disease, cancer, adults smoking, smoking during pregnancy, and for young people - teenage pregnancy and suicides in young people.)
To seek and take into account the views and experiences of patients,
carers and communities in designing, planning and improving healthcare services.
All NHS Boards will achieve year on year improvements in the involvement of the public in the planning and delivery of NHS services to 2008 and in the involvement of patients in decisions about their own health care and the development of services, as reflected in reports by the Scottish Health Council.
To improve the quality of NHS services to better meet the needs of patients, with particular priority to cancer, coronary heart disease, stroke and mental health.
All NHS Boards will demonstrate regular and sustained improvement, as reflected in the reports by NHS Quality Improvement Scotland ( QIS) in performance against the Healthcare Governance standards set by NHSQIS.
Ensure patients receive healthcare at the right time, in the right place and in the right way.
By the end of 2007:
- no patient will wait more than 18 weeks from GP referral to an outpatient appointment;
- no patient will wait more than 18 weeks from a decision to undertake treatment to the start of that treatment - down from the current 9 month maximum wait guarantee; and
- patients will be able to rely on shorter maximum waits for specific conditions:
- 18 weeks from referral to completion of treatment for cataract surgery;
- 4 hours from arrival to discharge or transfer for accident and emergency treatment;
- 24 hours from admission to a specialist unit for hip surgery following fracture; and
- 16 weeks from GP referral through a rapid access chest pain clinic or equivalent, to cardiac intervention.
We will reduce the number of people waiting to be discharged from hospital into a more appropriate care setting by 20% year on year between 2005 and the end of 2008, cutting to a minimum the number of people waiting more than 6 weeks to be discharged.
By 2008, increase the number of older people receiving intensive home care to 30% of all older people receiving long term care.
By 2008-09, we will reduce the proportion of older people (aged 65+) who are admitted as an emergency inpatient two or more times in a single year by 20% compared with 2004-05.
The Objectives and Targets set as part of the 2006-07 Health Department Delivery Plan are set out in Annex A
Spending plans 2002-08
Table 8.01 Categories of spending (Level 2)
National Health Service
Other Health Services
Mental Health Specific Grant
Welfare Foods budget transferred from Other Health Services to Health Improvement for all years
Table 8.02 Categories of spending (Level 2 real terms)at 2006-07 prices
National Health Service
Other Health Services
Mental Health Specific Grant
What the budget does
The Health portfolio's aim to improve the physical and mental health and wellbeing of the people of Scotland contributes to many of the Executive's key aims, e.g. to encourage economic growth, to improve educational attainment, whilst also promoting equality and closing the opportunity gap between the most and the least affluent. We will also ensure that our activities are sustainable and delivered in partnership.
Scotland's health is improving, but it remains relatively poor when compared to other European countries. In addition there is a substantial, growing gap in life expectancy and healthy life expectancy between the most and least affluent men and women in Scotland. The challenge of improving health outcomes in Scotland is one which faces the Scottish Executive as a whole. We set out in Improving Health in Scotland: The Challenge a strategic approach, drawing together actions and resources across a wide range of the Executive's responsibilities. The Challenge aims for action on three linked levels:
- life circumstances - promoting social inclusion, employability and closing the opportunity gap;
- lifestyles - diet, alcohol misuse, smoking and lack of physical activity; and
- health topics - tackling biggest killers and contributors to poor quality of life such as coronary heart disease, mental health and cancer.
We will focus on health improvement delivery, which will include anticipatory care, approach for people at risk of preventable ill-health in deprived communities, developing a healthy weight policy which builds upon existing work on physical activity and diet, and a framework for local health improvement actions by community planning partners.
Aspects of health improvement work (e.g. Mental Well-being, Diet and Physical Activity) have been commended by the World Health Organisation. We plan to celebrate the successes to date whilst also increasing the rate of improvement in population health.
In 2007-08 we will continue to do all we can to reduce smoking prevalence by building upon the benefits flowing from the smoke-free places introduced by the Smoking, Health and Social Care (Scotland) Act 2005. In addition to continuing to invest in smoking cessation services we will use the recommendations of the Smoking Prevention Working Group - expected to report in Autumn 2006 - to develop a new long term strategy to guide smoking prevention activity at national and local levels.
We will also drive forward Delivering for Health, our programme of action for the NHS which will see us shift the balance of care from reliance on episodic, acute care in hospitals towards a system which emphasises a wider effort to improve health and well being, through preventative medicine, support for self care, delivering services in the community and greater targeting of resources to those most risk.
We are committed to an approach which:
- places the patient at the centre of planning and delivery;
- reduces waiting; and
- raises the quality of care and promotes patient safety.
NHS Quality Improvement Scotland is at the heart of our efforts to improve quality and standards in the NHS in Scotland through developing standards, guidelines and reporting publicly on performance. It has recently concluded that the arrangements now being put in place by the NHS to protect the quality of patient care are more robust and coherent than at any time in the history of the service. The new Scottish Health Council will help to ensure that NHS Boards are communicating effectively with and listening to patients and the public, and that there is a clear patient-focused approach to the delivery of services.
Scotland's health policy can be represented pictorially as:
Statement of Priorities
Our immediate priority, will be to meet the targets set out in 'Delivering for Health', in particular:
- improving health and targeting action to address inequalities in health;
- meeting waiting times targets;
- a national strategy for the care of long term conditions;
- e-health review of emergency retrieving services;
- plans for the establishment of planned care services;
- development of a model of Rural General Hospitals;
- publication of a National Delivery Plan for Mental Health Services;
- managed Clinical Networks for tertiary paediatric care;
- we have initiated a National Review of Specialist Children's Services which is aiming to produce a National Delivery Plan for Specialist Children's Services in Scotland by the autumn of 2007 which will include building two new children's hospitals in Edinburgh and Glasgow.
- continuing investment in research ensuring that expenditure is as well-focused as possible to achieve the objectives of improving health and health services for the people of Scotland.
New Resources and transfers
In 2007-08 we are planning to spend more than £748m more on healthcare services in Scotland than we are doing in the current year. We will be using this additional funding to seek major improvements in performance through a sustained programme of reform and service redesign and through investment in capacity. We expect Community Health Partnerships ( CHPs) to help take reform forward and to strengthen the voice of healthcare at a local level. The CHPs will promote health and tackle health inequalities, together with better integration of primary care services with the specialist services in hospitals and with the social care services of local authorities.
We continue to invest to increase the capacity of the NHS, with Partnership Agreement targets to increase the number of doctors, nurses and other health professionals; with the largest programme of spending on hospitals and community health centres; and with a strategy to improve the use of information technology and telemedicine techniques. We are funding major reforms to modernise the pay and conditions of Health Service staff in support of the required redesign of services, providing a platform for new ways of working, delivery of higher quality care to patients, and the development of new roles for staff. Although the independent healthcare sector in Scotland is small, we will make increasing use of such independent providers, where this offers value for money and improvements in the patient's experience.
This investment in the NHS needs to be matched by a sustained commitment to redesign the way services are delivered, so as to shorten the patient's pathway of care and provide the right care in the right place and at the right time. Such redesign will mean major changes in the way healthcare is delivered in future: for example, more support for people with chronic conditions and their carers through primary care teams and local health centres, making full use of the professional skills of community nurses and pharmacists; more services to raise health standards delivered through local communities and voluntary bodies; more nurse-led clinics and day-care services; more investment in local diagnostic facilities; and clinically appropriate use of hospital-based services and care.
We will continue to invest in modernising community care services, through local authorities and the voluntary sector to meet the needs of Scotland's older people and younger adults who need care. Our aim is to deliver a wider variety of flexible, person-centred services, delivered through partnership arrangements to help more people to live independently for longer in their own homes or in sheltered housing, and to reduce inappropriate admissions and inappropriate length of stay in hospitals.
In 2006-07 and 2007-08, £31m was transferred to the Justice Portfolio who now have lead responsibility on drug policy.
Growing the economy
Although the main role of NHSScotland is to look after the health of the Scottish population, the health portfolio does contribute both directly and indirectly to help grow the Scottish economy.
- Employment - Public sector health and care services in Scotland are major contributors to the Scottish economy. Employment in the NHS in Scotland in September 2005 represented 6 per cent of the Scottish workforce. Furthermore, NHSScotland recognises its responsibility as a large employer and has formed strong partnerships with Jobcentre Plus to ensure that its vacancies are promoted to people who are currently out of work and that opportunities for NHS pre-employment training exist for potential candidates who do not hold the necessary skills to compete at interview.
