Programme for Government 2020 to 2021

Chapter 2 Promoting Lifelong Health and Wellbeing

The rainbows in windows across Scotland are testament to the remarkable response of our health and social care staff. We owe so much to them and the thousands of carers and volunteers who have provided, and continue to provide, vital support to those who need it most. In every community in Scotland people have shown incredible resilience, compassion and skill to provide everything from the most advanced intensive care to simple acts of kindness.

COVID-19 has highlighted and exacerbated inequalities that exist within our country. In response, we will promote lifelong health and wellbeing with an increased focus on improving population health and tackling health inequalities as we move into the next stage of living with COVID-19. We are also determined to further develop the strengths of our public health service.

We start from a position of strength. Patient satisfaction continues to be high in a range of patient surveys. We have record levels of health funding and staffing. Before the pandemic, Scotland's core A&E services had been the best performing in the UK for more than 5 years. But COVID-19 has tested our services like never before and it has underlined the necessity to address the underlying causes of ill‑health and support continued reform of our health and social care services.

Embedding a world-class public health system

Scotland is moving to a new phase of the COVID-19 pandemic and the nature of our response must adapt. As we move forward we must renew and recover sustainably, whilst being ready to respond quickly to any significant localised resurgence of the virus, or to a return of widespread community transmission.

Scotland's overall pandemic strategy is set out in COVID‑19: A Framework for Decision Making. That strategy is to suppress the virus - driving the number of cases to the lowest levels possible and effectively eliminate it - and therefore enable as close to normal life as possible to resume and continue. At the same time we must remain vigilant and ready to respond quickly to prevent new cases transmitting onwards.

At the heart of our public health‑led response to the virus is an effective partnership between Scotland's local public health teams and Public Health Scotland. This partnership has proven itself to be very effective in suppressing the virus - in particular through Test and Protect, surveillance and response - and will be critical to delivering vaccinations as and when an effective vaccine is available.

Testing

We know that meeting the challenge of COVID-19 requires a comprehensive set of public health measures. No single intervention on its own will suffice. Our testing strategy is a key part of this approach.

Our approach to testing is continually adapting as the pandemic progresses in Scotland, and it will continue to adapt as we head into winter and as the science and evidence base around the virus builds. The strategy focuses on a number of key objectives for testing:

• whole population testing of anyone with symptoms
• proactive case finding by testing contacts and testing in outbreaks
• protecting the vulnerable and preventing outbreaks through routine testing in high-risk settings such as care homes
• testing for direct patient care, to diagnose and to treat, and to support safe patient care as NHS services restart
• surveillance to build knowledge of the disease, track prevalence, understand transmission and monitor key sectors

One key development in the Strategy which will strengthen our surveillance work and help prevent the spread of the virus is the testing of contacts of COVID-19 index cases regardless of whether or not they have symptoms. This allows for further contacts to be identified and potential wider outbreaks to be contained.

However, testing does not in and of itself stop the virus spreading; it does not reduce the risk of becoming infected by the virus by touching a contaminated surface; and it does not mitigate the risk of being infected from droplets from an infectious person. The first line of defence against the virus is each and every one of us. That is why face coverings, avoiding crowded places, cleaning hands and surfaces, physical distancing and self‑isolation when necessary remain key to keeping the virus under control.

To support our contact tracing efforts, we will launch, later this month, a proximity app 'Protect Scotland' to inform users of the app when they have been a close contact of someone who has then tested positive for COVID-19. This will not replace the work of our contact tracers, but it will enhance it and add an additional means of notifying people that they may have been exposed to the virus and should isolate.

Seasonal flu and flu vaccination

We recognise the risk posed every year as a result of seasonal flu. At a time of an ongoing pandemic, that risk becomes even greater. We must ensure that we protect those who may be vulnerable from the seasonal flu at a time when there remains a risk from COVID-19. Starting this year we will extend the offer of seasonal flu vaccination to all social care workers who provide direct personal care, all those 55 years and over, all those sharing a household with people who are in the shielding category for the purposes of COVID-19, and those aged 50‑54 depending on vaccine supplies. We will embark on a campaign to raise public awareness, particularly amongst those groups who are newly eligible, and ensure we embed learning from seasonal flu expansion into COVID-19 vaccine planning.

