Piloting an Approach to Identifying Preventative Spend in the Scottish Budget

Annex B – Health and Social Care Portfolio Pilot (Health Boards)

Introduction

As part of the preventative budgeting pilot programme, we developed a bespoke pilot for NHS Boards to understand the mix of different types of activities, and how much could be considered under the definitions of prevention set out in the Preventative Spend Tool. This Annex covers the approach taken in the pilot and the aggregate results generated from the pilot study.

Approach

The Health Boards pilot was designed to cover a range of NHS Boards of different sizes and locations. This included seven Territorial NHS Boards and two National NHS Boards (set out in Figure 18). The pilots covered all NHS Board spending for those taking part in the pilots, and focussed on the 2025/26 Budget.

Figure 18 – NHS Health Boards taking part in the preventative spend pilot

NHS Boards in pilot

Territorial NHS Boards

• NHS Borders
• NHS Dumfries and Galloway
• NHS Fife
• NHS Forth Valley
• NHS Highland
• NHS Lanarkshire
• NHS Lothian

National NHS Boards

• National Services Scotland
• Scottish Ambulance Service

For each NHS Board taking part, they were provided with the Preventative Budgeting Tool and Guidance for testing against their budget cost centre hierarchies. Like the wider pilot programme, we adopted a “top down” approach, working with existing budget reporting structures to ensure replicability in future. The level of detail analysed by Boards varied, with some using a level of aggregation that covered several hundred budget lines, to some Boards looking at thousands of budget lines.

To ensure some consistency across Boards, we developed and agreed a rule book to support classification of larger areas of spend, such as primary care, acute care, dental care, community eyecare and corporate services. The rules were based on a mix of data, evidence, reviewing existing research, and professional judgement (where no evidence was easily available). For example, corporate services were broadly considered “other”, while elements of primary care were considered preventative (e.g. screening services, etc), while other elements were considered acute/responsive/treatment.

Developing these rules for large areas of spend and applying them across Boards ensured that the aggregate results for each Board landed in a broadly consistent range. For areas of spend not covered by the rule book (e.g. particular clinical specialties), Boards applied their own local judgement, typically with input from finance, clinical and public health teams. This approach was designed to balance rigour with proportionality.

As the preventative budgeting methodology is further developed in future, more work will be done to develop further rules that can be applied to spending outside of the larger spend areas included in the rule book so far.

Figure 19 sets out examples of different spend lines within Health Boards that were classified as per our definitions of prevention.

Classification: Examples

Primary Prevention

• Vaccine programmes
• Family Nurse Partnership
• Health visiting
• Health improvement and promotion

Secondary Prevention

• Screening services (e.g. breast cancer screening, diabetes retinal screening)
• Family genetic testing
• Pharmaceuticals for addressing early risk factors (e.g. vitamins for deficiencies)

Tertiary Prevention

• Physiotherapy
• Assistive technology
• Occupational therapy
• Pharmaceuticals targeted at stopping disease progression (e.g. heart disease medication, diabetes, anticoagulants, etc)

Enabling

• Lab services
• Training for those providing preventative services (e.g. health visitors)
• National Services Scotland National Screening oversight function

Acute/ responsive/ Treatment

• GP responsive activity
• Outpatient care
• Critical care
• Dental treatment
• Frontline ambulance services

Other

Corporate services – finance, HR, marketing, etc

Results

The results from the 7 Territorial NHS Boards and 2 National NHS Boards have been used to develop aggregate proportions that are applied to the broad Level 4 lines. Results presented here combine both Territorial and National NHS Boards level 4 lines.

Note these results should be taken as preliminary and treated with caution. Results could change between the pilot phase and the final preventative spend estimates planned for Summer 2026.

Preventative spend

We estimate that around 11% of NHS Board planned spending can be defined as preventative (around £1,776m) (Figure 20), while a further 4% was “enabling” (£670m). 55% was “acute/ responsive” (£8,863m) and 29% “other/ general service” (£4,692m).

Level of prevention

Of the planned preventative spend recorded, around 15% was primary prevention spend (£274m), with around 31% focussed on secondary activities (£544m), and 54% on tertiary spend (£9459m) (Figure 21).