Chapter 5: Health and Sport
The Health and Sport portfolio plays a central role in improving the health and wellbeing of the people of Scotland. Improvements in physical and mental health contribute directly to our success as a nation, particularly our national ambition to become a wellbeing economy. As part of our responsibilities, we are committed to shifting the balance of care - so that we live longer, healthier lives at home or in a homely setting. This budget ensures that we remain on track to deliver more than half of NHS frontline spending in community health services by the end of this parliament.
A core priority of this budget is to continue to make improvements to patient care, and deliver better health and better value for our nation. To help deliver this, in 2020-21 we are increasing investment in health and care services by over £1 billion, taking portfolio investment in excess of £15 billion for the first time. This additional funding sees every penny of additional health resource and capital consequentials passed on in full, with the Scottish Government allocating more than £100 million over and above consequentials to support frontline spending. This investment further builds on our record level of frontline health spending in Scotland, which is £136 per person (6.3 per cent) higher than in England.
To support the measures set out in the Medium Term Financial Framework, in 2020-21 the Scottish Government will further increase its package of investment in social care and integration. This investment will increase by a further £100 million, taking the total package of investment to £811 million, underlining the commitment to support older people and people with long-term conditions and recognising the vital role undertaken by unpaid carers.
Our record levels of investment in Health and Social Care Services allow us to make a significant contribution to the central purpose of the National Performance Framework (NPF) - enhancing population wellbeing through our core work delivering the healthy and active outcome. However, there is a wider benefit from investment in the health and social care portfolio, particularly in relation to outcomes for an inclusive and sustainable economy, reducing poverty and inequality, growing and sustaining inclusive and resilient communities, and promoting a bright future through our children and early years.
As well as supporting our national ambitions in relation to wellbeing, the portfolio also makes a valuable contribution to delivering the other key pillars of the Programme for Government:
- NHS Scotland will be a 'net-zero' greenhouse gas emissions organisation by 2045 at the latest.
- All NHS Scotland new buildings and major refurbishments will, from April 2020, be designed to have net-zero greenhouse emissions.
- The NHS supply chain will be reviewed to determine the extent of associated greenhouse gas emissions and environmental impacts. Once the extent of environmental impacts is established, a programme of work will be undertaken to minimise these impacts.
- Specific investment in key policy areas from the Health Portfolio that are contributing giving children in Scotland the best start in life. This includes Family Nurse Partnerships (£15 million), and Maternity and Neonatal services - including PfG commitment in relation to Best Start (£6 million).
- Central to the Portfolio budget is continuing to tackle poverty by sharing opportunities and wealth more equally - for example through universal healthcare free at point of need and free prescriptions.
- Investment in the health and social care workforce, as the largest set of employees in Scotland, continues to directly benefit the Scottish Economy.
- This is underpinned by progressive pay policies, such as payment of the living wage, no compulsory redundancy, and delivery of the third year of the Agenda for Change pay deal.
- Investment increases our potential to accelerate innovation and increase the pace of reform within health and social care, benefiting businesses and the wider economy.
The portfolio priorities are reflected in our good progress with the Health and Social Care Delivery Plan, as reported in the recent update that was published on 15 November 2019.
Our progress includes:
- the negotiation and ongoing implementation of the new landmark General Medical Services contract;
- in partnership with COSLA and SOLACE, the publication of public health priorities that will direct public health improvement across the whole of Scotland;
- planning on the expansion of new elective care capacity which is underway, with construction commenced at the Golden Jubilee National Hospital;
- early successes from the investment to date of £59 million in delivering our Cancer Strategy;
- as part of our service reform, maximising opportunities to recruit, retain and motivate our workforce by improving consistency in workforce practice and employee experience; and
- funding the delivery of 'Once for Scotland' business systems that enable NHS Boards to collaborate for improved patient outcomes.
We are clear that much more needs to be done to accelerate the pace and scale of short-, medium- and long-term reform to meet the challenges faced, and ensure the continued delivery of sustainable person-centred services, for the health and social care system of the future.
We will do this by driving forward the process of health and social care integration and improving access to services. Central to these reforms is the implementation of plans to improve primary care, mental health and social care, which will improve access to services and help deliver health and social care in a sustainable way, with an emphasis on prevention and providing care closer to people's homes.
