Health and Social Care Service Renewal Framework

3. Service Renewal Framework

This Framework is comprised of a set of principles, changes, and ‘enabling shifts’ which will ensure it supports the delivery of our vision for health and social care.

The principles focus on prevention, people, community, population planning, and digital. They capture the values that we consider must be at the core of a thriving, sustainable health and social care system. Each principle is intended to guide the design, planning and delivery of services nationally, sub-nationally and locally. This means we will use the principles to, for example, guide resourcing decisions about workforce, finances, and infrastructure that focuses on achieving the best outcomes. These principles also all recognise the links between people’s physical, mental and social needs.

To enable the principles to become a reality, we have identified major changes that we will implement. To make all these changes possible, we set out three required ‘enabling shifts’ in the way we work, plan, and make decisions. The following section describes the principles and changes. The shifts are described in Section 4.

Renewal Principles

Prevention Principle: Prevention across the continuum of care

Health and care is focused on prevention and proactive early intervention to realise long term wellbeing and reduce the burden of disease. All parts of the community and health and social care system will work together to maintain better population health, and reduce inequalities and stigma.

Our current model of health and social care focuses most of its resources (workforce, finance, infrastructure) on caring for established sickness or care needs. Shifting towards a focus on the drivers of health - a good start in life including eliminating child poverty^[9]; access to education; good jobs and income; good quality, well-designed housing; sustainable places that enable healthy living, and contact with nature; and equitable access to good public services - is critical to achieving our vision for health and social care.

Prevention and early intervention activities seek to improve health and wellbeing by increasing the years people live in good health, enhancing their quality of life, and promoting independence^[10] (e.g. through housing adaptations). These activities are amongst the most cost-effective interventions the health and social care system can make, leading to improved outcomes, reduced inequalities, and less pressure on acute services. With growing demand for services, increasing health challenges, and financial pressures across the system, investing in prevention and early support has never been more important.^[11]

Taking a preventative approach to health and wellbeing in Scotland is a shared responsibility of the whole system. This is reflected in the connection between this Framework’s ‘Prevention’ principle and the Population Health Framework’s (PHF) Driver 4: Equitable Health and Care.

The PHF is focused on ‘primary prevention’ – action that is designed to stop problems from emerging in the first instance. Health and social care services – the focus of the SRF – also have a role in primary prevention by enabling healthy living, ensuring equitable access to services, and helping people maintain good health.

The SRF builds on primary prevention by setting a framework for a health and social care system which supports and promotes secondary and tertiary prevention. Secondary prevention is action which focuses on early detection of a problem to support early intervention and treatment or reduce the level of harm. Tertiary prevention is action that attempts to minimise the harm of a problem through careful management. Both are critical components of a sustainable health and social care system – one that not only promotes good health but also responds quickly when risks or early signs of illness or crisis emerge.

Spotlight on Current Services: A Prevention-Based System in Practice

The Preventative and Proactive Care (PPC) programme provides an example of how we can continue to build a primary and prevention-based health and care system with a community focus, in line with the vision for health and social care. The programme, which ran until March 2025, had the core aim of increasing and improving preventative and proactive ways of working together, to support Scotland’s citizens and communities to have more control over their health and be able to access and benefit from preventative and proactive resources and services. This aim was achieved through delivery of initiatives including the GIRFE National Practice Model, Waiting Well supporting those waiting for health or social care intervention, and a Cardiovascular Disease (CVD) National Toolkit and Directed Enhanced Service.

Primary Care reform, through general practice, dentistry, optometry, community pharmacy and community urgent care, are all critical aspects of this and are already making impacts in prevention and access.

For example, in dentistry, as part of our ambitious payment reform programme dentists are now directly remunerated for providing preventative advice, adding primary and secondary prevention into appointment times. According to official statistics reporting annual treatment activity in 2024/25, nearly 2 million instances of preventative advice were delivered in the first full year of dental payment reform^[12], supporting patients to better manage and improve their own oral health between appointments. This approach is further supplemented by changes to examinations, also introduced by reform, which ensure that patients are seen at a check-up recall interval which aligns to their own oral health need. We have also introduced a system of adult oral heath metric data collection for the first time, based on key data points routinely charted during enhanced dental examinations, and this will empower clinicians to track and monitor long-term improvements to their local patient cohort’s population oral health over time, including the impact of enhanced prevention.

A further example is community pharmacy, where the team play a key role in preventative care, informing and empowering individuals to manage their own health, and increasingly playing a key role in secondary prevention of cardiovascular disease and diabetes. Delivery of some women’s health services are now undertaken by community pharmacists, including advice on and access to emergency and bridging contraception and treatment of some urinary tract infections, thereby avoiding the need for a GP appointment. Access for treatment under NHS Pharmacy First increased 86% from June 2021 to June 2024 with a 93% increase in treatment for urinary tract infections over the same period. In the areas of highest deprivation, access and treatment similarly increased 77% and 73% over the same period for treatment under NHS Pharmacy First and urinary tract infections.^[13]

Major Change: Services that prevent disease, enable early detection and effectively manage chronic and long-term conditions

We are committed to improving health and wellbeing across Scotland by focusing on prevention at every stage – from helping people stay well, to detecting problems early, to supporting those living with long-term conditions.