- Expenditure - Pay represents the major component of expenditure on health and care services. The provision of employment opportunities and spending power results in indirect multiplier effects that further increase the contribution of the NHS to the economy.
- Equity - In rural and remote regions of Scotland the NHS provides work and spending power, thereby contributing to the local economy and helping to mitigate the effects of depopulation.
- Investment in Scotland to support involvement in the United Kingdom Clinical Research Collaboration ( UKCRC), has been influential in helping to attract recent investment of c.£33m by Wyeth Pharmaceuticals, in a translational medicine initiative involving the Universities of Aberdeen, Dundee, Edinburgh and Glasgow and the NHS. It has also attracted an additional investment of up to £17m from Scottish Enterprise.
- The collaboration will create the world's first 'Translational Medicine Research Collaboration' in Scotland and provide the impetus for Scotland to lead the world in medical research and bring lifesaving new drugs to patients more quickly. The collaboration will create 50 jobs at a state-of-the-art Laboratory in Dundee in the first instance, rising to as many as 120 over 5 years.
- A recent UK Health Research Analysis report published by the UKCRC confirms that Scotland attracts a disproportionate amount of directly funded research (13.1%) when compared to regions in England. A separate survey indicates that Scottish healthcare research is the most productive in the World.
- The main drivers of economic growth are the quantity (and quality) of an economy's factors of production. The quality of that labour force is a major contributor to an economy's international competitiveness. The health service provides a vital role in ensuring that the labour force remains healthy and available for work.
- Public health care available free at the point of use has a significant effect on the labour force. Better health enhances labour productivity by reducing:
- the number of working days lost due to illness;
- the number of early retirements; and
- the number of premature deaths amongst those of working age because of treatable illness.
- Although not all output lost through absenteeism is preventable through increased health expenditure, particular programmes of health expenditure are clearly more relevant than others. For example, it is estimated that approximately 35 per cent of absences from work are caused by mental health problems 1. Figures for Scotland suggest that 72 per cent of people with mental health problems are unemployed - the highest of all the disability groups - yet 80 per cent go on to make a complete recovery.
- Another example of health expenditure that has the potential to improve economic performance is health improvement. Health improvement in Scotland is a multi-agency, multi-stranded approach which ranges from action focused on key settings (workplace, homes, communities and schools) to mental health, suicide reduction, sexually transmitted diseases, alcohol, tobacco and drugs misuse to programmes aimed at healthier eating and physical activity. This is particularly important in preventing (or reducing) the prevalence of diseases such as cancer, coronary heart disease and stroke. The effect on economic and social productivity of these problems should not be under-estimated, in particular alcohol and drug misuse. For example, a study commissioned by the Scottish Executive Health Department ( SEHD) in 2001 estimated that the total economic cost of alcohol misuse to the Scottish economy was in excess of £400m per annum. Nearly 50 per cent of this loss was because of premature mortality and the remainder through unemployment and absenteeism from work.
- The indirect costs of supporting research in the NHS in Scotland is met from the Health Budget. It is estimated that every £1 of this support generates another £6 of direct research funding through charities and other research organisations. This spending contributes towards the continued advances in medicines, leading ultimately to improved services for patients. It also provides an incentive to leading medical practitioners to remain (or to relocate) in Scotland, improving the overall quality of the economic output.
- It is estimated that the introduction of new smoke free laws could save up to 1,000 lives through reduced exposure to second hand smoke in addition to lives saved by people giving up smoking as a result of the ban. Reductions in smoking prevalence could also potentially lead to savings for the NHS in Scotland which is estimated to spend £200m a year on treating smoking related diseases. A Regulatory Impact Assessment was published by the Executive in 2005, which suggested that the benefits of a ban on smoking over a 30 year period would amount to over £4bn in NPV terms, compared to the option of continuing with a voluntary approach to prohibiting smoking in public places.
The main role of public expenditure on health should be to provide clinical and community care to all those in need of these services. This is and will continue to be the main aim for NHS Scotland in the future. However, in addition to providing these essential services, the health service has and does play a key role in maintaining and improving the productive potential of Scotland's population and in so doing, contributing to ensure a solid base for the future economic growth of Scotland.
Closing the Opportunity Gap/Promoting Equality
Closing the opportunity gap
- A high level Closing the Opportunity Gap objective for health was announced in July 2004: to increase the rate of improvement of the health status of people living in the most deprived communities, in order to improve their quality of life, including their employability prospects.
- Supporting this Closing the Opportunity Gap objective, a specific health inequalities target was agreed as one of the Health and Community Care targets for SR2004: to reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15% by 2008. Six key indicators have been selected:
These targets are ambitious and stretching given that recent evidence points to an increasing health inequalities gap between most and least affluent, and will require concerted and effective action at local and national level.
- under 75 CHD mortality;
- under 75 cancer mortality;
- adults smoking;
- smoking during pregnancy;
- teenage pregnancy (aged 13 - 15); and
- suicides in young people (aged 10- 24).
- We are currently developing Prevention 2010, this takes forward the recommendations in the Kerr report: that we identify people at risk in deprived communities and actively recruit them into interventions programmes and follow them to ensure progress is effective. The Prevention 2010 Programme will aim to deliver effective health interventions through enhancing primary care services in deprived communities in the context of the new Community Health Partnerships, and will seek to demonstrate that it is possible to engage with people in deprived communities with the long-term aim of reducing deaths and hospital admissions from conditions such as stroke and CHD. The World Health Organisation has stressed the importance of preventing obesity through combined action to tackle the problems of lack of physical activity and poor diet. Scotland is responding to this by driving forward an integrated multi-sectoral implementation of our national Physical Activity and the Scottish Diet Action Plan and the World health Organisation has strongly commended Scotland in adopting this preventive approach and developing a healthy weight policy advice to tackle the rising obesity epidemic, and developing a framework for local health improvement actions by community planning partners.
- Smoking, poor diet, poor mental health, high levels of alcohol consumption and low rates of physical activity are all major contributory factors to chronic ill health and the major causes of morbidity and mortality. National guidelines and programmes will support local partnerships to have a particular focus on positive outcomes around these factors. Action plans on each of these areas have already been published by the Executive and a ban on smoking in public places came into force in spring 2006. In addition to driving forward implementation of smoke-free areas legislation, efforts will be stepped up to reduce the number of smokers in the general population and to close the gap in smoking prevalence between the poorest and the most affluent groups.
- We will devote specific resources as follows:
- £1m per annum until 2009-10 for the Glasgow Centre for Population Health;
- £9m for 2005-08 for Phase 2 of the three National Health Demonstration Projects and associated Learning Networks, all with a clear focus on tackling health inequalities;
- Up to £25m for 2005-08 for the Prevention 2010 Programme, providing additional resources to strengthen primary care in deprived communities and national support for the Programme;
- £6m between 2006-08 for implementation of smoke-free legislation
- £20m between 2006-08 for smoking cessation activity
- Health improvement activity is funded through a range of SEHD and Executive programmes, many of which will impact both directly and indirectly on tackling health inequalities.
- In addition to traditional health improvement activity, NHSScotland also recognises that employment is a key contributor to good health. This factor coupled with a genuine recruitment need has led a number of NHSScotland employers, with the support of SEHD, to develop structured routes to employment for economically inactive citizens. Current schemes target claimants of Incapacity Benefit, Income Support, Jobseekers allowance and people with refugee status, but are open to any one who is not working or is in low paid/low skilled work. The courses are designed to enable participants to compete for vacancies on a level playing field. NHS Boards are being encouraged to develop courses appropriate to their local circumstances to ensure that equality of employment opportunity exists.
- Closing the Opportunity Gap also means that the NHS needs to respond effectively to the individual circumstances of people's lives - including age, gender, ethnicity, disability, religion, sexual orientation, mental health, economic, location or other circumstance - so that all individuals are treated in a fair and sensitive way, and can access the right health services for their needs. This is central to our commitment to social justice and the need to bridge the opportunity gap for all.