We will also continue our efforts to improve access to hospital-based services through continuing delivery of the Waiting Times Improvement Plan. Work is underway now to support NHS Boards to develop three-year Annual Operational Plans for 2020-21 onwards. These plans will include a focus on Waiting Times, specifically relating to inpatient and day cases, as well as wider plans to deliver sustainable solutions, including progress against the development of the elective centres.
There will also be a focus on longer-term sustainable solutions, including delivering improved elective activity using proven methodology and implementation of Access Collaborative programmes in order to balance demand and capacity while reducing use of the independent sector in the future. We will invest in new services, including £1 million to support the introduction of a thrombectomy service for stroke patients.
We will strengthen our contribution to reducing health inequalities through the establishment, working with local government, of Public Health Scotland and through investment to reduce the harm caused by poor diet, alcohol, tobacco and other drugs.
Funding for Frontline services
This budget provides record funding for the NHS in Scotland, investing over £100 million more than Barnett consequentials. This funding strengthens our support in shifting the balance of spend from hospitals towards community services and supports our commitment that by the end of this Parliament, more than half of spending will be in community health services. In 2020-21 we are continuing to prioritise frontline services. Our additional funding for frontline NHS Boards will amount to £333 million. Along with increased investment for improving patient outcomes set out below, this will deliver additional investment of £454 million in our frontline Boards (4.2 per cent).
Table 5.01: Investment in Improving Patient Outcomes
|Improving patient outcomes|| 2019-20
|Mental Health and CAMHS||61||89||28|
The health capital budget of £428 million includes all additional health capital consequentials and will again support the Scottish Government's strategic priorities of economic growth, climate change and the place principle. NHS Boards are fully committed to achieving the Scottish Government climate change targets and as part of upgrading health facilities, will take the opportunity to improve energy efficiency, as well as delivering more co-ordinated and integrated local health and social care services.
We recognise that patients and those who accompany them, particularly in our remote and island communities, spend many hours travelling to and from healthcare facilities. It is estimated that Islanders in Scotland alone travel three million miles to attend outpatient clinics on the mainland. Already, many return outpatient clinic attendances are now undertaken by video using technology called 'Attend Anywhere', a virtual clinic and waiting room. We will expand this service, reducing the amount of time it takes for patients to travel to an appointment, reducing our emissions, and benefiting the economy as patients who are in employment require less time off work.
Additionally, our capital investment programme will:
- support the Elective Centre Programme in delivering additional capacity and reducing waiting times;
- invest more than £200 million in the Baird and Anchor Hospital, which will deliver a new family hospital and cancer centre in Aberdeen; and
- provide over £13 million of new radiotherapy equipment, which is an essential element of our cancer strategy.
Health and Social Care Integration
In 2016, in one of the most ambitious reforms of public services, we integrated health and social care to ensure people have access to the services and support they need, their care feels seamless to them, and they experience good outcomes and high standards of support. Integration is core to our plans for a strong future for health and social care services that focus on prevention, quality and sustainability. With local arrangements now bedded in across Scotland, we recognised in 2019 that the pace and effectiveness of integration needs to increase. With our partners in the NHS and local government, we reviewed progress and agreed 25 actions for delivery, all of which are now progressing well, with many either complete or nearing completion. For 2020-21, our key priorities are to continue to improve the availability of, and people's access to, community-based services, and, working with local government, to agree outcomes and standards for delivery, and to further develop accountability arrangements.
Through integration, over £9.4 billion of resources previously managed separately by NHS Boards and Local Authorities is now pooled to maximise local improvements under Integration Authorities' direction. In recent years, significant work and investment has, in particular, gone into supporting older people and people with long-term conditions to live well in their own homes or in a homely setting for longer. We are seeing improvements in supporting people to stay at home and in their own communities and are on track to deliver our commitment that more than 50% of frontline NHS spending will be shifted to community health services by the end of this Parliament.
Primary care is the cornerstone of the health and care system with the majority of healthcare delivered in primary care settings. It is vital in promoting prevention and self-management and in influencing the level of demand on other parts of the health and social care system. Getting primary care right is therefore vital to improving the health of the nation and the sustainability of the whole health and care system.