• In delivering the SRF, we will continue to align with the Population Health Framework, including on its commitment to develop and implement a new Healthcare Inequalities Action Plan to help us tackle the root causes of poor health, and reduce unfair differences in health outcomes across communities.
• We are supporting national efforts to improve healthy weight, not only through promoting healthier lifestyles, but also by treating the physical and mental health impacts of overweight and obesity. This includes early intervention and tailored support for those already affected.
• We are implementing the Mental Health and Wellbeing Strategy and updating our delivery plan, recognising how inequalities can affect mental health and understanding the connection between mental and physical health needs. Our approach includes prevention, early support, and ongoing care for those living with mental health conditions.
• We will further enable innovative and inclusive rehabilitation across settings and sectors.
• Our new Long Term Conditions Framework^[14], to be published by end of 2025 will improve the quality of care and support for people living with long-term conditions. This includes helping people manage their conditions well, avoid complications, and maintain their independence and quality of life.
• We are also supporting efforts within the PHF to publish a Health and Work Action Plan, which will include improving support for people with ill health^[15] who wish to return to work. This Framework will deliver enhanced and cross-organisation services that deliver tailored, employment-focused care and support.
• We are shifting funding and workforce capacity into primary and community care, ensuring that prevention is embedded across the full spectrum of care.

We will also improve how we use and analyse data, allowing us to identify key risk factors and make targeted interventions for high-risk subsets of the population. People with long term conditions or other health issues interact with multiple parts of the health and social care system, so we will continue to improve sharing of information so that, where possible, people do not have to repeat their stories.

Spotlight on Current Services: Community Appointment Day

Some NHS Boards in Scotland have now implemented the community appointment day model for people living with musculoskeletal (MSK) and pain conditions. These appointment days, hosted in local leisure facilities, bring together physiotherapy services, health and third sector partners to combine specialist MSK assessment with holistic care needs assessment to understand what matters most to people living with these conditions. This approach provides the opportunity to provide preventative and proactive care to individuals. The focus of these days is to understand what matters most to the patient in relation to living with their condition and providing multiple options to support them to improve their condition or live well with it. In this evolving method of service delivery, colleagues are collaborating across traditional boundaries to learn and evolve the model building on user experience.

For example, in Lanarkshire, over 500 people attended the first community appointment day at a local sports centre in East Kilbride. It provided same-day access for people from across the community to a range of support including rehabilitation, advice on self-care and health promotion. Feedback from both staff and patients were very positive.^[16] A recent scientific journal article noted that community appointment days allowed for more than three times as many patients to be booked in compared to routine outpatient clinics.^[17] Further, these events had positive outcomes for patients and were successful in reducing waiting times.

In Moray, a community appointment day session was held in a local sports hall for 200 people who are on the MSK waiting list. When people arrived, there was an 'about me' conversation, and they completed their 'personal health passport' which helps staff understand the person's care needs and what matters to them. They then had a physiotherapy or podiatry appointment, followed by visits to other relevant services that were located within the sports centre for the day. People therefore had access to a range of relevant professionals in the same place, without requiring referrals or additional waiting time. Further, various professionals were enabled to work collaboratively around people’s needs and provide them with the required support in one place.

People Principle: Care designed around people rather than the ‘system’ or 'services'

Health and care is responsive, respects individual needs and delivers outcomes that matter to people. People will be more in charge of their own health and wellbeing as we enable self-care. People will have the information they need to share decision-making about their own physical health, mental health and social care, and services will trust their choices. Services will be equitable (i.e. proportionate to need).

We will place the individual at the centre of our decision making. In doing so, we will more proactively apply the principle of participation in health and social care, supporting people to be in charge of their own health and wellbeing and empowered to make decisions about the care they receive.^[18] We will ensure that the principles of Planning with People underpin our approach to service changes, along with ensuring people’s voices are heard^[19] and they are able to realise their rights and responsibilities.^[20] Services and support will be designed with the people that access them, aiming to better meet their needs, and leading to greater effectiveness and efficiency in the system overall.

To help achieve this, we will ensure easier access to information about individual’s own health and care, and about the services they can access. We will implement innovations to help people self-care, such as remote monitoring of specific conditions, which give people flexibility and a different way of living their lives.

We recognise that people have different levels of need and so levels and types of support will vary - but always with the aim of being proportionate and equitable.

Major Change: Delivering health and social care that is people-led and ‘Value Based’

Getting it Right for Everyone (GIRFE) is a model of delivering health and social care support that puts the recipient front and centre, based around a series of GIRFE principles. The approach has been co-designed with people who have direct experience of care, together with several local partnerships.

The GIRFE model allows people to make an informed choice about the care options that are right for them. However, we also know that if people are fully informed about and involved in decisions about their care, they often choose less treatment or consider a more conservative approach. They are also far more likely to value the treatment they choose, and this reduces waste and potential harm. This approach therefore leads to appropriate use of available resources while delivering care that really matters to people – the key objective of Valued Based Health and Care.

Implementation of the GIRFE practice model is already showing tangible results for people (see case study below) and for the workforce. We will now roll out the use of the GIRFE practice model to all areas of Scotland, ensuring that the core GIRFE principles are part of all of health and social care delivery, enabling people to fully participate in their own care.

