NHS Scotland operational improvement plan

Shifting the balance of care

We will work to ensure people receive the right care in the right place, recognising that acute hospitals are not always best for patients or their families. This will include making it easier to see a first point of contact with the NHS, for example a general practice team member, a dentist, optometrist or community pharmacist. It will also mean that, increasingly, assessments and specialist care will be delivered in new and innovative ways and settings, including at home.

Reducing the pressure in our hospitals

We will improve flow throughout the system, reducing delays into the hospital and lengths of stay across all areas of a hospital. This will be done through, for example, optimising alternatives to hospital admission, reducing avoidable admissions, ensuring discharge planning takes place from the point of admission, reducing delays to inpatient investigation and developing remote investigation services. This work will also support acute hospitals to move towards an optimal level, for quality and patient flow, of 85% occupancy at a national level. Measurements of admissions and attendances will assist in monitoring performance.

Work to anticipate and address demand will include early identification of individuals who will need significant healthcare services or interventions in the future, maximising the health and wellbeing of people living in care homes and optimising vaccination for vulnerable groups. In addition, embedding the Getting It Right For Everyone practice model and toolkit nationally, across health and social care services, will provide a multi-agency and person-led approach to care planning.

Our actions will support people to access the right healthcare setting for their care needs, first time, and where possible avoid unnecessary attendance at an Emergency Department. For example, we will increase the number of clinical supervisors at NHS 24 to support signposting and reduce call answering times. We will also optimise the use of Flow Navigation Centres (FNCs) to increase virtual access to Emergency Department teams, involving professionals such as those working in a care home or ambulance who need advice to prevent an unnecessary move of a person to hospital. Those working in FNCs will have more options to refer patients away from the Emergency Department with access to a range of services such as diagnostics, Same Day Emergency Care or Hospital at Home. This will also mean fewer people need to wait in an Emergency Department, thus reducing pressure on these services.

We will support local systems to improve community capacity by increasing responsive community home care support, optimising community rehabilitation and reablement services, expanding Hospital at Home, and increasing step down facilities that provide rehabilitation and prolonged periods of assessment. These interventions will support people to maintain their functional ability, reduce the escalation of their care needs and improve health and wellbeing in their own environment.

As part of on-going delivery planning we are working with all territorial health boards and their health and social care partners to strengthen plans by spring 2025 that set out how they will improve flow in acute hospitals. One of the aims is for each acute setting to improve resilience and to use its capacity to best respond to increases in demand throughout the year.

Hospital at Home

Hospital at Home provides equivalent care to that provided in a hospital in a person’s own home. The service is led by a hospital team who have access to hospital level diagnostics and treatment. For patients, this type of care offers additional benefits, such as reducing the risk of losing physical abilities in the hospital, preventing confusion (delirium) and lowering the chances of getting an infection. In addition, patients seen via Hospital at Home services have reduced risk of becoming dependent or facing delay because they can keep any care package they have in place while they receive their Hospital at Home care.

There is now some form of Hospital at Home pathway in every territorial NHS health board in Scotland. Currently we have 555 Hospital at Home beds for the older people’s pathway. We will build on this and expand the number of Hospital at Home beds across a range of pathways to at least 2,000 by December 2026.

To deliver this expansion, we are working with health boards to ensure plans are in place by April 2025 to increase Hospital at Home capacity in line with demand and to support services to work collaboratively. These pathways could include older acute adults, outpatient parenteral antibiotic therapy, respiratory, heart failure and paediatrics. We will work with national boards to ensure that appropriate training and quality improvement expertise is in place to support the development of existing staff and improve the standard of services.

We will look to develop national benchmarking of Hospital at Home services and by summer 2025 key performance indicators of Hospital at Home services will be co-produced with clinical leads. We will work with partners to establish pathways that provide direct referrals from the ambulance service, flow navigation centres, emergency departments, and frailty units to Hospital at Home services by March 2026.

“I was very impressed with the care giving to me at home, I cannot express enough how well I were cared for, I was able to stay in the comfort of my own home with the confidence of home hospital looking after me with the greatest respect. They reassured me at all times and explained everything of their intentions to my care plan.”

Patient supported by NHS Forth Valley hospital at home team.

Specialist frailty services

As our population ages, the prevalence of frailty is increasing. It is clear based on the evidence that, to improve patient outcomes and deliver high-performing healthcare systems and minimise delays, we must address the issue of frailty.

We will reduce the time that frail people spend in hospitals through prevention, admission avoidance, increased use of short-stay pathways and supporting people to live independently in their communities.

We will achieve this by prioritising care at home, or as close to home as possible, where clinically appropriate. Interventions that can help to do this include using technology that supports 24/7 remote monitoring, and additional preventative and ‘home first’ services with national and local partners working with providers and service users to develop alternative approaches based on local need and choice.

Frailty at the front door of the Emergency Department

The HIS standards for the care of older people demonstrate ways to optimise outcomes and reduce harm in hospital by identifying and addressing frailty at the earliest opportunity.

By putting in place processes to identify frailty early we can significantly improve a person’s quality of life. Early detection means teams can quickly put in place preventative measures which reduce the risk of falls, long periods in the hospital and other complications associated with frailty. We will ensure there are local systems in place to identify people living with frailty at the earliest opportunity.

For patients being admitted to hospital, access to frailty services has been shown to shorten their length of stay and result in better functional outcomes, including reducing the likelihood of being admitted to a care home. Frailty Units are specialist beds to which people can be admitted directly from the Emergency Department or by arrangement. Those units provide intense assessment, specialist skills and early discharge, thereby reducing delays and length of stay.