In 2020-21, our investment in primary care services will help support the implementation of the new GP contract and our wider primary care reforms so that patients can see the right person at the right time. Our priorities over the next year are:
- continuing to build primary care multi-disciplinary teams to improve patient access and outcomes;
- continuing to implement the GP contract to make general practice an even more attractive career;
- from January 2021, beginning to discharge low-risk glaucoma and treated ocular hypertension patients out of hospitals into the management of community optometrists, helping to build hospital capacity;
- supporting the Oral Health Community Challenge Fund and new arrangements for providing oral health in care homes;
- accelerating the development of a new model of oral health care for adults, focusing on practice-based preventive care with the introduction of an Oral Health Assessment;
- beginning to roll-out our commitment for the remission of dental charges for care-experienced young adults; and
- launching the new NHS Pharmacy First and the Medicines: Care and Review Services, provided by our network of community pharmacies.
Our key mental health priorities are to improve access to high quality clinical services, while at the same time making real progress in implementing new measures that widen and deepen our whole approach to mental health.
Building on the widespread, daily achievements of Scotland's mental health workforce, we will continue to provide investment focused on meeting waiting time standards and addressing long waits for treatment.
Our Programme for Government has mental health at its heart with a package of measures to support positive mental health and to respond effectively to mental ill health.
In 2020-21 we will provide funding to:
- support the work of the Perinatal and Infant Mental Health Programme Board;
- widen the approach to children and young people's mental health;
- progress our commitment to provide 800 additional mental health professionals in key settings by 2021-22;
- continue with the development of the Distress Brief Intervention programme;
- support the National Suicide Prevention Leadership Group;
- put those most directly involved in mental health services at the heart of developing our approach to supporting adults through the Adult Mental Health Improvement Collaborative; and
- invest in the exciting opportunities offered by the creation of Brain Health Scotland.
Social care support is an investment in Scotland's people, society and economy. As an example, in 2017-18, an estimated 230,117 people in Scotland received social care support and services.
Our focus is on helping people to live independently, be active citizens who participate in, and contribute to, society, and maintain dignity and human rights. We aim to raise the profile, quality and sustainability of social care, including the status of social care as a profession. We will continue to work with local government, people who receive support, carers and the social care sector to improve experiences and outcomes. Scotland receives international recognition for its human rights-based approach to social care.
Our priorities in the year ahead are:
- developing a vision and plan for a sustainable care home sector;
- promoting fair work principles;
- designing and testing a framework of practice for adult social care;
- continued implementation of the Carers (Scotland) Act to improve support for Scotland's 700,000 to 800,000 unpaid carers;
- delivering the Adult Support and Protection Improvement Plan to improve the wellbeing and quality of life for vulnerable adults and support a multi-agency inspection programme to provide assurance;
- supporting the Independent Living Fund to provide a high quality service to disabled people, financially supporting them to achieve positive independent living outcomes; and
- procuring a new contract for contactScotland-BSL, the service that connects Deaf and Deafblind British Sign Language users throughout Scotland with statutory and voluntary bodies and private organisations on a 24/7 basis.
Reducing Health Inequalities
Reducing health inequalities is one of the biggest challenges we face. We recognise that health inequalities are symptomatic of wider social inequalities, and therefore it is imperative to tackle the wider determinants of health such as poverty along with helping people to live longer, healthier lives through interventions such as smoking cessation.
This year, we will, working with local government, establish Public Health Scotland to make the best use of Scotland's public health assets to support communities to improve health and wellbeing.
The harm caused by poor diet, alcohol, tobacco and other drugs is the leading cause of health inequalities in Scotland. In 2020-21, we will make an additional £12.7 million available to tackle the harm associated with the use of illicit drugs and alcohol. This is a 59 per cent increase in direct funding from the Scottish Government, and comes on top of spending by NHS Boards to address these issues.
This funding will be used to:
- support improvements in alcohol and drug services and mental health services;
- develop a national pathway for Opiate Substitute Therapy to reduce drug deaths; and
- establish an Inclusive Scotland Fund to help improve outcomes for people with experience of severe, multiple deprivation, and their families.
We will also invest:
- £1.35 million to ensure that our workforce can respond to people affected by trauma in ways that prevent further harm; and
- in weight management services to improve support for people living with, or at risk of, type 2 diabetes and for children and young people at risk of obesity.