Case Study: Using a GIRFE Approach to Support People in Alcohol and Drugs Services

An individual known as ‘S’ had a history of drug and alcohol dependency, self-harm, and seizures which resulted in 15 admissions to hospital between May 2023 – May 2024. When discharged from hospital, S was deemed to be at risk in terms of his social care and health needs as he had no tenancy, clothes, furniture or access to funds; was socially isolated; and was not receiving relevant community support.

The relevant Local Authority team then applied the GIRFE ‘Team Around the Person Toolkit’ to its care and support for S. This included involving S in conversations with those supporting him and allocating him a designated care co-ordinator. S and the professionals involved were able to share information and develop a clear understanding of how S would like to be supported, enabling collective decision making. Weekly meetings co-chaired and facilitated by the Clinical Nurse Manager and Principal Social worker brought together all the professionals involved in the care of S, from multiple agencies and organisations.

The Toolkit provided a framework for the professionals to have conversations with S and develop a robust and preventative plan of care and support. As a result, S only had one 24 hr stay in hospital in the following three months. This admission wasn’t for self-harm or seizures, but was related to another acute health condition. S now actively engages with his plan of support and substance use support programme. When S was asked about the support he has around him, he said, “I have got my life back and never felt so safe”.

As another example of people-led services, Whole Family Support is our approach to integrating services, supporting local partners to use the resources they have in the way they find most effective to support families in their area to thrive.

Whole Family Support enables services at a local level to wrap around families, prioritising their needs and delivering integrated, responsive and preventative services. We know this type of support can help families to thrive and prevent future crises (see case study).

Our expectation is that all partners will work collaboratively with each other and with people to transform services to deliver whole family support through better coordination, alignment, integration and local control of resources. We have already seen excellent partnership working across health, social care, housing, the third sector and employability services.

Case Study: A holistic support project for families in General Practice (Glasgow Health and Social Care Partnership together with Includem)

A GP referred a mother and baby to the Family Wellbeing Worker in the new “Whole Family Support through General Practice” programme, part of innovative healthcare inequalities reform work in primary care in partnership with Includem, a third sector organisation. The GP had cumulative concerns about the impact on the mother’s health of her financial debt, being pregnant with her second child, and her partner being in prison due to domestic violence. The mother was due to attend court to give evidence, which was impacting her mental health. The baby was not sleeping, impacting further on the mother’s mental health.

The Family Wellbeing Worker supported the mother by listening to her and offering her emotional support. Once their relationship had been established, the mother was empowered to consider the support she needed. The Family Wellbeing Worker was able to: facilitate housing support in the mother’s preferred area where she had family support; make several referrals including to a welfare adviser, ‘Thrive Under 5’ and Livewell; and connect with the baby’s nursery to secure additional support for the mother. The Family Wellbeing Worker also quickly identified the cause of the baby’s poor sleep, which related to their bedding, and applied to the Young Person’s fund to access a cot bed.

Positive outcomes from this referral have helped to improve the mother’s mental health and the baby’s wellbeing. The mother reports feeling ‘stable’, less emotional, and has commented that her relationship with her family has improved. She has engaged with the welfare adviser and her benefits have been maximized, helping to control her debt. Whilst she declined the Livewell support (due to a move away from the area), she has accessed the Pantry support, including vouchers for cooking essentials. Her housing support has continued although the family has moved on from the service.

To enable the overall shift to people-led and value based health and care, we will:

• Enable local areas to embed the GIRFE principles and the Team Around the Person Toolkit and, integrated with Getting it Right for Every Child, develop the model to one which can fully support families.
• Help people have their voices heard and participate fully in decisions about their care by enhancing independent advocacy provision.
• Ensure people’s own health and care information will be more readily available to them so they know more about their own care, through the creation of a digital health and care record.
• Make it easier for people to access the tools and support they need to manage their wellbeing and be informed of their rights and access to services.
• Drive improvements to the complaints process in adult social care, by building upon the ‘codesign’ used to develop the National Care Service Programme, where people were supported to participate in planning and decision-making.

Community Principle: More care in the community rather than a hospital focused model

Health and care is accessible, seamless, and equitable across settings. People will be able to access more services and support in the community – and hospitals will focus on the most acute and complex procedures or levels of care.

This principle is about bringing more healthcare closer to home—whether that is a local General Practice, pharmacy, or wider primary and community health teams, or treatment from hospital-based specialists. We will make this possible by moving more staff, funding, and services into local areas, as well as building on the core skills and capacity we have in our community. This will mean people can get the care they need in the places they know and feel comfortable, within their own communities. It will also mean they are further supported to ‘live well locally’, having more of their needs met within a reasonable distance of their home.^[21]

Primary care, community health and social care services (including those provided by the third and independent sectors) already play a vital role in keeping people well, treating and managing health conditions and supporting people to live well locally. We have made significant progress in integrating primary and community health and social care since the enactment of the Public Bodies (Joint Working) (Scotland) Act 2014, but further whole system integration is still required.

Our model of care is still overly specialist, organised around hospital-based care settings rather than person-centred pathways and approaches. This means it often feels like hospitals are at the centre of our healthcare system, rather than primary care, community health and social care services.