Supporting those who have had the virus

We are continuing to learn about the longer term effects of the virus. For those who have received hospital care, recovery can be a long road. Most will recover with the support of those close to them, but some people may be left with post-traumatic disorders including anxiety, depression and PTSD, or longer term health problems including chronic pain, fatigue and breathlessness.

We will ensure recovery is a key part of our Framework for Rehabilitation and Recovery. This will focus not just on physical health but also on mental health and social support. To aid recovery, we will ensure that patients discharged from Intensive Care Units (ICU) who are assessed as needing mental health and other specialist support are able to receive appropriate treatment through a new network of local mental health services. These rehabilitation programmes will be extended nationwide to all Scottish ICUs.

Before the pandemic, we recognised the importance of ensuring people living with respiratory conditions can access clinically appropriate, safe and effective person‑centred healthcare treatment and support. That becomes even more important now. Following consultation earlier this year, we are in the process of finalising our Respiratory Care Action Plan for Scotland. As our understanding of the impact COVID-19 has had on the health of the people of Scotland develops, including in relation to those that have developed long‑term respiratory problems as a result of contracting the coronavirus, the final Respiratory Care Action Plan will respond to the implications and consequences of COVID-19 for many aspects of respiratory care going forward. We will continue to work with key stakeholders, including the third sector, on how best to raise awareness and engage with patients as we take this forward.

The impact of COVID-19 on minority ethnic people and communities

There is increasing evidence that COVID-19 has affected minority ethnic groups disproportionately and it has highlighted the deep‑rooted health and socio‑economic inequalities that minority ethnic communities face. The independent Expert Reference Group on COVID-19 and Ethnicity (ERG) has put forward initial advice and recommendations on data, evidence, risk and systemic issues to ensure disparities can be identified quickly and resolved. This work highlighted that the lack of high-quality population‑based data on ethnicity hampers our understanding of ethnic variations in COVID-19 and its outcomes in Scotland. To overcome this the ERG recommended a number of actions which we will take forward, including:

• Making ethnicity a mandatory field for health databases
• Developing a linkage to the census
• Embedding the process of ethnicity data collection in the culture of the NHS in Scotland

NHS mobilisation

Routine services are being restarted across the country, with the approach and timing in each area carefully tailored to individual circumstances and demands. We are working closely with Health Boards on the further development and implementation of their individual mobilisation plans. NHS Scotland will have three core tasks over the coming months:

• To deliver as many of its normal services as possible, as safely as possible
• Ensuring we have the capacity that is necessary to deal with the continuing presence of COVID-19
• Preparing health and care services for winter

Our approach will continue to be informed by national and local clinical priorities, with a focus on people's quality of life. We will continue to work with Health Boards, local authorities, Royal Colleges, health and social care partnerships, professional bodies, unions and other key stakeholders to ensure our approach is robust and up-to-date and treats those most in need first. This work is being overseen by the Mobilisation Recovery Group (MRG), chaired by the Cabinet Secretary for Health & Sport.

We must also ensure that we have the infrastructure and the capacity our NHS and care staff need to meet demands. The National Elective Centre Programme will deliver additional elective capacity across Scotland.

The first of the elective centres at the Golden Jubilee will open to patients in October 2020. In October construction will commence on the Highland Centre, with construction due to start on the Lothian, Grampian and Phase 2 of Golden Jubilee Centres during 2021.

