Scottish Budget 2019-2020: Equality and Fairer Scotland statement

Chapter 8 Health and Sport

Introduction

The Health and Sport portfolio is responsible for ensuring that the people of Scotland get the right care and support, in the right place, and at the right time through the NHS and wider health and social care services.

The Health and Sport portfolio strives to improve the health of the nation, so that people live longer, healthier lives and experience lower levels of health inequalities throughout Scotland.

While progress continues to be made, Scotland still experiences lower levels of life expectancy than most other countries in Western Europe and health inequalities between the most and least deprived communities in Scotland persist.

Key Inequalities of Outcome

The portfolio is crucial in delivering the following key National Outcomes:

• We are healthy and active.
• We live in communities that are inclusive, empowered, resilient and safe.

Recent evidence shows that health inequalities exist across the protected characteristics in Scotland:

• In 2017, older people were less likely to report being in good or very good health (52 per cent) than younger people (86 per cent).
• The proportion of girls reporting 'good' or 'very good' health decreased slightly between 2016 (96 per cent) and 2017 (93 per cent) while most boys (94 per cent) continued to report their health as 'good' or 'very good'.
• In 2017, men, younger people and people living in relatively affluent areas were most likely to meet the guidelines for moderate or vigorous physical activity.
• In 2017, men were less likely to be in the healthy weight category (31 per cent) compared with women (35 per cent) and a higher proportion of men were overweight (40 per cent) compared with women (33 per cent).
• With respect to children, 12 per cent of boys and 15 per cent of girls were at risk of obesity. The proportion of boys at risk of obesity has fallen in recent years, from a peak of 20 per cent in 2011.
• In 2016, a lower proportion of people with a disability or long-term limiting condition reported having good or very good general health (29.3 per cent) compared with the rest of the population (87.8 per cent).
• In 2016, individuals with a disability or a long-term condition reported lower levels of mental wellbeing than the rest of the population.
• In 2014, a higher percentage of individuals in the "Asian" and "All other ethnic groups" groups reported good or very good general health compared to the White: Scottish group after age-standardisation (80.4 per cent and 81.5 per cent versus 71.5 per cent, respectively).
• In 2016, the proportion of people identifying as lesbian, gay, bisexual (LGB) or other reporting good or very good general health was significantly lower than the rest of the population (64.0 per cent vs. 73.8 per cent, respectively).
• People identifying as LGB or other reported slightly lower average mental wellbeing than heterosexuals.
• The decline in activity levels by age among both men and women corresponded to increasing levels of very low activity (less than half an hour a week of moderate activity or the equivalent level of vigorous activity) as age increased.

In addition to the health inequalities discussed above, there are known health inequalities between people living in the most and least deprived areas of Scotland. Among those living in the most deprived areas the prevalence of cardiovascular conditions, diabetes, heart disease and strokes is higher, along with experience of problems with drugs and alcohol misuse. Mental wellbeing is also significantly lower.

Unpaid caring affects women more than men. Evidence^[1] shows that unpaid carers are more likely to be women (59 per cent women: 41 per cent men) and that working age women are much more likely to be carers than men.

Caring is also linked to poverty. Evidence^[2] shows that there is a direct correlation between hours spent caring and living in Scotland's most deprived areas with 47 per cent of carers living in the most deprived areas caring for 35 hours a week or more compared with 24 per cent of carers living in the least deprived areas.

In addition to tackling general health inequalities in the population, the investment detailed across the priorities discussed below will address equalities issues for specific groups such as older people, women and infants, children and young people, young males, Lesbian, Gay, Bisexual and Transgender people and those living with poor mental health and/or disabilities.

Key Strategic Budget Priorities

The key priorities of the health and sport portfolio are:

• To improve access to health and care services including reducing waiting times and supporting the overall workforce to deliver effective services including in specialist skills such as radiotherapy.
• To improve mental health services including a five year priority for adolescents and young people's mental health services.
• Provide integrated community-based health and social care including our commitment to fund personal care and to ensure social care workers are paid a living wage.
• Support community based health care through a modernised GP service contract, pharmacy, dental and optician services.
• Improve patient care to ensure that people receive appropriate and beneficial care that is evidence-based and aligned with their personal preferences.
• To focus all public services on improving the health of our population.
• To reduce physical inactivity in adults and children.

Equalities Implications of the Scottish Budget 2019-20

The investments and actions outlined in the Scottish Budget are expected to have a positive impact on the health of several social groups who possess protected characteristics.

The budget for the portfolio is set out in the Scottish Budget document showing that around 80 per cent of the funding is directed to NHS general or specialist Boards. As public bodies, NHS Boards are subject to the Public Sector Equality Duty and its Scottish specific duties. They are required to produce a mainstreaming report which explains how they will ensure that as an organisation they value diversity and promote equality. Mainstreaming is a long term approach that aims to make sure that decisions made are fully sensitive to the diverse needs and experiences of patients, carers and staff and that equality is mainstreamed into working practices, policies and representation.