We will also put in place a Women's health plan to tackle women's health inequalities and create a £1 million fund to support women affected by mesh complications.
Priorities for a More Active Nation
Being physically active is one of the best things we can do for our physical and mental health, helping to protect us from many of the most serious long-term health conditions, and contributing significantly to physical and mental wellbeing. Our Physical Activity Delivery Plan sets out what we are doing to achieve our vision of a Scotland where people are more active, more often. The World Health Organization has welcomed our Delivery Plan's systems-based approach to working across sectors, and has recognised Scotland as one of the forerunner countries in responding to the challenges set out in its Global Action Plan on Physical Activity. In the coming year our work will include:
- investing in people, places and spaces providing sport and physical activity to provide opportunities for all to participate;
- working with the Scottish Women and Girls in Sport Advisory Board to examine ways to increase female participation;
- embedding the Changing Lives Through Sport and Physical Activity programme to help transform lives;
- providing £1.2 million to support walking groups throughout Scotland as it is the easiest and most effective way to be active;
- working with sportscotland to further develop disability sport in Scotland;
- expanding activity to increase participation of under-represented groups in sport and physical activity;
- continuing to develop the community sport hub model in areas of deprivation, reaching the target of 200 hubs across the country by the end of 2020; and
- working with sportscotland to protect sport investment and mitigate the impact of continued reductions in lottery income, providing an underwrite in funding in line with previous years.
Table 5.02: Spending Plans (Level 2)
|Level 2|| 2018-19
|Health and Sport||13,583.8||14,311.1||15,327.9|
|Food Standards Agency||15.3||16.0||16.0|
|Total Health and Sport||13,599.1||14,327.1||15,343.9|
|Total Fiscal Resource||12,874.8||13,607.4||14,532.3|
|of which Operating Costs*||-||53.9||64.7|
|UK Funded AME||100.0||100.4||100.4|
* Scottish Government operating costs have been presented in this way within portfolio budgets since 2019-20.
** The Financial Transactions total presented here represents the 'net' portfolio position after adjusting for forecast Financial Transactions income. To see the 'gross' or total amount of financial transactions that will be spent by the portfolio in 2020-21, please see Table 3.02.
|Level 2|| 2018-19
|Presentational Adjustments for Scottish Parliament Approval|
|sportscotland (NDPB Non-cash)||(1.3)||(1.2)||(1.3)|
|Food Standards Scotland - shown separately||(15.3)||(16.0)||(16.0)|
|Total Health and Sport||13,670.5||14,447.9||15,347.6|
|Total Limit on Income (accruing resources)||2,050.0|
What the Health and Sport budget does
The Health budget helps the people of Scotland to live longer and healthier lives, through focusing on early intervention and prevention, reducing health inequalities and providing sustainable, high quality and continually-improving health and care services locally, regionally and nationally. It supports the triple aim of better care, better health and better value.
The Sport budget supports the people of Scotland to get more physically active as part of our efforts to prevent ill health and improve our wellbeing whilst delivering world-class sporting performances.