Providing quick access to Same Day Emergency Care services and creating access for GPs and the Scottish Ambulance Service to get advice from specialists can help reduce the number of people who attend or are admitted to hospital. People can also avoid being admitted or have shorter waiting times if there is better access to assessments and care plans. For example, Frailty Multidisciplinary Teams working alongside emergency departments can help manage people living with frailty and its effects by providing early access to assessment. These teams will have strong relationships with community services which will allow rapid discharge where appropriate to Hospital at Home or enhanced community support.

We will work with health boards to ensure that local plans are in place by April 2025 to develop new frailty services and expand existing services. We will publish guidance by May 2025 which sets out ‘what good looks like for a ‘front door’ frailty service’ based on evidence-based practice, to support health boards. By summer 2025 we will have direct access to specialised staff in frailty teams in every core Emergency Department in Scotland. This will mean that frail, often older patients with complex needs, will receive the wrap-around care they need supporting them to return home or into a care setting as soon as possible ensuring better outcomes. It will mean better care for these most vulnerable patients.

Access to GPs and other primary and community care clinicians

General Practice is at the heart of our healthcare system. Annual investment in General Medical Services now sits above £1 billion and there has been an additional investment of £73.2 million in 2024-25 to uplift core GP services and £190 million for multi-disciplinary team members to support general practices.

In 2025-26 we will continue to increase capacity in General Practice. A 20-point action plan on General Practitioner (GP) recruitment and retention, published November 2024, builds on previous work to support the GP workforce. It includes new GP early career fellowships and an enhanced GP Retainer Scheme. We will deliver this action plan by the end of 2026 and GP workforce data will be monitored to measure progress. We will also scope a new quality framework in 2025 to make GP services more consistent across Scotland, so everyone can rely on getting the care they need, no matter where they live.

Pharmacy First Service

We have already widened the range of common clinical conditions, such as shingles, skin infections, urinary tract infections and impetigo, that can be treated by a community pharmacist as part of the NHS Scotland Pharmacy First Service.

We will further expand our Pharmacy First Service, enabling community pharmacists to treat a greater number of clinical conditions and prevent the need for a GP visit – with the first expansion by November 2025. We have already started work with health boards, including NHS 24, GPs and community pharmacists, to scope out further conditions that can be appropriately treated in a community pharmacy. From there we will develop patient group directions (PGDs), which allow community pharmacists to provide a prescription-only medicine without the need to see a GP or other qualified prescriber. We will also work with NHS Education for Scotland to provide any training required to support community pharmacists in treating these further conditions.

In addition from August 2026 all newly registered pharmacists will be able, like doctors and dentists, to practise as prescribers from the point of registration, with newly qualified optometrists also being able to do so from 2029. We will also continue to invest in prescribing training for pharmacists already working in community pharmacy. Between April 2025 and March 2026 there will be investment in a further 240 places. As more pharmacists qualify or train as prescribers this will reduce the requirement to use PGDs when expanding the Pharmacy First service.

Dentistry

We will further strengthen primary care dental services through targeted investment in the workforce to improve capacity and patient access across Scotland.

We have already begun work to improve access to NHS dentistry and provide long-term sustainability of services through the introduction of payment reform in 2023. This has led to clearer and fairer payments to dentists and increasing clinical freedom within our NHS offer, allowing for more personalised care for patients. We recognise, however, that we now need to look urgently at our dental workforce to ensure there is continued capacity to meet demand into the future and support equitable access to services across Scotland. Our targeted investment programme from 2025 will therefore work holistically to deliver workforce improvements now and into the future.

Existing financial incentives and eligibility will be refreshed and targeted following completion of work with the Board Chief Executives’ Dental Services Reference Group by the end of December 2025. This will bring benefit and greater sustainability to communities in accessing NHS dental care.

We are working with NHS Education for Scotland to develop and deliver an innovative training package for General Dental Council (GDC) registered dental therapists – who have qualified overseas – to articulate to full dentist registration status. This will allow them to establish their own practices, if they wish, as well as to deliver care directly to patients in existing practices.

We will also deliver a 7% increase in domestic student numbers from September 2025 – the first regular increase in student numbers in ten years – to ensure an expanded pipeline of new dentists entering the workforce from 2029.

Primary care optometry

We are committed to move optometry services into the community, bringing eye care closer to patients’ homes and away from centralised hospital settings.

From summer 2029, optometrists in Scotland, like doctors, dentists and pharmacists, will graduate as independent prescribers - the only UK nation where this will be the case. This will promote a greater contribution of professionals working in the community, supporting wider workforce sustainability.

Building on the success of the Community Glaucoma Service, we will further extend the care delivered by some of our independent prescribing community optometrists in 2025. There will be a new acute anterior eye condition service. There will be changes made to the Statement of Remuneration to enable complex acute anterior eye condition care to be delivered by approved independent prescribing optometrists as part of General Ophthalmic Services, by August 2025. Patients with any one of ten acute anterior eye conditions (e.g. anterior uveitis) will be seen and treated nearer to where they live. The services will be fully operational in most health boards by the end of March 2026, with the opportunity to free up around 40,000 hospital appointments per year. The increased capacity within our hospital eye services will allow people waiting for care to be seen more quickly.

“My Dad was one of the first patients to use the Community Glaucoma Service in Glasgow. He no longer has to go on the bus to the Queen Elizabeth Hospital every 3 months. The optometrist who is now managing his glaucoma is actually his own optician who knows him well and he can walk from his home in less than 10 minutes. He is delighted with the service. Thank you”