Health and social care delivery plan: progress report

4 Public Health Improvement

4.1 A shift to prevention, integration, and closer collaboration to deliver improved population health outcomes is one of the central themes of the Plan. The key priorities of the Public Health Improvement pillar are to identify national priorities; establish a new Public Health Body; and to address public health issues including smoking; alcohol; diet and obesity; substance misuse; and mental health.

What we have done

4.2 Scotland's public health priorities have been developed through a process of engagement with stakeholders from across the country. The agreed priorities reflect public health challenges that are important to focus on over the next decade to improve the health of the nation. This process identified six public health priorities for Scotland, where by working together we can improve healthy life expectancy and reduce inequalities, the priorities are:

• A Scotland where we live in vibrant, healthy and safe places and communities.
• A Scotland where we flourish in our early years.
• A Scotland where we have good mental wellbeing.
• A Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs.
• A Scotland where we have a sustainable, inclusive economy with equality of outcomes for all.
• A Scotland where we eat well, have a healthy weight and are physically active.

4.3 Work is well underway with COSLA and SOLACE to develop the new public health body, Public Health Scotland, that will direct public health improvement across the whole of Scotland. It will enable us to make best use of Scotland public health assets - data and intelligence and our public health professionals - in supporting local areas to create the conditions for health and wellbeing.

4.4 Public Health Scotland will be formed from NHS Health Scotland, Health Protection Scotland and Information Services Division of National Services Scotland and will be established during 2019/20. A programme of work has already started on designing the organisation which will be jointly accountable to both Scottish Ministers and COSLA Leaders. This includes the establishment of joint public health partnerships between local authorities, NHS Scotland and others to drive national public health priorities and adopt them to local contexts across the whole of Scotland.

4.5 We have continued the delivery of the ambitious targets we set out in our 2013, with smoking prevalence rates down to 18% according to the latest Scottish Health Survey^[22] (compared to 21% in 2016).

4.6 Smoking is still the most significant cause of avoidable death and disease in Scotland. Our most important target is to achieve a reduction in smoking rates to 5% or less by 2034. To support our aim, we published our new five year Tobacco Control Action Plan^[23] in June 2018. As part of that plan we have already removed tobacco from prisons in November 2018 and run national campaigns encouraging smokers to get support to quit from our newly-branded stop-smoking services: Quit Your Way.

4.7 Following the Supreme Court's ruling in 2017, we introduced Minimum Unit Pricing for alcohol on 1 May 2018 and published our refreshed Alcohol Framework and our new Drug and Alcohol Strategy in November 2018.

4.8 There are huge preventable costs to NHS Scotland and society associated with poor diet, as one of the critical health issues we are facing, and it requires a different approach to diet and obesity. Following a consultation process, the Diet and Healthy Weight Delivery Plan was launched in July 2018 containing a range of actions to combat this, including the consideration of restricting the promotion and marketing of foods high in fat, salt and sugar within premises where these foods are sold to the public.

4.9 In addition, funding was allocated to Early Adopter Health Boards in 2018 to support them in the delivery of Phase 1 of the delivery of the implementation of the Type 2 Diabetes Framework. All Early Adopter boards are prioritising services and education to support the following high risk groups:

• Pregnant women with gestational diabetes (GDM) and those with high risk pregnancies due to complex obesity.
• Those diagnosed with pre-diabetes or at high risk of development of type 2 diabetes.
• Those diagnosed with type 2 diabetes, where remission may be possible, including the provision of "Counterweight Plus" - an evidence based, total diet replacement programme that has produced successful remission results for patients with type 2 diabetes.

4.10 The Active and Independent Programme^[24] was launched in 2017, detailing six ambitions to drive significant culture change in how people can access and receive Allied Health Professional (AHP) support for self-management, prevention, early intervention, rehabilitation, and enablement services. Significant progress has been made including:

• AHPs across Scotland are prioritising prevention and early intervention to ensure access to interventions at the earliest time for maximum benefit, this includes:
  • the development of a self-management resource for those living with dementia, in partnership with Alzheimer Scotland and the Royal College of Occupational Therapists, which will soon be available online;
  • home based memory rehabilitation, a specialist occupational therapy intervention, now available in 13 NHS Boards across Scotland;
  • development of a speech and language therapy on-line resource to enable Health Visitors to be confident and informed in supporting children and families with speech, language and communications needs; and
  • collaborative work with Downs Syndrome Scotland to develop red flag postcards covering weaning, vision, posture and positioning to increase parental understanding of the key issues to look out for in their baby or toddler with Downs Syndrome.
• In addition, development of a national Falls and Fracture Prevention Strategy is underway which will provide an opportunity to present an achievable vision of a joined up, whole system approach to falls and fracture prevention and management which will help to deliver on strategic objectives to support people to age well.
• The 'Take the Balance Challenge' campaign which raises awareness of age-related loss of muscle strength and balance. It invites people to check their balance, provides six simple exercises to improve strength and balance, and sign posts to a range of resources providing information about keeping active and well, improving bone health and preventing falls. This was developed in partnership with Age Scotland and the Care Inspectorate, and over 400 partners locally to deliver the campaign across Scotland.

4.11 As part of the delivery of the Maternal and Infant Nutrition Framework^[25] we rolled out universal vitamins to all pregnant women in 2017. In addition, a draft competency framework to promote and support breastfeeding was published in June 2019.