Table 5.03: Health and Sport Spending Plans (Level 3)
|Level 3|| 2018-19
|NHS Territorial Boards||9,718.2||10,070.1||10,704.0|
|NHS National Boards||1,184.3||1,225.6||1,312.1|
|NHS and National Boards Capital||361.2||356.0||448.0|
|Community Health Services|
|General Medical Services||870.5||931.2||1,035.8|
|Pharmaceutical Services Contractors Remuneration||184.8||191.9||198.0|
|General Dental Services||414.8||416.6||428.6|
|General Ophthalmic Services||107.4||108.4||109.5|
|Mental Health Services||70.2||85.5||117.1|
|Additional Support for Social Care||-||120.0||220.0|
|Workforce and nursing||193.1||216.2||262.1|
|Health Improvement and Protection||62.7||68.3||85.8|
|Active, Healthy Lives||12.8||13.4||13.4|
|Care, Support and Rights||112.1||111.3||112.4|
|Quality and Improvement||13.2||18.7||20.1|
|NHS Employer Pension Contributions||-||121.8||-|
|Miscellaneous Other Services (restated)||(114.7)||(133.8)||(164.1)|
|Revenue consequences of NPD||44.7||50.0||65.0|
|NHS Impairments (AME)||100.0||100.0||100.0|
|Total Health and Sport||13,583.8||14,311.1||15,327.9|
|UK Funded AME||100.0||100.0||100.0|
Table 5.04: Territorial and National Boards Spending Plans (Level 4)
|Level 4|| 2018-19
|Improving Outcomes and Reform||196.7||189.2||228.6|
|NHS Ayrshire and Arran||694.9||720.0||762.4|
|NHS Dumfries and Galloway||289.1||299.1||316.1|
|NHS Forth Valley||506.8||527.0||558.7|
|NHS Greater Glasgow and Clyde||2,154.5||2,231.2||2,364.7|
|NHS Western Isles||73.0||75.7||80.0|
|NHS Waiting Times Centre||54.0||54.2||60.0|
|NHS Scottish Ambulance Service||237.9||259.9||278.4|
|NHS National Services Scotland||328.2||338.5||327.7|
|Healthcare Improvement Scotland||24.7||24.9||26.3|
|NHS State Hospital||34.8||35.3||37.6|
|NHS Education for Scotland||420.0||425.9||461.5|
|NHS Health Scotland||18.4||18.3||-|
|Public Health Scotland||-||-||47.9|
|Total Territorial and National Boards||10,902.5||11,295.7||12,016.1|
Food Standards Scotland Priorities
The vision of Food Standards Scotland (FSS) is to deliver a food and drink environment in Scotland that benefits, protects and is trusted by consumers. FSS launched its first strategy in 2016, which set out the high-level direction until 2021 and FSS will continue to deliver its strategic objectives across the breadth of their remit during the financial year. In 2020-21, FSS will begin work to develop a new strategy, which will continue to contribute to the delivery of several of the Government's National Outcomes, and this will again be delivered through a corporate plan that outlines the priorities and key activities to be taken forward using an outcomes-based approach.
The budget will also enable FSS to initiate some of the work required to increase the capacity and capability of the organisation so that it is best placed to manage the impact of exiting the EU. As the central regulatory body for food and feed, FSS will be significantly affected by EU exit, due to the current regulatory framework deriving from EU law. FSS will also need to help businesses and local authorities be ready for legislative and regulatory change as a consequence of leaving the EU, to ensure that high standards of consumer protection are maintained in Scotland.
What the Food Standards Scotland budget does
The budget of Food Standards Scotland supports consumer protection - making sure that food is safe to eat, ensuring consumers know what they are eating and improving health through better diet.
The objectives of Food Standards Scotland (FSS) as set out in the Food (Scotland) Act 2015 are to:
- protect the public from risks which may arise in connection with the consumption of food;
- improve the extent to which members of the public have diets which are conducive to good health; and
- protect the other interests of consumers in relation to food.
Table 5.05: Food Standards Scotland Spending (Level 3)
|Level 3|| 2018-19
|Total Food Standards Scotland||15.3||16.0||16.0|
|UK Funded AME||-||0.4||0.4|
Contribution to National Outcomes
This table summarises the portfolio's contributions to the Outcomes of the National Performance Framework.
Table 5.06: National Outcome
Health and Social Care Integration
Primary National Outcome: Health
Secondary National Outcomes: Communities, Economy
Integration Authorities have real power to drive change, managing over £9.4 billion of resources that NHS Boards and local authorities previously managed separately. Pooling budgets in this way gives local systems greater opportunities to maximise the use of all of their resources and co-ordinate the work of general practices, community services, hospitals and third and independent sector to improve health and wellbeing for their local communities.
Based on Christie commission principles, Integration Authorities plan services across the whole unscheduled pathway extending accountability to better match control and reducing disconnects and opportunities for cost shunting and consequently improving best value. Health and Social Care integration contributes therefore to the wellbeing of Scotland and sustainable and inclusive economic growth.
Investment in the work of general practices, community services, hospitals and third and independent sector will improve health and wellbeing for their local communities.
Evaluation has evidenced that the ILF Transition Fund has had a positive impact on young disabled people, improving their chances of getting employment.
Contribution to National Outcomes
National Outcome: Primary Care
Primary National Outcome: Health
Secondary National Outcomes: Communities, Economy, Children and Young People
The National Clinical Strategy for Scotland states that 'across the world it has been shown that effective primary care, with universal coverage, can significantly improve outcomes for patients, and deliver the most cost-effective healthcare system'. Our policies are aimed at building the capacity of primary care services so that they can better manage the increased demands caused by changing demographics and increase their contribution to mitigating health inequalities.