We have therefore set out two major changes within this section on Community, building on our learning from what people have told us about their experiences of accessing and receiving support.^{[22],[23],[24],[25],[26]} First, to strengthen integration across the system, and second, to improve access to services and a wider range of treatments in the community.

In doing so, we must ensure distribution of resources is equitable and transparent so that different health conditions, for example diabetes or musculoskeletal problems, are supported fairly and in line with the needs of our communities. This means allocating resources not only based on population size, but also on the specific health challenges faced by different areas, including rural and island communities, where access to care can be more limited.

Major Change: Strengthening system-wide integration

Reform of Social Care

Building on the work of the Independent Review of Adult Social Care and the two joint statements of intent between COSLA and the Scottish Government, we will continue to improve the Social Care Support and Social Work sectors in Scotland. Scottish Government and COSLA have worked closely with key partners and stakeholders in recent months to understand the challenges within the current adult social care support and social work system.

The National Care Service Advisory Board is now in place and will provide an opportunity for partners to work to deepen integration, putting people at the heart of that work; support a collaborative culture of improvement, improve quality and consistency of support and services, understand performance; and ensure the workforce is supported to deliver. The work programme for the Advisory Board is in development and will be published in the coming months.

Working Together to Plan Better Care

We will make sure that leaders across the NHS, Local Authorities, and other services, including third sector and independent commissioned social care services work together to plan care that meets the needs of people and communities — not just based on current organisational, or territorial practice and boundaries. We recognise the important role that Community Planning Partnerships play in supporting this collaboration across partners at local level, and will seek to strengthen these partnerships to drive forward joint working. By planning at national, sub national, and local levels, and focusing on what communities really need, we can make better decisions that support more care being delivered closer to home. This means more focus on prevention, early support, and joined-up services that help people stay well and live independently for longer.

We will enhance whole system cohesion, centred around our shared Vision and these principles, building on the GIRFE approach. This includes developing seamless, person-centred pathways that span services (e.g. primary and secondary healthcare and social care) and settings (e.g. within communities and between community and hospital care).

We will focus on fostering leadership, nurturing a culture of continuous improvement, and creating the space and time needed to support quality improvement. We will also promote joint working across sectors, with active involvement from service users and the third sector.

Working with partners, we will explore avenues for more coordinated and integrated inspection regimes, building on recommendations to date on patient safety and the Independent Review of Inspection, Scrutiny and Regulation.

Spotlight on Current Services: Enhanced Mental Health Pathway

Since November 2023 the Mental Health Hub, within the NHS 24 111 service, has responded to over 180,000 calls^[27], ensuring anyone in mental health crisis or distress can quickly and easily connect with professionals who are experts in that field. The award winning Enhanced Mental Health Pathway enables emergency calls received by Police Scotland or Scottish Ambulance Service, where callers are identified as requiring mental health advice, to be directed to the Hub. This ensures people in distress can access support from an appropriate mental health professional more quickly while also removing pressure from other emergency services. Work is also underway to establish a new self-referral pathway to respond to increasing demand and provide access to digital therapies and psychological treatments without the need for a referral from local GPs, protecting primary care and unscheduled care services.

Case Study: Care from multi-disciplinary teams

“M” is an older female with a long term neurological condition. She uses a power chair full time, and requires moving and handling equipment to transfer between seated surfaces. M lives on a ferry link island in the north of Scotland. She was attending the mainland for a routine follow-up appointment, but travel to the mainland involved a journey of more than one and a half hours each way – overall she was out of her house for more than 10 hours each time.

The local ferry service does not have wheelchair access to the passenger lounges, cafeteria or toilets, therefore M’s self-care, personal care and privacy and dignity were at risk. Flying for the journey was not an option because small airplanes have no, or very limited, wheelchair access. There was a risk that M’s health and mobility would deteriorate further with prolonged periods of sitting while undertaking this journey, and the trip created emotional stress, with negative impacts to M’s wellbeing and mental health.

A multi-disciplinary team (MDT) was stood up to support M, based on the GIRFE principles and ‘Team Around the Person’ toolkit. The team involved M in planning and decision-making processes about her care and identified an island wellbeing coordinator for her care. The coordinator looked at other possible ways in which M could attend appointments, and as a result virtual meetings were established with her consultant (who was on the mainland) for her routine appointments. The coordinator also supported M to ensure she had appropriate equipment (and was comfortable using it) for attending these virtual appointments.

This approach enabled health and social care professionals to involve M in decisions around coordination of her support, and gave her the opportunity to have her wishes and views heard. Collaborative working between professionals and M using the My Plan and Virtual Meeting GIRFE tools reduced the physical and emotional stress of attending in-person routine appointments. Utilising the GIRFE co-ordinator tool enabled M to have a point of contact to have support to attend Team Around The Person meetings and to be able to use digital technology to attend routine healthcare appointments.

Major Change: Improving access to services and treatments in the community

We will increase access to health and social care services and treatments in the community. Hospitals will focus on the most complex and acute areas of care and treatment that cannot be delivered at home or in the community.