- The Fair for All approach was initially developed to ensure that the needs of ethnic minorities and refugees were effectively met. We are committed to ensuring an effective approach across the NHS to delivering all of the equality strands, including race, disability, gender and sexual orientation, to ensure that health services respond sensitively to individual needs. The NHS Reform (Scotland) Act 2004 now underpins this commitment by placing a specific duty on NHS Boards to promote equality of opportunity.
- We will raise awareness of equality and diversity issues in the workplace and promote accessible recruitment methods. This will allow us to offer improved equality of employment opportunity. Attracting a wider pool of talent for NHS vacancies and improving retention rates will help us ensure that the workforce reflects the local community which in turn assists in the delivery of a culturally sensitive service which is responsive to the needs of the public and our patients.
- By 2008 we will increase the number of older people receiving intensive home care to 30% of all people receiving long term care.
- Our National Health: A Plan for Action, a Plan for Change describes how "we will achieve over time, our core aims of building a national effort to improve health, reduce inequalities in health and make the NHS a national health service not a national illness service". This is an integral part of sustainable development. To help develop a sustainable workforce the Health Portfolio is encouraging men to take a greater interest in their own health by providing support services including the development of well man clinics.
- Initial analysis of the data identified in the pilot on smoking prevention and cessation underlines a marked difference in the response of girls and boys. Since 2000, the number of 15 year old boys smoking has remained significantly lower, at around 15%, than that of girls at around 24%. Our commitment to equality will be enhanced by utilising information from the pilots to identify gender differences and inform resource allocation. In addition, by making the link between objectives like smoking prevention and cessation and increasing participation in sport, we will be better able to link policy priorities, resource allocation and implementation strategies.
- NHSScotland has a target for 2% per annum reduction in climatically adjusted energy consumption over the 9 year period 2001-2010. The NHSScotland Property and Environment Forum are introducing web-based environment data gathering software which will facilitate the benchmarking of water and effluent consumption. Indications are that savings of up to £3m may be achievable if benchmark consumption levels are met.
- Our commitment is to develop Scotland as a health improving environment, including the Health Promoting NHS, identified in the Health Improvement Challenge which complements and can add value to sustainable development. These agendas combine to deliver shared goals such as providing opportunities for walking and cycling and influencing food distribution and food provision outcomes. The NHS has a major role to play as an exemplary manager of its estates, contracts and staff, to be a force for change for a significant proportion of the population.
- Ensure that NHS Estates Policy addresses access to services that also promote walking and cycling including building planning as well as outdoor space planning.
- Building on learning from experience in food provision in schools, introduction of standards for food in the NHS supported by specifications for food purchased and procured in the public sector.
- Development of NHS procurement to allow opportunities for provision of fresh local food.
- Development of the NHS as a health promoting workplace and NHS outlets as health promoting environments.
- Outside the NHS, we will continue to co-ordinate and lead work across Government and delivery sectors to improve food and health, and opportunities for people to be physically active as part of normal daily life. Led by Cross-Government Ministerial Councils for Food and Health and Physical Activity. Environment and Transport Departments are involved to ensure health benefits are integrated into transport and environment policy and vice versa
- Continue productive joint working between the health and education sectors to support the further development of health promoting schools through action to further develop whole school approaches to food and physical activity and to promote emotional well-being and good mental health.
- Continue to work with NHS Scotland and other partners to drive forward the tobacco control agenda including through implementation of smoke-free legislation.
- NHSScotland's annual expenditure on waste disposal is currently in excess of £8m - the cost of 400 full time equivalent nurses. NHSScotland disposes of over 45,000 tonnes of waste each year of which 15,000 tonnes is categorised as clinical waste. Low/ medium clinical waste disposal costs are approximately six times more than domestic waste on a weight by weight basis. The introduction of landfill tax reinforces the need to minimise the amount of waste sent to landfill sites by better segregation and recycling policy. NHSScotland Boards have in place plans to achieve reductions in the amount of waste.
- It is our policy to ensure that all NHSScotland bodies as an integral part of the commitment to the health and well being of the community do the utmost to ensure that all activities are sustainable. To deliver on this commitment all NHSScotland Bodies must have in place effective environmental management systems through which the environmental performance of property assets can be monitored and improved. NHSScotland's Property and Environment forum has developed an ISO14001 compliant system, known as Greencode. ISO 14001 is the international environmental management system standard. Greencode and the recently developed Corporate Greencode system which enables waste, fuel, energy and water use to be monitored at NHS Board level demonstrates our commitment to supporting NHSScotland in achieving a healthier environment and a healthier population.
Health continues to make significant contributions to the 3 Year Efficient Government Efficiency Programme. Over the life of this programme Health and Community Care will release over £1.1billion of efficiency savings. All savings will continue to be retained within individual board areas and will be ploughed back into the NHS to supplement announced spending. The table below provides a breakdown of savings initiatives identified to date and their respective cumulative savings targets year on year.
Total Aggregate Savings £'m
NHS Support Services Reform
NHS Efficiency Savings
Facilities Management Systems
Care Commission Efficiency Savings
Reduction in Absence
Increasing Consultant Productivity
Scottish Primary Care Collaborative
Specialty Redesign Projects
Patient Focussed Booking
Electronic Transmission of Lab Results to GPs
Digital X-rays/ PACS
Countering NHS Fraud
Total Health and Community Care Savings
National Health Service
In their report on Stage 2 of the 2006-07 budget process, the Finance Committee made a recommendation that the spending assumptions for differing forms of care on which the block allocations to NHS Boards is made should be published in the Health Chapter. The Special Adviser and the SEHD Department Director of Finance met and agreed that this information should be provided and that SEHD will aim to include it in the 2008-08 Draft Budget.
Spending plans 2002-08
Table 8.03 More detailed categories of spending (Level 3)
NHS Board Unified Budgets 1
Argyll & Clyde NHS Board 2
Ayrshire & Arran NHS Board
Borders NHS Board
Dumfries & Galloway NHS Board
Fife NHS Board
Forth Valley NHS Board
Grampian NHS Board
Greater Glasgow NHS Board
Highland NHS Board
Lanarkshire NHS Board
Lothian NHS Board
Orkney NHS Board
Shetland NHS Board
Tayside NHS Board
Western Isles NHS Board
Special Health Board Unified Budgets 1
National Waiting Times Centre
Scottish Ambulance Service
Common Services Agency
NHS Quality Improvement Scotland
NHS Education for Scotland
NHS Health Scotland
Total available for NHS and Special Health Boards
Cancer Services 3
Coronary Heart Disease/Stroke
Joint Improvement Team 4
Drug Misuse expenditure by NHS Boards 5
Audiology services modernisation
Centre for Change and Innovation
Education and training
Education & Training
Primary care services
General Medical Services 6
General Dental Services
General Ophthalmic Services
Resources still to be allocated for primary care services 7
Information Technology - revenue
NHS Central Register
Waiting Times Co-ordinating Unit
Clinical workforce redesign
Miscellaneous Hospital & Community Health Services
National Health Service receipts
Departmental Unallocated Provision
1.Indicative allocations for 2007-08 are not yet available because the Arbuthnott formula will require to be updated for in-year changes.
2. NHS Argyll and Clyde was dissolved on 1 April 2006 and its functions were split between NHS Greater Glasgow and NHS Highland.
3.From 2005-06 expenditure on cancer services has been included within NHS Board Unified Budgets.
4.The Joint improvement Team was formerly part of the delayed discharge programme line.
5.Policy and financial responsibility for drugs transferred to the Justice Department during 2005-06.
6.From 2006-07 General Medical Services has been included within NHS Board Unified Budgets
7.Individual allocations for demand led services have still to be decided. The resources available include the financial commitment made by the Executive in relation to the Action Plan for Improving Oral Health and Modernising NHS Dental Services.
What the budget does
Delivering for Health, our action plan for NHS Scotland, builds on the analysis in the National Framework for Service Change of the changing nature of demand for health services in the longer term. Despite the general age for age improvement in the health of the population of Scotland a number of issues must be addressed, including the combination of an aging population and the growth in long term conditions; the trend of rising emergency admissions among older people; and the growing divergence in life expectancy.
NHS Scotland must respond to these factors by changing the balance of services it provides, not by providing simply "more of the same". By providing clearly defined commitments, clear responsibilities and effective mechanisms to hold the service to account, Delivering for Health is driving that change of direction. NHS Scotland will shift towards preventive medicine; towards more continuous care in the community, with targeting of resources and anticipatory care towards those at greatest risk; strengthening local services; providing more support for self care; intensive case management for those vulnerable to emergency hospitalisation; and with more local diagnosis and treatment.