We will continue to develop our Women's Health Plan which will underpin actions to tackle women's health inequalities by raising awareness around women's health and improving access to healthcare for women throughout life. Priority actions for the plan will be to ensure women have access to specialist menopause services for advice and support on the diagnosis and management of menopause; improve access for women to appropriate support, speedy diagnosis and best treatment for endometriosis; improving access to information for girls and women on menstrual health and management options; improve access to abortion and contraception services; ensure rapid and easily accessible postnatal contraception; and reduce inequalities in health outcomes for women's general health, including work on cardiac disease. We will also continue to work to delivered improved services for women who have suffered complications as a result of transvaginal mesh.

We remain committed to introducing a high-quality and clinically-safe thrombectomy service in Scotland to ensure the best treatment for patients with severe stroke, and to reduce their risk of long-term disability. The pilot of the North of Scotland Thrombectomy service will commence in autumn 2020, with a fully operational service in Tayside anticipated by 2023. The Queen Elizabeth campus will provide a 'hub' thrombectomy service for the West of Scotland, and NHS Lothian will provide a thrombectomy service on the Little France site by 2023.

However, the reality is that COVID-19 is likely to be with us for some time to come and it will continue to bring significant operational challenges. We have made significant progress in reducing waiting times over the last few years but we know that progress has been interrupted by the pandemic and we have seen a significant increase in the numbers of patients waiting for routine appointments and treatments. We will tackle that challenge with vigour and on the basis of clinical priorities, drawing upon guidance jointly developed by the surgical Royal Colleges across the UK. In doing so we will ensure that available capacity is used to treat safely those in most urgent clinical need and that, as far as is practical, this is done consistently across the country. However, the challenge of addressing the increases in waiting times for routine treatments and appointments will be one we will face for some time to come.

Infection Prevention and Control was a key issue pre-COVID-19 and the experience of NHS Boards in dealing with COVID-19 has reinforced how fundamentally important it is. As well as learning from experiences with COVID-19, lessons about the design and build of healthcare facilities and infection prevention and control are being learnt from the Independent Review of the Queen Elizabeth University Hospital. This is informing the early work of the new national body to strengthen infection prevention and control in the built environment which will be established in spring 2021.

Resumption and redesign of cancer services

Cancer services will remain a key priority. The National Cancer Recovery Group is providing oversight of cancer services in Scotland, including promoting the framework for recovery of cancer surgery to assure patients of consistent prioritisation within the NHS. We will continue to create and promote, where appropriate, national approaches to diagnosis and treatment, ensuring patients have equitable access across Scotland. The national cancer recovery plan to be published in the Autumn will drive all of this activity.

Scotland's adult national screening programmes, which include breast, bowel and cervical cancer screening, as well as screening for Diabetic Retinopathy and Abdominal Aortic Aneurysm, are now resuming following the temporary pause to the programmes due to the COVID-19 pandemic. The programmes are restarting in a phased, careful and prioritised way, in line with the recommendations of the Scottish Screening Committee. The safety of screening participants and staff will be an overarching consideration throughout the stages of fully resuming screening services.

We will continue to prioritise early detection of cancers through the development of Early Diagnostic Centres, where patients can have multiple diagnostic tests at one appointment, rather than requiring repeat visits for different tests.

Recognising the public health drivers of smoking and lung cancer, the Scottish Government is committed to increasing early detection rates of lung cancer, and through our Detect Cancer Early initiative the proportion of lung cancer diagnoses at the earliest stage have gone up by 36%, and more in the most deprived areas. A number of areas of work are underway to ensure Scotland contributes to the emerging evidence base. As part of this, Urgent Suspicion of Lung Cancer Guidance has been published to support GPs in decision‑making when checking patients with symptoms similar to COVID-19. We will continue to explore the best options for possible further actions to tackle lung cancer that both match our unique circumstances in Scotland and avoid creating further health disparities. We will also launch a new lung cancer public awareness campaign through our Detect Cancer Early programme.

We will seek to permanently embed some of the positive impacts of the National Cancer Medicines Advisory group, which has approved 19 new options for treatment for people with cancer using new rapid decision making processes. A cancer clinical trials subgroup will be established to accelerate progress on the restarting of clinical trials, ensuring these often final treatment options for patients are maximised and that we continue to make leading contributions to clinical research internationally.