To achieve this, we must ensure a strong and thriving primary care and community-based health system – this is most people’s first point of contact with the health service. Most health and care needs are already managed entirely in the community, without being escalated to a more ‘acute’ level or needing hospital-based treatment. There is a growing body of evidence and experience that shows that many of these health needs can be managed safely in people’s own homes with more intensive multi-disciplinary or specialist support.^[28]

This is not about shifting demand and responsibilities to community teams, but a rebalancing of the overall health and care system, and a greater proportion of our resources (workforce, finance and infrastructure) being moved towards our community settings. This is covered more in section 4 on Enabling Shifts.

Specifically, we will set out a clearer model of care that will work across three care settings - home, community and hospital. This will enable a more preventative approach, as well as contribute to closer integration of health and social care services so that they are delivered and communicate with each other seamlessly around the person. As we implement this approach, people and the workforce can expect to see:

• Specialists delivering more care in the community, allowing them to develop expertise with better technology and national clinical support.
• Community services providing more generalist and specialist care as close to home as possible, building on the capacity, role and strengths of primary and community healthcare teams.
• Seamless transitions between care settings being facilitated as part of a coordinated care plan, supported by multi-disciplinary teams with staff working across settings in structured networks.
• Unpaid carers receiving the recognition and support they deserve.
• The same high-quality care being provided, no matter where someone lives. including planning for the unique needs of rural and island communities.
• All people (and the staff providing them with care) having access to relevant key information about themselves, regardless of organisational boundaries, through the digital health and care record.
• The individual and their care needs being at the heart of all decision-making, with and for them, reflecting GIRFE principles.

To achieve these ambitions, we will:

• Enable NHS Boards and wider system leaders to take the lead in national, sub-national, and local planning and decision making, and ensure that planning guidance issued to them reflects the Community principle set out in this Framework.
• Build on the work of the Primary and Community Health Steering Group^[29] to ensure primary care outcomes, such as sustainable, equitable and timely access to healthcare in the community, are realised and the capacity of this critical part of the health and care system is progressively improved and supports wider changes to specialist care.
• Set out in the detailed Primary Care Route Map the actions and enablers required for this shift (workforce, infrastructure, systems), clarify the role and services to be delivered in the community, and support leadership and cohesion in our health services in the community.
• Maximise flexibility and cohesion across the primary and community health workforce to increase access, building on core General Practice capacity and wider primary care professionals across the MDT and beyond.
• Help GP practices to improve their appointment systems by supporting the implementation of digital telephony by January 2027, which will enable practices to enhance access via more modern and higher capacity patient communication tools.
• Ensure the future planning and delivery of community hubs considers opportunities for infrastructure co-location to further develop person-led approaches for access to seamless and coordinated care.
• Continue to implement the Once for Scotland rehabilitation approach as part of population planning, drawing on our existing Rehabilitation and Recovery Framework^[30], and ensure service change plans enable patients to be treated as close to home as possible and recover more effectively.
• Build on our existing work in relation to follow up outpatient appointments, where they are necessary, ensuring that where possible these are delivered in the community and are patient initiated.
• Build on work established as part of the Delayed Discharge Mission to ensure that stays are minimised for those who have to be admitted to hospital.
• Take advantage of changing technology, meaning that tests which are currently only possible in hospital settings will be able to be delivered in the community or at home.
• Increase collaboration between NHS 24 and the Scottish Ambulance Service, building on highly successful joint working to date to improve the patient journey – including developing an annual Collaboration Plan focused on urgent care service improvement.

Spotlight on Current Services: Hospital at Home

Scotland’s first Hospital at Home service began in Lanarkshire in 2011 and this approach has since grown and developed across every area of Scotland. While services might look different depending on the needs of the local population, all share the core ambition of helping people stay at home during a period of acute illness rather than being admitted to a hospital setting.

From the densely populated central belt to our island populations, Hospital at Home provides acute, hospital-level care by healthcare professionals for a condition that would otherwise require a stay in hospital. Hospital at Home services prevented almost 16,000 people spending time in hospital during April 2024 to March 2025.^[31] These people were able to stay with their families and loved ones in familiar surroundings throughout their treatment, instead of spending this time in a hospital, and this relieved pressure on A&E and Scottish Ambulance Service. This avoids the risks of infection and deconditioning or dependence that can occur in hospitals.

This programme has high satisfaction and patient preference, reduces pressure on hospitals by avoiding admissions and accelerating discharge, and has consistent evidence of lower costs compared to inpatient care.^[32]

Spotlight on Current Services: Keeping people safe in their own homes - National Support for Local Services

All 32 Local Authorities in Scotland, in a number of cases in partnership with the housing sector, use a range of sensors, falls detectors and community alarm pendants to support people to remain safely in their own homes. This service is usually referred to as 'telecare' and collectively around 132,000 people currently benefit from this core social care support service.^[33] By 2027, everyone will have had the technology in their homes upgraded to newer digital technology, away from the traditional landline-connected analogue systems currently in use.

To support this, the core systems used by Local Authorities to manage the alerts and receive calls from individuals needing help - known as the Alarm Receiving Centre - also needed to be replaced. Working with COSLA, the Scottish Government asked the Local Government Digital Office to explore national options for embracing modern cloud-based digital solutions in a way that allowed individual Local Authorities to manage their own services, but with stronger national support. Stakeholders recognised that digital enabled new ways of working in a more collective, collaborative manner that also allowed for a reduction in the number of systems purchased by the public sector, creating greater efficiencies and improved resilience.

