NHS Scotland operational improvement plan

Prevention - working with people to prevent illness and more proactively meet their needs

We want to do more to detect and prevent ill health before it happens - improving health for people and reducing demand on our health and care services.

The Population Health Framework, due to be published in spring 2025, will set out our long-term collective approach to improving Scotland’s health and reducing health inequalities. Improving Scotland’s health and reducing health inequalities are fundamental contributors to and enablers of each of this Government’s four key priorities. The Framework will stimulate and drive improvements – requiring the support of the whole of government and public services, the voluntary sector and private sector and communities – to the key building blocks of what makes for good health. It will take a long-term approach, starting now but with action across the coming decade on primary prevention – actions that support people to live healthy and fulfilling lives and stop problems arising in the first instance^[1].

The Health and Social Care Service Renewal Framework will also then focus on the key reform areas that will drive our model of service to be more preventative, to find risk factors sooner and raise the level of early intervention and proactive care. This will help to detect and prevent ill-health. This Framework is due to be published late June 2025.

Proactive prevention

Taking preventative action at any point of a person's health or care needs can make a significant difference. Detecting modifiable risk factors sooner can lead to working with the person to reduce those risk factors through a combination of lifestyle or healthcare interventions. This can also make a difference when a person's health or care needs have become more advanced. For older people, being aware of the risks of frailty and being proactive in maintaining a person's ability to be as active and connected as possible can prevent health deteriorating.

A further £10.5 million will be invested in 2025-26 to expand targeted interventions for cardiovascular disease and frailty prevention. We will agree an Enhanced Service with the BMA in spring 2025 that will increase the number of proactive interventions to prevent cardiovascular disease having a significant impact on patients’ long-term health outlook. We will offer by spring 2026 a Frailty Enhanced Service to General Practices, enabling each practice to identify a Frailty Lead. This lead will help drive improvements in frailty care through training, data optimisation, and cross-sector collaboration.

Cardiovascular disease (CVD)

We will invest in a General Practice enhanced service for CVD risk factors (including high blood pressure, high cholesterol, high blood sugar, obesity and smoking). This enhanced service is part of a wider national CVD risk factor suite of improvements. This enhanced service will commence in spring 2025.

This enhanced service will focus on identifying people who may have higher CVD risk and do not currently have that identified. By focusing on people with the highest unmet need, and finding risk factors soon and commencing early interventions, the risks to people’s health will be reduced. We know this can make a real difference, for instance lowering a high blood pressure by 10 mm Hg reduces major CVD events by 20%.

Frailty prevention

With an ageing population in Scotland, there is a growing need to identify and manage frailty earlier to reduce avoidable hospital admissions and support people to live well for longer. We will offer a Frailty Enhanced Service to General Practices, enabling each practice to identify a Frailty Lead. This lead will help drive improvements in frailty care through training, data optimisation, and cross-sector collaboration. The terms of the frailty programme will be issued to GPs in April 2025.