The key actions can be summarised as:
Delivering for Health
reduce the health gap
(the inequality in life expectancy across Scotland)
- developing and delivering anticipatory care for those 'at risk' wherever they live
- increasing health care services delivered in disadvantaged communities
enable people with long-term conditions to live healthy lives
- increasing support for self care
- anticipating the needs of vulnerable people
- identifying those people at greatest risk of hospital admission and providing them with earlier care to prevent deterioration of health and reduce emergency admissions
establish new health and social care services in communities
- prioritising investment in local services, including Community Health Centres that deliver diagnostic and day case treatment
- developing practitioners with extended roles
- fully utilising the skills of all professionals through stronger teamwork in Community Health Partnerships
accelerate improvements in mental health services
- identifying priorities for investment in a delivery plan that builds on our Framework for Mental Health in Scotland
build on recent progress on waiting times
- delivering our waiting time commitments
ensure that wherever people need care, their medical history is available to the service provider
- implementing a national information and communication technology system, including an Electronic Health Record
streamline unscheduled (emergency) hospital care
- delivering services locally in Community Casualty Units when it is safe to do so, and in well-resourced Emergency Centres when it is necessary to do so
separate planned from unscheduled care
- making day case surgery the norm
remove bottlenecks in diagnostic services
- delivering on our diagnostic waiting time commitments for 2008
- increasing the range of locally available diagnostic services
apply a systematic approach to decisions regarding the concentration of specialist services
- basing our decisions on National Framework recommendations
strengthen health care in remote and rural areas
- establishing the Scottish Centre for Telehealth
- identifying what services can be safely delivered in Rural General Hospitals
- educating and training health care professionals with specialist skills for practice in those hospitals
decide where national specialist services such as neurosurgery and neuroscience and tertiary paediatric services should be provided
- aiming to make the best use of valuable specialist skills, and delivering services of the highest quality
We will harness the nursing and midwifery contribution to Delivering for Health by implementing Delivering Care, Delivering Health Action Plan:
- Ensuring caring is the essence of nursing and midwifery practice with patients, families and carers the central focus
- Developing the Capability of staff, equipping them with the skills and knowledge and to deliver services in a different way
- Growing the workforce that will enable sustainability of services
We will support the implementation of the Action Plan flowing from the review of the AHP Strategy including the implementation of the AHP Workload measurement/management publication.
We will support the implementation of the Rehabilitation Framework and the Action Plan for Healthcare Scientists.
Research represents an important investment in the future delivery of health and healthcare. Research must be underpinned by an environment in which research can flourish - this means ongoing investment to:
- support the existing disproportionately successful Scottish science base;
- encourage the translation of more basic science to address healthcare needs;
- support innovative treatments in the NHS for patient benefit; and
- generate income by providing the infrastructure which attracts commercial trials.
We will continue to invest in these areas in 2007-2008 through the following.
The formula-based Support for Science budget meets the additional clinical costs incurred in the NHS while undertaking non-commercial research funded by external partner organisations, general R&D management and other costs relating to undertaking and sustaining research in the National Health Service in Scotland. The Chief Scientist Office ( CSO) will continue to allocate these resources to NHS Boards in 2007-08 (~ £29m) in direct proportion to the volume of research undertaken. This ensures that funds are flexibly and appropriately allocated according to outputs.
Research in the NHS which does not have an external funder is supported by CSO through the NHS Priorities and Needs budget. In order to give this work an appropriate degree of focus and management, this work has been arranged into Programmes of research in clinical priority areas of NHS need with funding totalling in excess of £10m. Following evaluation, agreed Programmes of research will continue to be monitored in 2007-08.
CSO will also continue to progress Scotland's involvement in the United Kingdom Clinical Research Collaboration ( UKCRC), a partnership of organisations working to create a clinical research environment that will benefit patients and the public by improving national health and increasing national wealth.
The main focus of the new investment awarded for this initiative in Scotland to date has been the establishment of Scottish clinical research networks in the areas of medicines for children, diabetes, stroke and mental health, and additional investment in infrastructure in the NHS to support the clinical research flowing from these networks and in other areas. Key outputs for these new activities, which will be closely monitored in 2007-2008, will be an increase in participation in clinical studies, an increase in patient recruitment, and the attraction of both commercial and non-commercial external funding.
Involving the public
The NHS Reform (Scotland) Act 2004 placed two new statutory duties on NHS Boards to promote equal opportunities in all their functions and to involve the public and patients in the planning and delivery of NHS services. Boards are expected to demonstrate year-on-year improvements in the delivery of these new duties as demonstrated in the annual reports of the Scottish Health Council. This year the Minister used the Council's independent assessment as a basis for discussion with a representative group of patients prior to each Board's annual review.
Reducing the maximum waiting times continues to be one of our key priorities for NHSScotland for two reasons: quality of life and clinical outcomes will be improved overall through shorter waits; and patients consistently say that this is what they want from the NHS.
The Service has already delivered on the Executive's targets of no-one with a guarantee waiting for more than six months for a first outpatient appointment or for in-patient and day-case treatment by the end of 2005. It is also on course to deliver the shorter maximum wait targets of eighteen weeks for a first outpatient appointment and for in-patient and day-case treatment by the end of 2007. For the first time, waiting times targets have been set for key diagnostic tests. From the end of 2007, the maximum waiting time for CT, MRI, Ultrasound and Barium Scans, Upper Endoscopy, Cystoscopy, Sigmoidoscopy and Colonoscopy will be nine weeks. From that date, no patient will wait more than 18 weeks for a first outpatient appointment or for inpatient/day case treatment. The nine-week standards for diagnostic tests will be included within these maximum waiting times - they are not additional.
NHSScotland is consistently delivering the Executive's targets of a maximum wait of 8 weeks for Coronary Angiography and a maximum wait of 18 weeks for Angioplasty and heart bypass surgery. From the end of 2007, no patient will wait more than 16 weeks from GP referral, through a rapid access chest pain clinic or equivalent, to cardiac intervention thereafter. For those patients not presenting with chest pain, from the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment.
Additional condition-specific waiting times targets have also been set for delivery by the end of 2007. From that date, no patient will wait more than 18 weeks from GP or Optometrist referral to cataract surgery and all orthopaedic departments handling trauma cases must ensure that any patient entering a Specialist Orthopaedic Unit for surgery following hip fracture should be operated on within 24 hours of admission.
We have also set a target for patients seen in accident and emergency units. From the end of 2007, patients will wait no longer than 4 hours between arrival at a unit and admission, discharge or transfer. This target will apply to all other unscheduled care in Community Casualty or Minor Injuries Units or areas of assessment units where trolleys are used.
National Waiting Times Centre
The Golden Jubilee National Hospital in Clydebank has played a very important role in providing additional facilities for planned surgery and other patient procedures, and contributing to reductions in waiting times, since it was purchased for the benefit of NHS patients in summer 2002. At that time, it was undertaking 2,500 procedures a year. In 2005-06, the Hospital performed over 28,600 procedures, exceeding its target of 25,000 procedures by 14.5%. This was a 54.7% increase in activity on the previous year. The Hospital has delivered the commitment in fair to all, personal to each to perform 28,000 procedures a year by 2007-08 two years ahead of schedule, and is now working to build on this performance by undertaking over 30,000 procedures in 2006-07.
We also reaffirm our commitment to reduce the numbers of people who remain in hospital when ready for discharge because of a lack of community or home based health or social services. The number of patients inappropriately delayed in hospital for more than six weeks has reduced by 73% since the launch of the Delayed Discharge Action Plan in March 2002. This is a significant improvement and continuing investment in joint NHS/Local authority partnerships is expected to produce further reductions in delayed discharges. The challenge is to plan community care capacity for the future of our ageing population. Partnerships are developing a whole systems approach to tackling the problem to prevent avoidable admissions, facilitate appropriate rehabilitation and improve patient management processes.