The result of this work was a shared procurement via Scotland Excel for a single Alarm Receiving Centre platform (a 'Shared ARC') that all service providers can use. To date, 18 Local Authorities, along with several housing providers, have signed up to use this single digital platform. Having a single national platform that all Local Authorities can use significantly reduces the technical burden of individual organisations, increases the cyber resilience of our services, allows different Local Authorities to support each other for service resilience purposes, improves data sharing, makes it easier to integrate into health services and offers up far greater potential for data-driven personalised predictions to be made for the people supported at home.

Population Principle: Population planning, rather than along boundaries

Our planning of services will be based on evidence-based, strategic assessments of population needs across Scotland, at national, sub-national and local level.

Planning on a population basis, rather than planning along geographical boundaries, means we will analyse the changing needs of the population at a macro level, and use that data and information to provide the right services, in the right places to meet these needs. For example, we will look across Scotland at the demand and need for particular services and treatments, and plan the provision of our services according to that need and how we can achieve the best outcomes for the population.

There is overwhelming evidence^[34], especially for surgical treatments, that patient safety and surgical outcomes are better when the surgeon is doing that particular surgery more frequently.^[35] By concentrating certain surgical treatments in fewer centres (with number and place informed by evidence of population need), the surgeons within them can be very practised and highly experienced in that particular procedure, and we can improve patient outcomes as well as improve efficiency. As a result, we will see hospitals which each treat a greater number of patients for the intervention they are specialised in, ensuring they can take advantage of specialist teams, attracting and developing a world class workforce, and equipment and infrastructure.

This is just one example. We will apply this population planning principle across a much wider range of clinical services and treatments to better understand where care is best delivered and by whom. As demonstrated in the surgical example, this will involve careful balancing of evidence of population need (e.g. demand, demographics, geography), with evidence of what delivers the best outcomes for people and for the population (e.g. clinical quality, safety, efficiency).

We are already doing this in some hospitals and this has been at the core of the development of our five National Treatment Centres, which are a network of healthcare facilities across Scotland that provide extra capacity for planned inpatient care, day case treatment and diagnostic services, and which have already generated positive feedback from patients. They support regional working across territorial NHS health boards, helping to improve people’s access to treatment, and support them to do so more flexibly.

We will apply a population level planning approach across the entire health and care system – engaging with partners in acute care, primary care, community healthcare and social care. This joined up approach will support both national and local services to make more informed and sustainable decisions that are tailored to the needs of their populations. For example, this could include:

• Designing services for people with specific needs, such as older adults or those requiring highly specialised care home provision
• Planning for early identification and intervention in conditions with known risk factors, helping to prevent illness and reduce long-term demand on services.
• Deliberately targeting opportunities to collaborate across traditional organisational boundaries and deliver more seamless services. Service providers will use this approach to consider how to better share resources and improve efficiencies.

By taking this whole-system view, we can ensure that care is better coordinated, more proactive and aligned with what people and communities truly need.

Spotlight on Current Services: Pharmaceutical Care Service Plans

Health Boards define their pharmaceutical care needs within an area through Pharmaceutical Care Service Plans (PCSPs), and are a good example of population based planning in primary care led by NHS Boards. PCSPs provide information to the public, community pharmacy providers and wider NHS services on the pharmaceutical care services currently available from the network of community pharmacies within a Health Board’s area and take into account evidence of local need - this helps decision-makers map where there are possible service gaps or wider issues. PCSPs also recommend improvements to help the Board ensure patients have reasonable access to pharmaceutical care services. PCSPs has been fundamental to improving service provision. We will continue to develop PCSPs through wider reform of the pharmacy contractual planning framework.

Across health and social care, there is a relatively small but significant group of individuals with multiple, complex needs who require intensive and specialised care support in their communities. Evidence shows that a coordinated, population-based approach to planning for this support can be beneficial to those who need that support – both for those receiving care and for the systems that provide it.^[36] As part of this approach, it is important to also recognise and address the needs unpaid carers who play a vital role in supporting these individuals.

More broadly we will use data and other sources of evidence to guide decisions on where and how we deliver health and social care services. This will support a strategic shift to greater provision in community settings. Our planning will include consideration of remote care models, centres of expertise for specialist acute services and innovative approaches to commissioning highly specialised social care support.

In taking this approach, we will consider the impact on health inequalities, ensure that care models are appropriate to the needs of different populations and pay particular attention to the unique challenges faced by rural and island communities.

At the national level, this approach will require strengthened collaboration between the Scottish Government, NHS Boards, IJBs, Local Authorities and wider delivery partners. Together these partners will need to make strategic decisions about the redesign of services – determining what is best delivered, how it should be delivered, and where it should be located to ensure equitable and effective access.

We also recognise that this type of population planning approach for the health and social care system means that, in some cases, people may have to travel further for treatment. Encouragingly, the results of the latest survey (June-September 2024) of the Citizen’s Panel for health and social care showed that 84% of respondents agreed they were willing to travel further for specialist services such as surgery if it resulted in better outcomes for them.^[37] However, as we implement, we will seek to ensure that making it easy to access services is an integral part of NHS Boards‘ service planning and decision-making, including travel and transport needs.