Chronic pain services

We recognise that persistent pain can have a really significant impact on quality of life. We will publish the Recovery Framework for Pain Management Services which sets out the clear expectation for prioritisation of urgent care needs for pain management, taking account of the impact of delays on people's quality of life and we will work with Health Boards to support the safe and rapid remobilisation of pain management services. We are also currently exploring the potential for Health Boards to utilise additional regional and national capacity for delivery of pain management procedures. In addition, the format and remit of the National Advisory Committee for Chronic Pain is urgently being reviewed to ensure there is improved oversight and support of chronic pain service remobilisation and improvement.

We will work with local, regional and national stakeholders, including patient groups, to develop the current Scottish Service Model for Chronic Pain and to publish a new Framework for Chronic Pain Service Delivery in 2021. This will involve agreeing pain management pathways that are sustainable, improve health outcomes and minimise harmful variation. These will build on the value of self‑management and reduce long‑term reliance on specialist services and treatments that demonstrate limited health outcomes. We will also publish revised Opioid Prescribing Guidance for Chronic Pain. This will provide tools to support appropriate prescribing and review of opioids, with practical advice about reducing or stopping opioids completely.

Digital access to care

In responding to COVID-19, healthcare services have moved quickly and innovatively to ensure better access to flexible and digital health support. For individuals, this has increased choice and flexibility. For services, it has eased pressures, freeing up time and capacity for services which cannot be performed digitally. We will now, with COSLA, look to refresh our digital health & care strategy and create a dedicated data strategy for health & social care for the first time.

Early on in the COVID-19 outbreak the video health consulting service 'Near Me' was scaled up. We doubled funding to £1.2 million, increasing the service's capacity, trained more than 7,000 people, and supported 650 GP practices in its use. This saw Near Me video consultations go from 336 in the week before the scale‑up to almost 17,000 in the last week of June. It has been very popular, with a patient survey saying 98% would use the service again.

While video consultations are not for everyone or every clinical situation, the benefits are significant. Near Me provides more patient choice, reduces travel for patients and clinicians, and has economic benefits such as reducing the need for time off work. We will now move to a position of Near Me as the default option where that is right for a person and they are happy to use the service, with the aim that all health and care consultations are provided by Near Me or telephone whenever clinically appropriate. We will also develop its use in social care, with an initial priority on use in care homes. This will be taken forward as part of a wider Digital in Care Homes Action Plan, to facilitate adoption of digital approaches in care homes for residents, staff and families.

For greater remote support for areas such as recovery, rehabilitation, falls and ongoing management of conditions, we will build on our previous work on home and mobile health monitoring and telecare. This will include the roll‑out of a new digital monitoring solution to support people who are dealing with a diagnosis of and the longer term effects of COVID-19, offering access to online support and information whilst also allowing the patient to be able to feed in important information on their condition from home and at a time that suits them.

In partnership with NHS Health Boards we will expand Computerised Cognitive Behavioural Therapy (cCBT) service provision by increasing the number of treatment options available from 1 to 12 through the introduction of a new cCBT platform. By October 2020 cCBT will be deployed at scale without limitation on treatment numbers while rapidly increasing treatment choice to include anxiety disorders such as social and health anxiety. We will also support the development of internet enabled CBT (ieCBT), a therapist-led treatment which provides easy access to evidenced‑based CBT for those people experiencing common mental health problems. Together, these services will support at a minimum a further 10,000 people - with the potential to support 30,000 people - to access therapy. It will increase service provision in those areas of Scotland where the identified need is the greatest as a consequence of the COVID-19 pandemic, and is particularly suited for use in remote and rural areas.

The right care, in the right place, at the right time

Urgent and Emergency care

To protect the public, patients and our NHS staff we will redesign our Accident and Emergency services. As we move towards winter it is essential that we minimise overcrowding in Emergency Departments so hospitals can continue to adhere to physical distancing guidelines and provide safe and effective care. By the winter, we will have implemented the first phase of our reform of urgent care for the over one million patients each year who attend A&E or minor injury units.