Healthcare Associated Infection and Clean Hospitals
Tackling healthcare associated infection ( HAI) in hospitals is a key priority, most importantly in relation to improving patient safety, but also in terms of improving NHS efficiency by freeing up the resources currently spent on avoidable infections (a broad brush estimate of the cost of HAI in Scotland is up to £180,000,000 per annum, or 380,000 bed days lost). Over the last three years, the Healthcare Associated Infection Task Force has developed a range of national policy, guidance and best practice. This includes a groundbreaking Code of Practice; a National Cleaning Services Specification that clearly sets out cleaning requirements and a tool to monitor compliance; and guidance on antibiotic prescribing. This coherent national approach has provided a strong foundation for tackling HAI across Scotland.
The Task Force's new phase of work seeks to achieve a reduction in avoidable HAI by focusing on continuous improvement in infection control practice at a local level. This will involve driving full implementation of the procedures developed in the first phase of work, and ensuring that non-compliance within NHS Boards is highlighted and addressed. The Task Force has already rolled out the National Cleaning Services Specification monitoring tool to NHS Boards and the first report on compliance is due to be published in August 2006. The number of NHS staff completing the Cleanliness Champions Training Programme has increased threefold since August 2005 from 550 to well over 2,000. The Task Force is also developing a national hand hygiene campaign - a key issue in tackling infections at the front line - and a National MRSA Control Strategy. This work is supported by £15 million of funding over three years.
Community based services
Delivering for Health reinforces the overall policy direction that more care should be delivered locally. It underlines that patients should be at the centre of the delivery of responsive care and treatment, with more convenient services delivered more quickly at each stage of the patient's care, with services being as local as possible. As well as shorter waits and greater convenience for patients, the public wants reassurance that services are being delivered safely and sustainably; and communities want to know that services will be available locally wherever possible. Investment is already in place and will continue to support these policies and to boost capacity including infrastructure developments, to improve access and to increase the range of services which can be provided closer to where people live and work.
A fundamental principle for us is that where healthcare services can be provided locally in a safe and effective way, they should be - while accepting that specialised services will often need to be provided in centres of excellence. NHS Scotland's approach can be summarised "as local as possible, as specialised as necessary". Primary care services play a central part in the provision of NHS services to people in their local communities, close to home and close to where they work. For many people, their only experience of the NHS is in primary care, and indeed over 90% of NHS care is provided a primary care setting. Many people rely on their GP practice, their pharmacist, dentist and optometrist to help them stay healthy, to provide treatment when they are ill, and to provide links to other services in the NHS either in the community or in hospitals, the voluntary sector or social care. The scope of professional practice is expanding across the professions which mean that a greater range of care and treatment is available in local settings. For example, nurses and community pharmacists are supporting the development of chronic disease management; and faster access to services is possible through NHS24 which provides telephone access to a health professional 24 hours a day for advice and support.
The Partnership Agreement and the White Paper "Partnership for Care" set out the context for partnership working in Scotland and for the development of Community Health Partnerships ( CHPs). Building better health and social care services around the strengths and needs of Scottish communities underpins the reforms included in the NHS Reform (Scotland) Act 2004 and provides the impetus for a strong Community Health Partnerships agenda.
CHPs are a central plank of the vision set out in Delivering for Health. They are local service delivery mechanisms through which health improvement, and shifts in the balance of care, will be delivered by the NHS, local authorities and the voluntary sector, with greater involvement of service users, carers, staff and independent contractors. They have two key aims:
- Shifting the balance of care to local communities; and
- improving the health of local people and reducing inequalities.
CHPs are fully involved in local NHS strategic planning, priority setting, decision making and resource allocation and play a lead role in wider community planning processes led by local authorities. They have delegated responsibility for all primary and community based services including joint health and social care services and community hospitals and resource centres. CHPs will need to maintain an effective and formal dialogue with their local communities through the development of a local Public Partnership for each CHP.
As well as changes in the organisation of NHS services with the development of 'single systems', including the development of CHPs, there are other significant developments underway as a result of the duty on NHS Boards to provide or secure 'primary medical services' for their population. NHS Boards have increased flexibility to use a range of contractual and delivery mechanisms to ensure primary medical services are developed and delivered in ways which reflect local circumstances and priorities.
The changes described above are complemented by modernised contracting arrangements in other areas of primary care; as well as strategic development of the infrastructure which supports an expanded range of services provided more locally. Examples of key areas of activity are given below. In all of these arrangements there is a greater focus on quality and the appropriate deployment of professional skills through teamwork.
The Right Medicine: A Strategy for Pharmaceutical Care in Scotland (Scottish Executive, 2002) provides a strategic framework for the development of community pharmacy including new contractual arrangements underpinned by an e-pharmacy programme. The drugs bill continues to be an area of significant activity in order to manage expenditure.
Oral Health and Dentistry
The Executive will continue to implement the measures outlined in An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland. The measures contained in the Action Plan aim to address Scotland's poor oral health record, provide better access for patients and provide an attractive package for the professional staff that the Executive wish to recruit to, and retain within, the NHS. Implementing these changes involves increased investment in NHS services and new and additional funding of £150m over the three years 2005 - 2008 has been provided for this purposes. Since 1 April 2006 the Executive had been delivering the Partnership Agreement commitment to provide free dental checks for all by 2007. From that date the dental examination which was previously chargeable has been provided free.
SEHD is addressing the shortfall in the number of dentists in some areas of Scotland. The number of dental students in Scotland has been increased and a range of recruitment and retention measures has been put in place to increase the dental workforce in NSSScotland, including golden hello payments. These payments range from an allowance of up to £6,000 to each newly qualified taking up their vocational training year in Scotland to an allowance of up to £20,000 over two years to dentists entering substantive general dental service in Scotland within three months of completion of training.. The increase in dental training capacity will be supported by more outreach training throughout Scotland, for example, the establishment of new outreach training centres in Aberdeen and Dumfries & Galloway. Through the dental action plan substantial new financial support of £150m over 3 years has been made available to improve oral health and modernise NHS dental services.
The final report of the Review of Eyecare Services in Scotland will be published in 2006-07. The aim of the Review is to encourage the development of integrated eyecare services to ensure patients receive a good quality and effective service, in a convenient setting without undue wait.
Since 1 April 2006 the Executive had been delivering the Partnership Agreement commitment to provide free eye checks for all by 2007. The free NHS eye examination which has been introduced extends the scope of the previous sight test to an examination which is tailored to the needs and symptoms of patients and allows them to receive, free of charge, an appropriate health assessment of their whole visual system. The eye examination will include a sight test where required.
A Review of Community Hospitals is currently underway. The purpose of the review is to address the Partnership Agreement commitment to develop the important role of community hospitals, and to develop a strategy for sustaining small, rural and community hospitals where they are safe and effective, including the provision of minor surgery, rehabilitation services and a resource for practitioners with special interests. The Review of Community Hospitals will thus support the implementation of significant elements of Delivering for Health.
Significant additional resource is planned to support the introduction of a comprehensive health information system built around an Electronic Health Records outlined in Delivering for Health. This will require investment in an infrastructure to support the Electronic Health Record including improved broadband network services, access to flexible workstation facilities such as wireless notepads, patient and staff authentication facilities and resilient all day, every day systems delivery. We will build on and exploit systems already in place and take national procurement action to fill gaps in systems supporting the sharing of information, with unified databases, effective communications links and standardised protocols, All of this is needed to support resource allocation in support of patient care and best care practice by multi disciplinary teams.
Information management and technology ( IM&T)
The provision of more services in the community means that the infrastructure has to be safe and clinically appropriate, provided in accordance with legislative requirements and good practice guidance, accessible for patients, their carers and the public. In addition to local investment, which is delivering an increasing number of new purpose built primary care facilities continued investment will further support joint working projects, 'community health service centre' projects, new 'dental centres' and premises extensions/improvements to support GP training. Work also continues in relation to IM&T to enhance patient care and support staff. For example, a functionality upgrade programme for GPIT is well underway, and the burden on GPs to provide and maintain infrastructure has been taken on by Health Boards. Almost all (99.8%) practices are computerised with supporting systems and the infrastructure to support and exploit electronic patient records in primary care is continually being enhanced, for instance by investment in scanners to help practices go paper light, phasing in of a generally available emergency care summary, ongoing work to improve the process for transferring patient records, and investment in the e-pharmacy programme. This is all designed to pave the way towards the introduction of an electronic health record accessible to all clinicians, not just those in primary care.