Access to Health Care Priorities

The Waiting Times Improvement Plan sets out the aim that by spring 2021, 95 per cent of outpatients and 100 per cent of inpatients and day cases will wait less than 12 weeks to be treated. It will:

• Increase capacity by expanding facilities;
• Increase clinical effectiveness and efficiency by implementing targeted action plans for key specialities and clinical areas; and
• Design and implement new models of care by accelerating whole-system design of local patient pathways through health and social care integration and regional service reconfiguration.

Over the next three years, the Improvement Plan will be supported by directing £535 million of resource funding, and £320 million of capital investment. This includes the £200 million that has been previously outlined to deliver the new elective centres.

This work will be supported by our £100 million cancer strategy. We will invest £50 million over five years in radiotherapy equipment, staff and training to ensure the provision of advanced radiotherapy services. We will also continue to invest up to £2.5 million to enable the Managed Service Network for Children and Young People with Cancer to lead and deliver the improvements set out in their second Cancer Plan, with a particular focus on improving services for teenagers and young adults.

Mental Health Priorities

We are introducing a comprehensive package of measures to improve mental health services. We are investing an additional £250 million over the next five years to support measures for children and young people, and the work of the Task Force on Children and Young People's Mental Health Improvement.

Actions include:

• creating around 350 counsellors in school education across Scotland;
• putting an additional 250 school nurses in place by 2022;
• ensuring that, by the end of academic year 2019-20, every local authority will be offered training for teachers in mental health first aid;
• providing more than 80 additional counsellors in further and higher education over the next four years;
• putting in place systems to fast-track those with serious mental illness to specialist treatment;
• developing services for community mental wellbeing for 5-24 year olds and their parents;
• improving training and awareness of people working with vulnerable families;
• expanding the Distress Brief Intervention programme to include people under 18; and
• expanding the range of perinatal support available to women.

Action is also planned to tackle adult mental health issues, including:

• trialing improvements to the NHS 24 Breathing Space service;
• more widespread online access to cognitive behavioural therapy;
• strengthening self-help platforms through NHS Inform;
• improving access to psychological assessment/therapies in rural areas; and
• enhancing the handling of 111 calls through specialist mental health training.

This funding will support a range of actions that will improve the mental health of the population, including among LGBT people who often experience higher rates of mental health problems. Significant investments are being made to improve the mental health of children and young people including the announcement of the Task Force on Children and Young People's Mental Health Improvement in June 2018. Additional commitments to promoting children and young people's mental health include: investing in 350 counsellors in school education; offering all local authorities mental health first aid training for teachers; and extending the Distress Brief Intervention (DBI) programme pilots to include people under 18. The DBI programme aims to support individuals experiencing distress by providing a range of time-limited supports including signposting, community-based problem solving and wellness and distress management planning.

Plans have been set out to further reduce Scotland's suicide rate by 20 per cent by 2022. Backed by a new £3 million innovation fund, we will:

• Implement refreshed mental health and suicide prevention training for Scotland's public and private sectors;
• Develop reviews of all deaths by suicide ensuring lessons are shared and acted on; and
• Develop innovative ways to use digital technology to prevent suicide.

These actions will be of particular importance to improving men's health, as just under three-quarters of suicides in Scotland are completed by men. Moreover, just under three-quarters of completed suicides in Scotland occur among persons who are unmarried or not partnered, and so increased suicide prevention investments will also help to improve the health of this population.

Workforce Priorities

Ensuring we have a health and social care workforce in place to respond to these challenges is crucial to these ambitions, and provision has been made for:

• 800 more GPs (headcount) over the next 10 years;
• 100 more medical undergraduate places by 2021;
• 2,600 extra nurse and midwifery training places by the end of this Parliament;
• an increase in GP Specialty Training posts from 300 to 400 per year;
• 50 more radiology specialty training posts over the next five years, supported by an additional £3 million investment;
• 500 more advanced nurse practitioner posts by the end of this Parliament;
• 1,000 additional paramedics by 2021.

Health and Social Care Integration and Social Care Priorities

The integration of health and social care remains one of the most significant reforms that Scotland's public services have seen. In 2019-20 we are increasing our package of investment in social care and integration to exceed £700 million, underlining our commitment to support older people and people with disabilities and recognise the vital role unpaid carers play.