In parallel, we will encourage NHS Boards to work collaboratively with Regional Transport Partnerships and other partners to co-design and implement transport options which support people to access treatment, guided by the Scottish Government’s Transport to Health Delivery Plan (2024).

To support a population planning approach where certain care and treatment may be concentrated in fewer specialist centres, whilst a broader range of care is also being shifted out of hospitals and into communities, we will need to ensure our hospitals and staff within them are prepared and supported for this fundamental shift.

Major Change: Redesigning our hospitals as we deliver more care within our communities

This Framework recognises that some of what happens in our current hospital sites will, over time, move to community settings. However, there will always be a requirement for the most acute and complex treatments, and these must be delivered from modern hospital sites with the highest quality equipment and infrastructure, and able to attract world class workforce, expertise and innovation.

The Scottish Government has started to work with stakeholders on future service models across our health services, drawing from our primary and community care enhancement work and in partnership with those delivering and receiving care.

In the first year after this plan is published, we will begin a major review of hospital care. This will be part of a bigger, long-term plan to improve the whole health system, based on what people and communities need. This long-term 10-year programme will be delivered in close collaboration with NHS Boards, clinical leaders, and system partners. Key priorities include:

• Development of a clear strategic assessment of population needs both now and, in the future, to inform planning and investment decisions.
• Working with NHS Boards to co-develop a future hospital model and improved care pathways that integrate care across settings and strengthen the interface with primary and community care. This will be implemented on a phased basis and supported by redesigned care pathways.
• Working with NHS Boards to ensure that easy access to services is an integral part of their service planning and decision-making, including travel and transport needs.
• Setting out a clear offering of core services for every area that are consistently applied according to population need. This will include development of core service specifications to guide planning and delivery, helping communities to understand what local services are available, and when travel to another area for care may be required.
• Creating national referral guidance to make it easier for people to move through the health and care system when they need treatment or are ill. This guidance will help ensure that care is well coordinated and easy to navigate, co-designed across primary and secondary care (including through interface groups). These clearer, more consistent pathways will help reduce waiting times and make sure people get the right care at the right time, especially when they are most in need.
• Developing clear guidance to define the roles of different types of hospital to ensure services are future-proofed, evidence-based and aligned with population needs.
• Aligning workforce planning with population-based service delivery, and reviewing national infrastructure planning processes, with a strategic approach to estates and capital investment to support this direction.

This programme of work will lay the foundation for a more integrated, equitable, and sustainable hospital system – one that is responsive to the evolving needs of Scotland’s population and supported by the right infrastructure and investment.

Digital Principle: Reflecting societal expectations and system needs

Using technology and innovation to change people’s experiences of how they interact with services and better manage their own wellbeing, whilst simultaneously maximising the use of data and technology to make services as modern, joined up and efficient as possible.

We have a population which is increasingly comfortable with using digital tools within their daily lives, and increasingly expectant of having digital ways of engaging with health and social care services. In support of this, our existing commitment to ethical, transparent uses of people’s data^[38], coupled with the desire to enable people to fully access their own data, remains fundamental. Our ability to deliver health and social care services in line with the objectives in this Framework depends on how effectively we use digital tools and data insights. We know that our current model of care does not yet do this consistently, as evidenced by multiple different consultations and engagements with the public and professional bodies on a wide range of subjects.

In reforming our health and care systems for the future, we need to create a ‘digital first’ mindset, taking into account issues with digital exclusion.^[39] Across the system we need to think how we can reshape our services by making greater use of digital to support people – delivering improved outcomes and helping people take ownership of their own wellbeing. This is not just about technology. It requires leadership and investment in core digital and data infrastructure, skills, and governance, including the knowledge, tools and resource to support digital inclusion to ensure equity and choice for the people of Scotland in accessing and engaging with health and care services using digital.

At the moment, information for social work, social care, and health is often held in silos and in systems that are unable to share information. Poor information sharing can impact adversely on a person’s “journey” across health and social care services and can also result in an inability to properly collate, use and share datasets for service planning and delivery purposes and to help inform strategic direction. The Scottish Government, Local Government and NHS are already working together to better manage how to share information more effectively and are using systems like Microsoft 365 to help them work better as a team.

Improving our digital capabilities will contribute to the reform of our services, improving productivity and efficiency, and releasing money and time to help us invest in the changes we have set out elsewhere in this Framework. It will also enable our workforce to focus on care and relationships. Our approach will be progressive, seeking first to maximise the use of technologies and innovations that we know are successful so that these are as widely available and familiar to people as possible. We will then build on these foundations, developing new services and the data-sharing capabilities that underpin them, and look forward to fully utilising rapidly emerging technologies such as AI for the public good.

In doing so, we recognise the need for individuals and clinicians to have choice around what approach works best for them. Ultimately, everyone should have the opportunity to be offered the choice to use digital, where appropriate, in an environment where they are supported to be digitally included.

Major Change: Services which are accessible through digital technologies, with people and our workforce able to access the right information.

Taking a digital approach is not simply about moving from paper to electronic systems. It’s about reimagining how we deliver care and how people interact with the care system — empowering people to take control of their own health, enabling professionals to work more efficiently and collaboratively, and creating data-driven systems that are proactive rather than reactive. This will be enabled via a renewed approach to digital delivery and change management, with an expectation of national by default, local by exception for major digital delivery initiatives.