Developing a more flexible workforce has implications for public protection, necessitating clarity around roles and responsibilities of staff, employers and regulators. See Workforce Regulation
The implementation of pay modernisation through the new Consultant and GMS contracts and Agenda for Change represents a major investment in our NHS workforce. These three strands share a common goal - to reward, motivate, and free up staff to deliver re-designed and improved services to patients. We expect delivery of these contracts to link closely with the Department's overall policy objectives for NHS Scotland with a particular focus on improved productivity, enhanced services to the public, service re-design around the needs of patients and carers, improved recruitment and retention and improved management and development of staff.
Pay modernisation is a toolkit which helps and supports systems to deliver on a wide range of key NHS priorities in securing sustainable, safe, and effective changes to service provision. It is also a driver for positive culture change in the NHS in behaviours, attitudes, and ways of working which will be of long term benefit to both staff and patients. Health Boards are required to provide Pay Modernisation Benefits Realisation Plans which will demonstrate how they are using the new contractual arrangements to support both the delivery of key targets and "Delivery for Health". This planning process which requires updates every 6 months, is now well established.
Agenda for Change commenced implementation in December 2004. The current focus is on matching and evaluating and assimilating over 140,000 NHS Scotland staff to the new system. The size and complexity of this task is acknowledged, as is the level of commitment demonstrated by those in NHS Scotland, both staff and management, who have been working together in partnership to bring in the new arrangements. The Scottish Pay Reference and Implementation Group is tracking progress on a monthly basis and providing support and assistance to Boards as they introduce the new system.
A clear timetable for completing the introduction of Agenda for Change across NHS Scotland by December 2006 has now been established, and progress towards delivery is actively monitored.
The new Consultant Contract was introduced from 1 April 2004 and over 95% of consultants now have agreed job plans. There is now emerging evidence through the Pay Modernisation Process of positive change flowing from the job planning processes associated with the contract, including more efficient use of consultant resource for the benefit of patient care. There are no significant additional cost pressures, beyond the identified pay inflation and pay scale progression from the Consultants contract anticipated for 2007-08.
The nGMS Contract was also fully introduced from 1 April 2004. The new contract encourages recruitment and retention in the GP workforce through better management of GP workload, investment in primary care infrastructure, and by transferring responsibility for out-of-hours services to Health Boards.
This contract also links GP payments to the quality of care that they provide for patients, through the Quality and Outcomes Framework (QoF). This Framework is realising significant benefits for patient care and clinical outcomes in the primary care sector. General Practitioners in Scotland have showed a high level of achievement in the provision of quality care to patients across Scotland, a reflection of considerable improvements made by practices over the previous year.
The Contract was reviewed on a UK-wide basis, and a revised set of arrangements were put in place from April 2006; some further changes are anticipated in 2007-08.
The NHS is here to deliver healthcare services that meet patients needs, however in order to do any of that, it needs people to deliver those services. People with the right training, skills, competence in the right place at the right time. Scotland's diverse and ageing population mean that there will be more work to do and more work that will require to be carried out differently. A changing workforce demographic provides us with an opportunity to reach out to non traditional recruits and take steps to ensure our employment and learning opportunities support the development of a workforce that is reflective of the population at all levels, there by improving our decision making processes and ultimately the services that we provide.
Workforce planning is complex and challenging especially in a changing environment but that makes it all the more important. The budget supports capacity for workforce planning in NHS Boards, and in the 3 workforce planning regions that have been established, to build on the progress achieved to date and improve the robustness and amplitude of the workforce planning function in NHS Scotland. At national level, the information from NHS Board and regional workforce plans will be used to populate the national workforce plan, inform future supply needs, and as a basis for setting training numbers.
Scotland is working with the other UK countries to regulate healthcare professionals across the UK, with the primary objective to improve patient safety. Scotland's continuing aim will be to ensure that any regulatory legislation supports the development of new roles and expansion of practice of existing professional groups to meet the specific needs of the devolved health service.
Scotland is leading a project on regulating Healthcare Support Workers through an employer-led regulatory model and a centrally held list. This will be piloted in three NHS Board areas from January 2007 and complemented by a concurrent action research project.
Future regulation will be influenced by the outcome of the DHUK-wide consultation on its reviews of medical and non-medical regulation. The implications will be fully considered with stakeholders for a Scottish Executive response. There is likely to be a stronger future role for NHS employers.
Medical Education Issues
The Modernising Medical Careers ( MMC) reforms of postgraduate medical education seek to provide better and more focussed training for doctors in future, meaning that less time is wasted during training so that doctors achieve their Certificate of Completion of Training in the fastest possible time. NHS Boards have been tasked to assess the local service delivery and financial impact of MMC, to determine the solutions required to maintain service continuity during the implementation phase and secure the long term sustainability of medical services.
Education Learning and Careers
The education and learning policy framework will be implementation and we will work with NHS Education for Scotland to ensure commissioned learning and education is fit for purpose and cost effective. We will launch the Career Framework which aims to provide staff with a coherent career pathway and the NHS with a flexible workforce. The career framework, in conjunction with the drive towards modernising healthcare careers, promotes the transferability of roles; skills competences and educational qualifications across the NHS. Opportunities for learning and development will be linked to the implementation of Personal Development Plans and the introduction of the Knowledge and Skills Framework. There are practical tools available that enable KSF outlines to be built into Personal Development Plans through health sector workforce competences.
Reputation and Attraction
The reputation of NHSScotland is to a large extent dependent on the experiences of staff and customers and therefore it is important that NHS staff understand the impact of their behaviours and the need to ensure policies promote equality and inclusion. We will continue to promote working in the NHS as a desirable career and develop NHS Scotland as an exemplar employer to best position Health Boards in the global labour market and enhance capacity to recruit staff.
Consultant 600 budget
We will continue to work with health boards to increase, where appropriate, the number of medical consultants working in the NHS, in the context of the wider impacts of delivering for health, the impact of modernising medical careers and service.
UK Medical Bodies
The Scottish Executive Health Department contributes a pro rata share of financial support to the Postgraduate Medical Education and Training Board, which is the statutory UK body responsible for setting and ensuring appropriate standards of post-graduate medical education and training and approving changes to the curriculum.
Children and young people
We will continue to support the outcomes from the Cabinet Delivery Group for Children and Young People and support the development of Integrated Children's Services Plans. Key initiatives at a national level include Getting it Right for Every Child and the child protection reform agenda and the implementation of joint inspection arrangements for children services by 2008.
To support this we will deliver an Action Framework for Children and Young People's Health in Scotland which will include health improvement, community based care, tertiary services, secondary care, Health for all Children (Hall4), children and adolescent mental health services, emergency care, workforce, public involvement, performance management and the interface with he integrated children's services agenda.
We have also established a National Steering Group for Specialist Children's Services which is expected to review current provision and produce a National Delivery Plan by the autumn of 2007. This will include proposals for a national and regional network for the delivery of specialist services in Scotland.
We are establishing a Ministerial Action Group on Maternity Services which will take forward work focusing particularly on neonatal services, models of maternity care and integrated working, transport issues, workforce and regional planning of maternity services.
We will issue an Infant Feeding Strategy for Scotland that will reflect outcomes of the 2005 public consultation on the draft strategy. We will also be proceeding with work originating from the recent review of infertility services in Scotland.
The Department places high priority on working effectively with NHS Boards and others to secure delivery of Ministers' priorities and objectives. A number of actions have been taken to increase the effectiveness of NHS Boards and to ensure that they are responsive not only to policy priorities but also to the needs and circumstances of their local residents. For example:
- single system working is now bedded in across all NHS Boards, helping to streamline management and accountability arrangements and improve integration between phases of care;
- Community Health Partnerships have been established, connecting primary and community care planning and delivery more closely to the communities they serve;
- Boards have been supported to strengthen regional planning arrangements so that better integrated approaches can be taken to planning and delivering more specialised services such as cancer, CHD and some mental health services.
In addition, the Department has introduced a number of changes designed to support delivery-focused planning and performance in Boards. In 2005, Boards were asked to complete the first Local Delivery Plans looking forward to 2006-07 and the 2 subsequent years. The plans focus on a clearly-defined set of key measures and targets, including financial targets, and Boards are required to provide planned profiles for each measure, demonstrating how Ministers' key targets will be met and against which actual performance is tracked through the year. The plans are made public by Boards. All plans were reviewed and accepted by the Department by May 2006.