Social care provides vital support for thousands of people in Scotland. To ensure the growing demand for social care and support is met, and to maintain its crucial role for many in being able to live independently and participate in society, we will:

• implement our commitment to extend free personal care to all those under 65 who are assessed as needing it supported by our investment of £30 million;
• reform the Independent Living Fund (ILF) Scotland charging policy to improve the disposable incomes of disabled people;
• continue to support delivery of the Living Wage for social care staff working in adult services;
• work with key partners, including COSLA, to support workforce planning for integrated social care services;
• continue to work to embed the recently established rights for Scotland's unpaid carers with an additional £10.5 million;
• improve access to support for survivors of abuse experienced while growing up in care;
• support improvements in adult support and protection;
• deliver the provision of communication equipment and support to children and adults who have lost their voice or have difficulty speaking; and
• consider evidence for and views on a potential new national scheme to provide extra financial support to people with the highest social care needs.

Continuing investments in social care and integration, including the Independent Living Fund, extending free personal care to all those under 65 who need it, and implementation of the Carers (Scotland) Act 2016, will help to improve the health of individuals living with disabilities and support an aging population. Moreover, funding to support the delivery of dental services within care homes will further help to maintain and improve the oral health of older people.

Our investment in community pharmacy demonstrates our commitment to the valuable core services that the network of pharmacies across Scotland provide in our communities. This includes services such as the Minor Ailment and Chronic Medication Services, and the Public Health Service which provides, for example, easy walk-in access to support and advice for smoking cessation. Past Audit Scotland analysis has indicated that the distribution of community pharmacies across Scotland varies by deprivation levels, with the highest number of pharmacies in the most deprived areas.

Community Health Services Priorities

Primary care is supported with an investment of £941 million. The first entirely Scottish GP contract came into effect on 1 April 2018 and focuses the role of Scotland's GPs on being clinical leaders in the community, leading enhanced, integrated community teams. The reform will reduce unnecessary workload for GPs, ensuring that GPs can spend more time with the patients who need to see them the most, and will make General Practice a more attractive career.

To enable more people to use their community pharmacy, we will invest £192 million to both deliver and support enhancements to core pharmacy services. Crucially, the main focus is to build on the learning from the extended Minor Ailment Service pilot in Inverclyde and the rollout of the Pharmacy First initiative by implementing a redesigned minor ailment/common conditions service available to all. We are also strengthening the Chronic Medication Service to enable community pharmacists to provide personalised care for people with stable long-term conditions.

On dental care, a new scheme to ensure people in care homes receive appropriate dental care will be introduced, and over time, expanded to include those being cared for at home. We will take forward new approaches to reduce inequalities by supporting communities and families to take positive action through our £2.5 million Community Challenge Fund over three years.

Funding for the construction of the Golden Jubilee National Hospital's ophthalmology expansion and NHS Highland's North of Scotland Elective Care Centre will help to meet the increasing demands for elective surgery as the population ages, and will therefore help to improve the health of older people in particular.

We are also supporting nursing and midwifery students by providing free tuition and investing £11.1 million to increase the level of bursary support in 2019-20, with a further £25.4 million in 2020-21 to increase the level of support further. We are investing £3 million to train more Advanced Nurse Practitioners by 2021, £20 million per annum to recruit and train additional health visitors, and £6.9 million over three years for the training and education of General Practice Nurses and District Nurses.

This investment will support the health of pregnant women and infants who will be supported through the provision of an additional 2,600 extra nurse and midwifery training places and increased investment in domestic and international recruitment of health professionals across a range of disciplines, including midwifery. In addition, we will be investing in the Baird Family Hospital and the ANCHOR Centre in Aberdeen. The Baird Family Hospital will contribute to improving the health of women and pregnant women and their children, through the provision of maternity, gynaecology and breast screening services.

Reforming Health Services and Digital Health and Care Priorities

Services need to adapt to meet the needs of a changing population and address the challenges that are currently facing our health and social care services. NHS Boards and their partners will identify which services would better provide for patients if delivered at regional and national level. We will support NHS Boards to collaborate in service design and delivery to ensure that redesigned services bring real change in immediate priorities, such as access to care, as well as achieve longer-term sustainability and reform.

Digital technology helps us to realise the integration of our health and care services as we build person-centred services for the people of Scotland. The new Digital Health and Care Strategy, published in 2018, sets out how we will work collaboratively across health and social care to use and develop technology to deliver more joined up, integrated, and effective services.

Realistic Medicine Priorities

The aim of Realistic Medicine is to improve patient care, ensuring that people receive appropriate and beneficial care that is evidence-based and in tune with their personal preferences. Scotland's shared vision is that 'by 2025, everyone who provides healthcare in Scotland will demonstrate their professionalism through the approaches, behaviours and attitudes of Realistic Medicine'. Survey and stakeholder feedback gathered in 2018 has identified the biggest barriers and challenges to practising Realistic Medicine as:

• insufficient staff time;
• lack of formal training on Realistic Medicine and Value Based Healthcare; and
• lack of local leadership on Realistic Medicine.

