Chapter 4 - Securing Value and Financial Sustainability
'...more needs to be done than simply giving the NHS extra money – which is why our plans for change and approach to investment and reform are so important'
Visit www.nhsscotannualreport.com for the online version of the Annual Report, including peoples' stories and key facts and figures.
While continuing to operate in a challenging financial environment, NHSScotland continues to make advances in securing value and financial sustainability, supported by year-on-year real-term increases in funding.
In 2016/17, spending on health received an above-inflation increase and rose to almost £13 billion. NHS Territorial Boards received a 5.5 per cent increase compared to 2015/16 budget levels. This included an additional £250 million which the new Health and Social Care Partnerships invested in social care under arrangements for the integration of health and social care.
Over the course of this Parliament, the NHSScotland revenue budget will increase by £2 billion, which will enable shifting the balance of care to mental health and to primary, community and social care, and will include additional investment of £500 million in primary care. As the First Minister has set out, this means that, for the first time ever, more than half of frontline spending will be on community health services, delivering primary, community and social care.
In 2017/18, funding on health has exceeded £13 billion. As part of this, the Scottish Government has committed an additional £327 million to NHS Boards, which is £176 million more than inflation. This is an important step towards achieving the Scottish Government's commitment to increasing the NHS revenue budget by £2 billion.
Despite the increased level of resources, it is clear that more needs to be done than simply giving the NHS extra money – which is why our plans for change and approach to investment and reform are so important. This is why the funding for NHS Boards in 2017/18 includes an additional £128 million to reform services to meet the changing needs of the population, take advantage of new technology and innovation and explore the added value and opportunities which working across traditional geographical boundaries brings.
The integration of health and social care is one of the most significant reforms since the establishment of the NHS. It is about ensuring that those who use services get the right care and support whatever their needs, at any point in their care journey.
Under the Public Bodies (Joint Working) (Scotland) Act 2014, Territorial NHS Boards and Local Authorities delegate some of their functions and resources to new Health and Social Care Partnerships. These functions cover primary and community health services, social care and unplanned admissions to hospital and give Health and Social Care Partnerships a unique position in being able to innovate and direct improvements across the entire care pathway to deliver best value.
Based on local priorities and working in partnership with the third and independent sectors, Health and Social Care Partnerships decide through their strategic plans how best to allocate their pooled budget to fund capacity where it is most needed, in order to improve outcomes for their local populations. By focusing on improving palliative and end of life care, reducing unplanned hospitalisation as well as delayed discharges, the Partnerships are key to ensuring the Health and Social Care Delivery Plan objectives are achieved.
In 2016/17, Territorial NHS Boards delegated £5.7 billion of their budgets to Health and Social Care Partnerships and Local Authorities delegated a further £2.5 billion, creating pooled budgets of £8.2 billion across the 31 Health and Social Care Partnerships. Despite this being the first full year of their operation, the Partnerships have already had a significant impact. For example, the Glasgow City Health and Social Care Partnership has seen significant improvement in performance following the introduction of discharge to assess, which aims to ensure patients are discharged within 72 hours of being medically fit. This, alongside the increase in step-down intermediate care beds commissioned from private sector care homes, has resulted in a reduction in the number of bed days lost to delay by over 50 per cent, from 46,250 to 23,770, over the last two years (2014/15 to 2016/17)  .
Sustainability and Value Programme
In order to manage within the levels of funding allocated, every year NHS Boards identify a level of savings which are then retained for local reinvestment in services. Plans based on these savings are continually developed throughout the year to deliver better services, better care and better value.
During 2016/17, there has been a focus on ways in which these challenges may be met through the Sustainability and Value Programme Board that oversees a range of work to deliver real productivity, efficiency and cash-releasing gains. This work is delivered by NHS Boards and their partners working collaboratively to implement transformational changes in practice across clinical and infrastructure services. These programmes of work (outlined below) have had some success in supporting NHS Boards to achieve their required efficiency savings. The focus on these areas will continue in 2017/18, along with digital transformation and capital planning.
The Sustainability and Value Programme Board currently oversees four workstreams: effective prescribing; workforce; clinical transformation; and shared services. The maturity of the model, as well as evidence from other healthcare systems working towards similar goals, suggested the need for a refresh of the workstreams in order to capture the range of activity being delivered. While the Sustainability and Value Programme Board does not 'own' most of the activities, its role is to identify, promote, support, monitor and report on the widest possible range of activities being delivered across NHSScotland.
The Effective Prescribing programme was established to accelerate change through clinical leadership, removing barriers to change and adding focus and pace to work already under way in NHS Boards or to identify new areas of work. The adoption of a 'once for Scotland' approach ensures the best use of resources through joint working in order to improve patient healthcare outcomes. Chart 2 highlights key areas of work during 2016/17:
Chart 2 - Effective Prescribing Impact Report for 2016/17*
|Intervention||Efficiency Impact (approx. £m)|
|Biologics – switch to 'once for Scotland' procurement and prescribing||8.4|
|Polypharmacy reviews – cost avoidance||2.4|
|Respiratory prescribing – implementing recommendations||0.3|
|Single National Formulary – preliminary work on local compliance||3.0|
*These are approximate figures and may manifest in the service through greater productivity, cost avoidance or efficiencies.
The workstreams for 2017/18 are: effective prescribing; workforce; clinical transformation; infrastructure; digital; and capital.
Work included in the programmes may flow from a number of sources and can be drawn from any evidence base (currently in place in Scotland; tried successfully in another healthcare system; potential carry-over from non-healthcare setting) but, crucially, all need to meet a number of criteria, namely:
- Outcomes are better;
- Staff gain from the initiative by, for example, improved utilisation of skills and competencies; and
- It is proven to be more cost-effective at a local, regional or national level.
In order to support a shift in the balance of care, the hub investment programme has taken forward a number of projects that will support the more-effective delivery of primary and community services across the country. These projects include: NHS Greater Glasgow and Clyde's Health Centres in Maryhill, Eastwood and Inverclyde; NHS Lothian's three health centres in Muirhouse, Firrhill and Blackburn in West Lothian; and the Stirling Care Centre, which is a joint venture involving NHS Forth Valley, Stirling Council, Forth Valley College and the Scottish Ambulance Service. NHS Lothian also started construction on the East Lothian Community Hospital which will provide a variety of community inpatient and outpatient services and is expected to open in 2019/20.