Within the Department, a new Directorate of Delivery has been established, drawing together performance management, improvement and support, analysis, planning and access support functions. The new Directorate is able to take a more integrated view of performance of individual Boards and of the NHS across Scotland as a whole. It can offer resources and other support to Boards if performance departs materially from planned levels or other risks to the delivery of Ministers' objectives emerge. The Directorate also has a role within the Department in assisting HD business areas to develop effective strategies for delivering new and existing policies.
The Directorate of Delivery, through the Improvement and Support function, is playing a key role in helping Boards redesign and improve services to enable them to meet Ministers' new, tougher access targets for the benefit of all patients. For example, collaborative work streams are helping to improve performance to meet the 4-hour maximum wait target for Accident and Emergency services, and the 9-week maximum wait target for diagnostic tests. Boards must meet both targets by the end of 2007.
Our approach continues to be about enabling and encouraging continuous improvement and good performance. The Annual Review process, which sees the Health Minister meet the chair of each Board and his senior colleagues, in public, for a discussion about past performance and future challenges, enables Ministers to highlight to individual NHS Boards areas where performance must be improved. Resources can be allocated to particular issues and conditions attached to the use of resources. Where there is poor performance that threatens service quality to patients or significantly increases the risk of a Board failing to achieve Ministers' targets, a range of interventions are sanctions is available. For example, Ministers may choose to send in a task force or a support team to help rectify issues in particular problem areas. Minister can also of course, replace the Chair or non-Executive directors of NHS Boards.
Improving the quality of healthcare is a key element in the Department's approach. This involves improving the quality of health care by raising the standards of all to those of the best. NHS Quality Improvement Scotland is leading this agenda. This involves giving advice and support to the NHS, and the development of national standards and inspections against those standards. The work of NHS Quality Improvement Scotland relates both to specific clinical conditions and to standards for key performance areas such as clinical governance and risk management, nutrition and hospital acquired infection. NHS Quality Improvement Scotland has developed a quality assurance framework to ensure that managed clinical networks - which have a vital role to play in delivering improved services and care - are effective. NHS Quality Improvement Scotland also has a major focus on ensuring patient safety, and ensuring that robust systems are in place to achieve this.
Other Health Services
Spending plans 2002-08
Table 8.04 More detailed categories of spending (Level 3)
Training for Prosthetists & Orthotists
Grants to Voluntary Bodies
Miscellaneous Other Health Services
Mental Health Act Implementation
Scottish Low Income Scheme Administration
Other Health Service receipts
1. Welfare foods has been transferred from Other Health Services to Health Improvement.
2. Genetic Services is now included within the Public Health and Workplace Health line within Health Improvement.
What the budget does
The Chief Scientist Office ( CSO) Research Budget promotes high quality research with the aim of improving health and health services for the people of Scotland. Typically, at any one time, CSO is directly supporting over 200 research projects in areas of NHS need, with an emphasis on, but not exclusive to, health priority areas. Projects examine questions about service delivery, prevention of disease and the effectiveness of both diagnosis and treatments. In addition, 7 research Units each pursue larger programmes of research in areas such as public health, health services research and health economics. These are regarded as an essential component of CSO's provision for conducting and developing capacity to conduct research. They are subject to quinquennial strategic and scientific reviews. CSO also helps to develop research capacity by providing funds for talented individuals through a range of research training fellowship and postgraduate studentship awards.
In 2007-08, research resources will be focused on:
- funding research projects and programmes of research with direct relevance to the Health Service with particular emphasis on research priority areas and on new science based approaches to the prevention, diagnosis and treatment of disease;
- advancing population research, in particular by co-funding the Genetics & Healthcare Initiative, now known as 'Generation Scotland', which focuses on the genetic base of common diseases which have a major impact on public health in Scotland. Participation into this family based study will continue in 2007-2008 with the aim of recruiting 50,000 individuals (aged 35-55 years) over 5 years with a cohort of 15,000 in the initial 2 year feasibility study;
- supporting the development of a highly skilled research workforce in Scotland by:
- funding a new scheme for approximately 6 pre-doctoral level fellowships per year leading to the attainment of a PhD (or MD) as part of a package of measures in Scotland to support the UKCRC Modernising Medical Careers Initiative,
- co-funding an £8m partnership initiative between SHEFC, NES and the Health Department for research capacity building amongst nursing, midwifery and allied health professionals.
Mental Health Act Implementation
The Mental Health Act implementation funding, which includes expenditure by the Mental Welfare Commission, continues to support various aspects of the implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003. This includes publication of the Code of Practice and topic guides on the Act; the Mental Health Tribunal for Scotland (which hears applications for and appeals against compulsion) and research into the operation of the new Act. These resources help ensure that partner agencies combine to deliver the benefits for service users and carers set out in the Act.
The Mental Welfare Commission for Scotland protects the interests of people with mental disorders by conducting inquiries, hospital visits, and meeting with patients, relatives and carers, and people subject to Community Care and Guardianship Orders.
We will continue to support further development and improvement of mental health services with a focus on promotion, prevention, protection, quality, care and recovery from settings that span a spectrum from specialist hospital care to care in people's own homes and communities.
Spending plans 2002-08
Table 8.05 More detailed categories of spending (Level 3)
Health improvement strategy 1
Tobacco control 2
Alcohol misuse 2
Public health and workplace health 3
Mental wellbeing 4
Welfare Foods 5
1. In addition to the above directly funded expenditure, significant spending on health improvement is carried out by NHS Boards through their unified budgets.
2. Prior to 2005-06 expenditure on smoking and alcohol misuse was not separately identified.
3. This line has gradually been expanded to include a number of other budgets including Genetic service which was previously shown separately under Other Health Services.
4. The "Mental wellbeing" figures for 2003-06 do not include funding allocations to Local Authorities, which were held on behalf of Community Planning Partners for local actions in support of the 'Choose Life' Suicide Prevention Strategy. This funding was transferred to Local Government Finance Division as part of General Allocated Expenditure. Budget figures for 2006-08, however, include the £3.198m of 'Choose Life' funds which will be held by Mental Health Division.
5. Welfare food expenditure was previously shown under Other Health Services
What the budget does
The overall strategy for health improvement was set out in Improving Health in Scotland: The Challenge. The strategy includes:
- a programme of co-ordinated action aimed at improving life expectancy by addressing life circumstances, lifestyle risk factors and priority health topics;
- better communication, higher profile and more focused delivery; and
- sustained action across four key settings: the early years, the teenage transition, health of working age people and community based health improvement.
The Challenge also has an overarching aim of tackling the health inequalities that persist in Scotland.
Successful improvement in health requires complex, multi-stranded actions to: promote safer, healthier lifestyles; improve diet and levels of physical activity; tackle the problem of alcohol abuse; address the health of homeless people; improve mental health and well-being, and co-ordinate initiatives to promote good physical and mental health in the workplace.
The Prevention 2010 programme, also discussed in the "Closing the Opportunity Gap" section, takes forward Delivering for Health recommendation that the health service actively targets those at high risk of ill health and provide early interventions designed to prevent a deterioration in their condition. The programme's pilots (receiving up to £25 million between 2005-08) will seek to demonstrate that it is possible to engage with people in deprived communities with the long-term aim of reducing deaths and hospital admissions from conditions such as stroke and CHD
Along with the Scottish Executive, the NHS including NHS Health Scotland, COSLA, local government, the voluntary sector, the private sector and Community Planning Partnerships have key responsibilities to lead this programme and deliver services both alone and in partnership to improve health.
We will continue to support community planning as the key framework for developing a joint plan for health improvement in a local authority area. Working in partnership with NHS, local authorities will lead the development of Joint Health Improvement Plans and will include input from all Community Planning Partners. NHS boards' local health plans may incorporate one or several joint health improvement plans. NHS Local Health Plans will also reflect regeneration outcome agreement priorities.
Similarly, the views of health professionals and a range of stakeholders are helping to shape the scope and structure of a reorganisation of health protection arrangements in Scotland. This reorganisation has been caused primarily by the need to ensure a cohesive, integrated response to the major health problems caused by exposure to biological, chemical, radiological and physical hazards and the challenges of new and re-emerging infections.