Primary Care reform contributes therefore to the cross-cutting priorities of wellbeing and sustainable and inclusive economic growth.
In 2020-21, our investment in primary care services will help support the implementation of the new GP contract and our wider primary care reforms so that patients can see the right person at the right time, contributing to the health of communities.
National Outcome: Mental Health
Primary National Outcome: Health
Secondary National Outcomes: Communities, Economy, Children and Young People
A strong and responsive range of services to support people's mental health needs will help to strengthen communities, enabling many individuals to participate more actively. They also underpin improvements in our economy, enabling fuller employment and greater economic contributions. Mental Health reform contributes therefore to the cross-cutting priorities of wellbeing and sustainable and inclusive economic growth.
Putting those most directly involved in mental health services at the heart of developing our approach to supporting adults through the Adult Mental Health Improvement Collaborative will support the cross cutting priority of sustainable and inclusive economic growth.
There is a range of investments and actions designed to improve access to and support from specialist services and to provide a greater array of alternative services for children, young people and their families that can provide timely and effective help, and enable many mental health issues to be addressed effectively at an early stage by 'universal' services such as schools.
National Outcome: Access to Healthcare
Primary National Outcome: Health
Secondary National Outcomes: Economy, Poverty
Ensuring access to good quality and sustainable healthcare is fundamental to a population that is healthy and active.
Ensuring waiting times standards and guarantees meets the rights of people of Scotland, and supports people to secure and maintain a working life, contribute to the sustainable and inclusive economic growth of Scotland, and allows to raise themselves out of poverty. All of which will improve the mental health and wellbeing of individuals and contributes to a better society.
National Outcome: Reducing Health Inequalities
Primary National Outcome: Health
Secondary National Outcomes: Communities, Children and Young People, Poverty
Reducing health inequalities will improve the health of people, families and communities.
This year, we will, working with local government, establish Public Health Scotland to make the best use of Scotland's public health assets to support communities to improve health.
Reducing the amount people spend on alcohol and drugs, will help to reduce poverty.
Public Health Priorities and Population Health improvements contribute to the cross-cutting priorities of wellbeing and sustainable and inclusive economic growth.
There is a strong link between trauma and adverse childhood experiences and problematic use of alcohol and drugs. Our trauma-informed policies will help break intergenerational cycles - to help children grow up loved and safe.
Interventions, which help children and young people and women in particular, will help ensure that we live in communities that are inclusive, resilient and safe.
Investments in Early Years, Women's Health Plan and Drug and Alcohol Related Harm Priorities will contribute to the cross-cutting priority of reducing child poverty.
National Outcome: Social Care Support
Primary National Outcome: Human Rights
Secondary National Outcomes: Communities, Fair Work and Business, Health, Economy
Supporting people to live independently and free personal care enable more people to remain in their homes for longer. Evaluation has evidenced that the ILF Transition Fund has had a positive impact on young disabled people. Calls to contact Scotland-BSL have increased substantially, clearly demonstrating its value to people.
Improving support for Scotland's 700,000 to 800,000 unpaid carers is a core element of our social care reform work. Scotland's carers make a huge contribution to the people they care for and to our communities. There are more people caring full time for relatives or friends than staff working in either the NHS or in social care.
Unpaid caring can impact health, incomes and social isolation. Inappropriate caring responsibilities can damage educational attainment and life chances for young carers.
National Outcome: Early Learning and Childcare
Primary National Outcome: Children and Young People
Secondary National Outcomes: Poverty, Health, Education
There is substantial evidence showing that attending high quality ELC improves children's cognitive, social, emotional and behavioural development, with positive outcomes sustained into later years. High quality ELC is particularly beneficial for the most disadvantaged children.
The expansion will save money for families who already pay for childcare, and so increase households' disposable income. Costs of living and income from employment are two of the three key drivers of poverty. Enabling parents to secure work or work more hours through expanding funded ELC will also increase families' income.
We expect the expansion to improve children and parents' health and wellbeing through helping children to form healthy behaviours and supporting parental confidence and capacity.