From April 2019, we will build on the good progress already made and begin to implement a new three-year Implementation Plan that will support the public, health and care professionals to overcome the perceived barriers and challenges to practising Realistic Medicine. The new Implementation Plan has been informed by survey and stakeholder feedback and sets out a vital value-based programme of work that will focus on delivering the priorities to help create a sustainable NHS, underpinned by a culture of stewardship with people as equal partners in their care.

Public Health Priorities

To focus all public services on improving the health of our population, together with COSLA, we have set out our Public Health Priorities for the next decade. They are shaping our actions over the coming year, including:

• creating Public Health Scotland, to lead progress against our priorities;
• supporting key strategies on preventing and treating tobacco, alcohol and drug harm;
• progressing action to address adverse childhood experiences;
• improving collaborative working between public services to improve health outcomes for people in contact with the justice system;
• consulting on restricting the promotion and marketing of targeted food and drink high in fat, sugar or salt; and
• providing practical support to SMEs to help them reformulate their products, making them healthier.

Tackling diabetes and obesity will be a critical area of action. In the coming year we will continue to progress the five-year plan to invest an additional £42 million to improve the range of weight management services offered by our NHS as a core part of treatment services for people with, or at risk of, type-2 diabetes.

The further investment of £20 million per annum to support alcohol and drug treatment will also continue. This will help to improve the health of men in particular, who consume more alcohol on average than women in Scotland and account for a higher percentage of alcohol-related general acute and psychiatric hospital admissions. Improvements in the health of the middle-aged would also be expected: among men, alcohol-related general acute hospital admissions are highest among those aged 55-64, and for women among those aged 45-54. This will also contribute to improving the health of those living in the most deprived areas of Scotland, where a higher proportion of the population are admitted to both general acute hospitals and psychiatric care for alcohol-related causes.

Moreover, investments in drug treatments will also help to improve the health of those social groups that account for disproportionately higher proportions of drug-related deaths in Scotland, including men, those aged 35-44 and people living in the most deprived neighbourhoods.

We will also increase our support for children and families affected by Fetal Alcohol Spectrum Disorder (FASD) with investment of £0.3 million. Over the next year, we will work to set up a third sector hub that will focus on both preventing instances of FASD arising in the first place and supporting families following diagnosis.

We will also:

• increase our investment in improving maternity services by funding implementation of the Best Start review recommendations;
• continue to deliver a Baby Box offering essential items for a child's first weeks to the families of all newborn babies in Scotland;
• establish a National Hub for the Prevention of Child Deaths;
• establish Best Start Foods which will provide support for low income families to access a healthy diet; and
• publish a 10-year Children and Adolescent Health and Wellbeing Action Plan, focusing on both the physical health and wider wellbeing of children and young people.

This will generate further improvements in the health of infants, pregnant women and children and young people.

Priorities for a More Active Nation

Scotland is one of the first countries in the world to set out what we are doing to address the range of priorities in the World Health Organization's Global Action Plan, which put forward a target of a 15 per cent relative reduction in the global prevalence of physical inactivity in adults and young people by 2030. In the coming year our work will include:

• expanding the Care About Physical Activity programme supporting older people in a care setting to be more active;
• continuing to support the Scottish Women and Girls in Sport Advisory board to examine ways to increase female participation;
• investing in 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;
• promoting female golf to ensure a legacy from the Solheim Cup;
• expanding activity to increase participation of under-represented groups in sport and physical activity; and
• increasing support to Community Sports Hubs within our 5 per cent most deprived communities.

We will work with sportscotland to protect sport investment and mitigate the impact of continued reductions in lottery income. We will again underwrite the potential shortfall in funding of up to £3.4 million for sportscotland in 2019-20 and will continue to encourage the UK Government to take the appropriate action required to address lottery reductions.

Promoting physical activity is a key strategy for population health improvement, and the actions above are designed to enable individuals to be more active. These actions will have a particularly significant impact on the health of those groups who are less likely to currently meet the recommended amount of physical activity in Scotland, including women. The expansion of the Care About Physical Activity programme, aims to help older people in a care setting become more active. In addition, there is increasing support for Community Sports Hubs within the most deprived neighbourhoods of Scotland.

Conclusion

The Health budget helps the people of Scotland to live longer and healthier lives, to help reduce health inequalities and provide sustainable, high-quality and continually improving health and care services. It supports the triple aim of better care, better health and better value.

The Sport budget supports the people of Scotland to become more physically active as part of our efforts to prevent ill health and improve our wellbeing.

Footnotes

1. Scottish Health Survey 2012- 2013

2. Scotland 2011 Census