Towards the end of 2006, the current Welfare Food Scheme will be replaced throughout the UK by a new scheme called Healthy Start. Under this new scheme, pregnant women and families from low-income groups and all pregnant women under 18 years old will receive vouchers which can be redeemed for milk, fresh fruit and vegetables and infant formula from their local shops. Vouchers can be used in a wide range of participating shops and pharmacies. The Welfare Food Scheme tokens could only be exchanged for milk and infant formula but the new scheme offers much more flexibility and choice. Breastfeeding and non-breastfeeding mothers are set to benefit equally from the scheme.
Spending plans 2002-08
Table 8.06 More detailed categories of spending (Level 3)
Grants to the voluntary sector
Scottish Commission for the Regulation of Care
Mental Health Specific Grant
What the budget does
We are committed to delivering a wider variety of flexible person-centred care services to help more people live independently for longer within the community, and so improve social inclusion. We have set out four national outcomes for which local partnerships are developing local improvement targets. We continue to support local authorities and the NHS in driving forward the Joint Future agenda and to reduce delayed discharges.
Local Authorities spend around £1.7 billion a year on these services, of which around £1 billion a year is on older people (65 or over), and employ 35,400 staff in adult Community Care services. Additional provision is being made available for local authorities through the GAE baseline for health and community care. This will provide significant extra resources for services for older people, whose numbers are expected to increase quite quickly in the years ahead.
With the pressures of an ageing population, we will continue to invest in social care services, through local authorities and the voluntary sector, with the aim of delivering a wider variety of flexible person-centred services to help more people live independently for longer in their own homes or in sheltered housing, to support family carers and to reduce inappropriate admissions and inappropriate length of stay in hospitals. At any one point in time, local authorities maintain 58,000 older people (65 or over) every day in their own homes with home care services, and support another 33,000 older people (often those over 80) in 970 care homes. They also give services to 22,500 adults with learning disabilities, and support wholly or mainly 1,000 adults with mental health problems in care homes, and give home care services to 3,000 such adults.
The new Social Work Inspection Agency will inspect community care services across Scotland. The Chief Inspector's annual report will inform Ministers of local authorities' progress towards objectives and standards of delivery.
The Executive is continuing to invest in community care services, making provision through Grant Aided Expenditure for an additional £182m of local authority funding in 2007-08, to expand services in response to increasing demand and to support improvements in quality of care.
- £57.5m to meet pressures on care home fees and bring stability to the care home sector.
- £42.0m to provide care for the increasing numbers of older people.
- £27.0m for staff training to improve quality of care and meet new requirements for workforce registration.
- £15.0m to provide faster access to homecare, contributing to the Executive's target of increasing the proportion of older people receiving intensive home care to 30% of all those receiving long term care, by 2008.
- £13.6m to improve the quality of care provided through the voluntary sector, meeting requirements for care standards, and for staff training and development.
- £5.0m to deliver additional services and support for people with learning disabilities in the community, following the resettlement programme set out in The same as you? learning disability review.
- £2.0m to alleviate waiting lists for self directed care through direct payments and increase uptake.
- In relation to the Executive's direct expenditure on community care, as set out in Table 5.06 above:
- The Executive awards grants under Section 10 of the Social Work (Scotland) Act 1968 to support a range of national voluntary sector organisations working in the Community Care field; and
- The Executive supports, through Grant-in-Aid, the Care Commission, which was established on 1 April 2002. The aim of the Commission is to further improve the quality of all care services in Scotland and to put people at the heart of regulation. It registers and regulates services against the provisions of the Regulation of Care (Scotland) Act 2001 taking account of the National Care Standards published by Scottish Ministers. The Commission is also partly financed through fees charged to registered services.
We continue the Mental Health Specific Grant at £20m per year overall (£14m from SEHD and £6m from local authorities) which supports 375 small scale but valued community based mental health projects. These projects and initiatives are mainly provided by the Voluntary Sector and among other provisions include drop-in centres, counselling services, and education and employment schemes.
Other Health and Community Care Related Local Authority Funding
Spending Plans 2002-08
Table 8.07 Local Authority Grant Aided Expenditure ( GAE) Provision for Core Services
Home Based Elderly
Residential Accommodation Elderly
Services for the Disabled
Care Home Fees
Other Health and Community Care
What the budget does
The Health and Community Care Grant Aided Expenditure ( GAE) figures relate to the level of local authority net revenue expenditure on these services that the Executive is supporting through grant. GAEs are not budgets, but rather a basis for the distribution of grant through AEF. Local authorities are, however, free to allocate their available resources to each service, including Health and Community Care, on the basis of local needs and priorities. The figures in this table are included in the GAE summary table (table 7.04) contained within the Finance and Public Service Reform chapter of this document.
Annex A: Health Department Delivery Plan Objectives and Targets
The 2006-2007 Health Department Delivery Plan will focus on the following areas:
The 4 key objectives of the delivery plan are:
- Health Improvement for the people of Scotland - improving life expectancy and healthy life expectancy;
- Efficiency and Government Improvements - continually improve the efficiency and effectiveness of the NHS;
- Access to Services - recognising patients' need for quicker and easier use of NHS services; and
- Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs.
Within these objectives we will be focussing on the following priorities:
Health Improvement for the People of Scotland
- Reduce health inequalities by increasing the rate of improvement for the most deprived communities by 15% across a range of indicators including: CHD, cancer, adult smoking, smoking during pregnancy, teenage pregnancy and suicides in young people: target date 2008.
- To reduce adult (16+) smoking rates from 26.5% (2004) to 22% (2010).
- Reduce incidence of exceeding the weekly alcohol limit of 21 units to 29% for men, and of 14 units to 11% of women: target date 2010.
- 50% of adults (aged 16+) accumulating a minimum of 30 minutes per day of physical activity on 5 or more days per week.
- 95% uptake target for all childhood vaccinations (ongoing).
- Reduce suicide rate between 2002 and 2013 by 20%.
- Reduce by 20% the pregnancy rate (per 1,000 population) in 13-15 year olds from 8.5 in 1995 to 6.8 by 2010.
Efficiency and Governance Improvements
- NHS Boards to operate within their revenue resource limit; operate within their capital resource limit; meet their cash requirement.
- Sickness Absence Rate: 4% by 31 March 2008.
- Productivity: increase in consultant productivity by 1% pa over the next 3 years.
Access to Services
- Ensure that anyone contacting their GP surgery has guaranteed access to a GP, nurse or other health care professional within 48 hours from April 2004.
- 60% of 5 year old children (primary 1) will have no signs of dental disease by 2010.
- No patient with a guarantee should wait longer than 6 months for in-patient or day case treatment from 31 December 2005, reducing to 18 weeks from 31 December 2007.
- By the end of 2005 no patient will wait longer than 6 months from GP referral to an out-patient appointment, reducing to 18 weeks from 31 December 2007.
- By end 2007 no patient will wait more than 4 hours from arrival to discharge or transfer for accident and emergency treatment.
- By end of 2007 the maximum wait for cataract surgery will be 18 weeks from referral to completion of treatment.
- By end of 2007 the maximum wait for admission to a specialist unit for hip surgery following fracture will be 24 hours.
- Women who have breast cancer and need urgent treatment will get it within one month where appropriate.
- By 31 December 2005 no patient urgently referred for cancer treatment should wait more than 2 months.
- From 30 June 2004 the maximum wait from angiography to surgery or angioplasty will be 18 weeks.
- By end 2007 the maximum wait for cardiac intervention will be 16 weeks from GP referral through rapid access chest pain clinic or equivalent.
- By the end of 2007 patients will wait no more than 9 weeks for any MRI or CT scans and other key diagnostic tests.
- From the end of 2007 no patient will wait more than 16 weeks for treatment after they have been seen as an out-patient by a heart specialist and the specialist has recommended treatment.
- By end 2007, 75% of 999 emergency calls responded to within 8 minutes.
Treatment Appropriate to Individuals
- For 2006/07 reduce all delays over 6 weeks by 50% and all delays in short-stay specialties by 50%.
- By April 2008 no one should be delayed for over 6 weeks and no patient should be delayed in short-stay specialties.
- By 2008/09 we will reduce the proportion of older people (aged 65+) who are admitted as an emergency in-patient 2 or more times in a single year by 20% compared with 2004/05.
- Cervical screening target 80% ongoing.
- QIS clinical governance and risk management standards improving.