4.12 The Mental Health Strategy^[26] set out the strategic direction for Mental Health but did not set out specific expectations of how the national ambition will be translated into local delivery, recognising that Integration Authorities are responsible for local service redesign. Since the publication of the Strategy it has become apparent that new models of support that are less specialist, available for significantly more people, and that are delivered across different services and settings are needed, and that a different leadership approach is required to deliver whole system change.

4.13 Going forward, activity to deliver the Mental Health Strategy has been restructured into four priority areas: Children and Young People; Adult Mental Health Service Redesign; Public Mental Health and Suicide Prevention; and Rights and Mental Health.

4.14 In addition, we published the Mental Health PfG Delivery Plan^[27], which sets out our approach to the commitments in the 2018/19 Programme for Government, and is the blueprint for the next phase of implementing the Mental Health Strategy. This Delivery Plan is complemented by the Children and Young People's Mental Health Taskforce Delivery Plan^[28], and the Suicide Prevention Action Plan^[29], all of which were published by the end of 2018. This year, working jointly with COSLA, we will take forward the Taskforce's concluding recommendations. We are establishing community wellbeing services across Scotland, focusing initially on children and young people from ages 5-24. This will be an open-access model and referrals can be made by those who work with and support children and young people. Crucially, children and young people will also be able to self-refer to the service. We will also scope out how this service can be made available in the future to people of all ages across Scotland.

4.15 The full national rollout of the Computerised Cognitive Behavioural Therapy (cCBT) service across all 14 territorial health boards was achieved in July 2018. Referral rates continue to rise with 16,761 being received in 2018 and this compared to 10,552 in 2017. Currently over 1,387 referrals are received per month across all services with a total of 38,427 referrals having been received since start of the implementation process in 2013. Patient wait no longer than 5 working days before being given access to treatment and cCBT services monitor the suicide ideation of over 2,300 patients a month.

4.16 Effective and sustainable models of supporting mental health in primary care are now being rolled out nationally through the Primary Care Improvement Plans. An additional 186 mental health workers are now in place within Primary Care, including 66 in GP practices, as part of the five year commitment (Action 15 of the Mental Health Strategy) for an additional 800 workers in four key settings to be in place by 2022 to support that activity.^[30]

4.17 22 Community Planning Partnership areas have adopted the Psychology of Parenting Project model (PoPP) to support parents of 3 and 4 year olds with conduct disorder. 775 PoPP groups have been delivered (or are currently being delivered) to almost 5,000 families (including over 6,000 caregivers)^[31]. Currently 62% of those children (for whom we have pre and post intervention data) whose behaviour at the start of the group was rated by their parents to be at an elevated level of concern, had moved out of this high-risk range when their parents had finished attending a group. From August 2016 the PoPP age range was extended to include 5 and 6 year-old children.

4.18 Ensuring people can access mental health services is a key priority. A comprehensive package of support is being implemented to improve access to Child and Adolescent Mental Health Services and Psychological Therapies. This includes the establishment by Healthcare Improvement Scotland of a Mental Health Access Improvement Support Team which is working in partnership with Boards to improve access to mental health services. Most recently, this includes £4 million of additional support to enhance the workforce and capacity of CAMHS in 2019/20.

4.19 Continued investment in mental health services and the examples of good practice, have not, to date, seen all the improvements in performance required. As a result, additional activities will be taken forward through the PfG Delivery Plan for Mental Health.

4.20 The Active Scotland Delivery Plan^[32] was launched in 2018, with implementation and investment underway. Key deliverables to date include:

• Funded the Scottish Women's National Team to go full-time ahead of the World Cup which has huge potential to inspire women and girls across the country.
• Established a £300,000 Women and Girls in Sport fund administered through sportscotland. This fund awarded projects that will increase participation levels of women and girls across Scotland.
• The number of operational hubs across Scotland increased to 197 during 2018-19, and sportscotland is on track to meet the target of 200 by 2020. Eight hubs are located in the 5% most deprived areas and 30 hubs are in the 20% most deprived areas. Through the Go Live! Get Active programme and Women and Girls in Sport Fund, sportscotland has provided additional support and resource to Community Sport Hubs, Scottish Governing Bodies and Local Authorities to provide new opportunities for people from underrepresented groups in sport and those at risk of inactivity to get active through participation in sport.
• NHS Tayside have developed a business case for a Social Prescribing Service that has broad support from Health & Social Care Partnerships, senior clinicians and the GP contractor body. It is recognised that the opportunity to address Healthy Weight and Physical Inactivity through Social Prescribing and Green Health Prescriptions is a key part of establishing a credible prevention agenda in the board. Connecting people with community support and reducing reliance on medication is an important feature for implementation of Realistic Medicine. Tayside will continue to engage with stakeholders, Voluntary Sector and communities and colleagues in Scottish Government as we progress with this work which is part of the transformational change for service improvement.
• We continue to work with the Daily Mile Foundation to broaden participation of The Daily Mile initiative within and beyond the education sector since the reinvigoration of the initiative across Scotland in August 2017. We now have two thirds of schools across Scotland participating as well as many NHS Boards, local authorities and private companies, all contributing to Scotland becoming a Daily Mile Nation.