Clearly, those who have a health emergency or life-threatening illness require treatment as quickly as possible, and access to emergency care is unchanged. However, from previous research and our experience of changes to emergency care during the pandemic it is anticipated around 20% of people could be supported to access more appropriate provision of care that would better meet their health needs without a trip to A&E.

A new 24/7 service, operated by NHS24 on 111, will encourage people who are not in need of immediate emergency treatment to get a clinical assessment by phone prior to travelling to A&E.

Where a further clinical consultation is required, NHS24 will make a direct referral to a clinician who could, if appropriate, offer a telephone or digital consultation in the first instance. However, if someone does need to be seen in person this will be arranged as safely as possible at an Emergency Department or a department that best suits the patient's care needs. Using a fast booking system, departments will know to expect the person and work to avoid unnecessary delays. This new system will aim to provide care as close to home as possible, avoid long waits in crowded emergency rooms and keep patients and staff as safe as possible.

This will ensure that patients get the right care, in the right place, with the minimum amount of time spent in hospital waiting areas. Our aim is also to strengthen community health services and provide as much care closer to home as is possible.

We will ensure that services from across our health, justice and social care systems are brought together to focus on the needs of any person experiencing distress, particularly those with multiple, complex needs. Our direction of travel is that people in distress with complex needs who find our various systems difficult to access will be quickly identified and supported by a clearer referral pathway to the intervention that they need. We will explore the adoption of a model of support akin to the COVID-19 Hubs used during the pandemic - an immediate and multidisciplinary response, triaging and navigating pathways for appropriate and compassionate care.

Community services and COVID-19

Community health services are the cornerstone of the NHS. They have played a vital part in our response to COVID-19. COVID-19 Hubs have been established across the country to support people with symptoms of the virus. NHS 24 provided advice and were able to encourage people to self‑isolate but also to direct people to treatment and support to those who needed it if the virus progressed, whether via virtual appointments or face‑to‑face assessments within their community. Between 23 March and 12 August 130,379 patients received a consultation through the Hubs and assessment centres.

With autumn and winter arriving we are expecting more people to experience cold and flu like conditions often with a fever or cough that will be indistinguishable from COVID-19 symptoms. We will therefore bolster these community services as part of our redesign of unscheduled care.

Delivering our Community Health Service

Our Pharmacy First Scotland service was launched on 29 July, replacing the Minor Ailments Services for treatment for conditions such as coughs, earache and cold sores along with clinical conditions such as Urinary Tract Infections. This extended service was delivered during our response to the pandemic, and means everyone registered with a GP practice in Scotland, including working-age people, could access it.

Additional common clinical conditions will be added to the Pharmacy First service during 2020-21 to support remobilisation of the NHS. All community pharmacists can now access Emergency Care Summary, allowing them to see all the medication that the patient has been prescribed.

Our ongoing work with GPs to reform primary care continues, and at the heart of our reforms of General Practice is ensuring that the full range of primary care health professionals are available to support people - whether that be a physiotherapist to deal with a musculoskeletal issue or a community paramedic if a home visit is required. If patients need a wound dressed, blood taken or a routine check to monitor a long‑term condition, they will be referred by the appropriate healthcare professional to a community treatment centre. These networks of support were being rolled out prior to the pandemic and we will now accelerate efforts to develop a nationwide network to help patients manage their conditions close to home.

To mitigate against the impact of inequalities, we will continue our recruitment of 250 community link workers by the end of this Parliament as part of our GP Contract commitment to deliver multi‑disciplinary teams in the community. Link workers are key in helping patients navigate and engage with wider services or assisting patients who need support. They often serve socio‑economically deprived communities. Primary care is the first port of call for many mental health issues and we are also recruiting mental health workers across primary and community settings. In addition we will progress our commitment to recruit 800 mental health workers to key settings, including to GP practices, and continue as part of our discussions on the GP contract to look at further ways to support the recruitment of mental health workers in the community.