We must also be conscious of inequalities as we develop digital-focused approaches. Embedding and mainstreaming digital inclusion support across health and social care as part of ‘business-as-usual' processes in service delivery is vital for long term sustainability and progress in ensuring digital equality.

• We will speed up delivery and improve our digital services by bringing together teams and resources from different national boards to work in a more joined-up and efficient way.
• We will deliver the first iteration of the Digital Front Door and progressively enhance the services available, making it easier for people to: manage their interactions with health and social care services; access and update their own data; and to find health and care information they can trust.
• We will embed the learning from the Digital Inclusion Programme across health and social care to equip providers with the tools and resources to develop local approaches to digital inclusion as part of person-centred care.
• We will work with partners across Local Government and more widely to adopt the use of CHI in Local Government, ensuring that there is a common identifier for verification and data matching to support better information sharing across organisations.
• We will strengthen Primary and community healthcare and social care data and digital infrastructure to ensure a relentless focus on outcomes.
• We will implement Digital Prescribing and Dispensing initially in General Practice and then across all primary and community settings, bringing benefits in relation to safety, efficiency and experience.
• We will establish a Primary Care Data and Intelligence Platform which will enable controlled access to data for Boards to support service delivery, planning, monitoring and research.
• We will continue the ongoing rollout of digital telecare to enable a far greater range of equipment than is currently used and support better use of data to make earlier and more effective interventions, thereby improving outcomes and potentially reducing hospital admissions and delayed discharges.
• We will continue to accelerate the embedding of digital therapies within mental health pathways.
• We will use data and AI to help predict people’s needs and provide more personalised services, like spotting who might be at risk of falling and offering support through digital telecare.
• We will redesign NHS Inform to make it easier for people to find and use trusted health information and services that supports them to better manage their health.
• We will introduce an AI framework for the safe, efficient and ethical application of AI across our services.

Spotlight on Current Services: Remote Monitoring of High Blood Pressure

High blood pressure affects an estimated 1.3 million Scots and is the leading preventable risk factor for heart and circulatory disease, associated with around half of all strokes and heart attacks. Since 2019, we have had a digital-first blood pressure remote monitoring service that to date has empowered well over 100,000 patients to take control of their blood pressure, reducing the risk of heart attacks and strokes while easing the burden on the NHS.^[40]

This uses the ‘Connect Me’ service which enables primary care patients to share their blood pressure readings with healthcare professionals without attending General Practice appointments and promotes self-management to help control the condition. As well as prioritising a digital approach, this programme delivers on the SRF principles related to people, community, and prevention. It allows clinicians to monitor patient trends and change medication as required, whether levels improve from healthy habits or start increasing over time.

The service is estimated to have saved over 400,000 unnecessary appointments for blood pressure alone using simple technology. For every 50,000 people who routinely monitor blood pressure up to 745 strokes and 500 heart attacks could be avoided over a five year period. One of the largest programmes of its kind globally, through this framework we aim to expand this approach to a greater range of conditions supporting more people than ever be in greater control of their health and wellbeing.

Spotlight on Current Services: Computerised Cognitive Behavioural Therapy

Digital mental health therapies offer the option of instant and free access to evidence-based 24/7 support. Thirty-five computerised Cognitive Behavioural Therapy treatments (cCBT) are now available in Scotland, spanning programs referred to and supported by local NHS staff who check in during the online programme, to apps that are free to download and help with anxiety or insomnia. Additionally, our wellbeing website Mind to Mind offers short videos on how people living with mental health conditions manage them and signposts to support services. This is an innovative and rapidly expanding space. Over 70,000 referrals to digital therapies are now processed annually, with scope to provide even more proven options for the right care, in the right place, at the right time in future.^[41]

Case Study: Digital and data enabling multi-agency support

A young woman in supported housing, Sophie has schizophrenia and gets support with alcohol addiction. Like many people, she gets care support from more than one service. Sophie’s social worker has overall responsibility for ensuring she remains safe, well, and independent. Sophie is additionally supported by a Multi-Disciplinary Team (MDT):

• A psychiatrist who prescribes medication and recommends the most appropriate form of treatment
• Community psychiatric nurses who give medication and manage community-based care and support
• An occupational therapist, recommending activities to help maintain independence
• An alcohol support worker helping Sophie manage her alcohol addiction.

They support Sophie through integrated use of digital technologies, co-ordinating their engagement through enhanced use of Microsoft Teams and Microsoft 365 collaboration tools. The National GP IT System, hosted online, means the information they record and share is accurate and up to date, enabling them to work more closely and collaboratively.

Sophie is anxious about leaving her home, but engages through video consultation using Near Me, and gets information through NHS inform. Sophie was recently in hospital and was prescribed medication through the Hospital Electronic Prescribing and Medicines Administration system. In future, Sophie’s information will be entered directly into her Integrated Social Care and Record, alerting professionals to changes in her medication and treatment. Sophie will also communicate using the Digital Front Door, meaning she only needs to tell her story once. These digital systems and processes allow staff to deliver person-centred care, ultimately addressing social and health inequalities.