We will accelerate the reform programme for NHS dental services and introduce a new model of preventive oral health care for adult patients. Patients will receive a comprehensive assessment of their oral health, including gums, tooth decay and soft tissues, and along with lifestyle risk factors such as smoking and alcohol, will receive an appropriate treatment plan. The intervention could be either preventive, self‑care or restorative.

We will accelerate the reform programme for NHS eye care services, including continuing to implement the recommendations of the Community Eyecare Services Review. This will enable more care to be delivered safely in the community, closer to people's homes and includes funding to support an additional 50 optometrists to train as independent prescribing optometrists. Independent prescribing optometrists can safely manage more eye conditions within the community without the need for a patient to attend the hospital eye service.

Community optometrists have a vital role to play in supporting patients with long-term eye conditions and additional funding being provided will mean more care can be provided by local opticians. The aim is that community optometrists will deliver 50,000 appointments for lower risk hospital ophthalmology patients. This is supported by a £3 million investment.

Rethinking social Care

COVID-19 has had a significant impact on all of Scotland's public services, but we know that at points this has been most keenly felt in our social care and support sector. Those services and staff have responded heroically to the challenges they have faced as they care for some of our most at‑risk people, often within a person's own home. At the same time, we have seen more people taking on roles as unpaid carers- caring for friends, family, and loved ones, and further adding to their own personal pressures at a time of global crisis.

During the pandemic, we put in place a number of interim measures to support the social care and support system. This includes £100 million of funding to meet any additional costs of COVID-19 and support the sustainability and resilience of the sector. We have also put in place strengthened clinical oversight of Scotland's care homes to ensure clarity and consistency across the country about the role of care homes, Health Boards and local authorities in helping to keep residents safe.

As we move forward, we will ensure that people using social care services are provided with the best possible care. We owe it to them to acknowledge the challenges that social care has faced, learn from them, and reconsider the most effective model for the future. We will immediately establish a comprehensive and fundamental independent review of adult social care, which will report by January 2021. This will consider changes required to achieve the highest attainable standard of support for the independence and wellbeing of people who use adult social care support.

The aim of the review will be to recommend improvements to adult social care in Scotland, focused on the outcomes achieved by and with people who use services, their carers and families, and the experience of people who work in adult social care. The review will take a human‑rights based approach with a particular but not exclusive focus on the views of those with lived experience, about what needs to change to make real and lasting improvements. Using the powers that are available to the Scottish Parliament this will set out how adult social care can be reformed to deliver a national approach to care and support services. It will include consideration of a national care service.

Ahead of that independent review reporting, a new stakeholder group will govern our approach to adult social care recovery and remobilisation as we move through and out of the COVID-19 pandemic period. The group will provide input to the Health and Social Care Mobilisation and Recovery Group. It will also have oversight of the support and reform of social care services in the immediate term, not least where those needed to be paused as we responded to the immediate requirements of COVID-19.

We will also take forward immediate improvements, working to:

• Set standards for how adult social care assessments and allocation of resources are carried out so that people accessing support are fully involved in decision making and experience greater consistency and transparency
• Complete a review of care services definitions. Developing new definitions for registered services and care roles will enable social care support services and workers to be more flexible and responsive to people's needs, to work more autonomously, and to work with others across professions
• Work with Integration Authorities and Local Authorities to ensure planning and purchasing of social care support is focused on flexible and person centred support

Within social care, we cannot forget that a significant element is delivered by unpaid carers who play an immense and vital role in supporting the people they care for. Quite simply, our health and social care systems would be unsustainable without that support, and we could not have got through the pandemic without them.

As a result of lockdown, unpaid carers have had to take on additional responsibilities, including balancing the challenges of home working and increased caring responsibilities, often without the same support which would have previously been available to them. Emerging research suggests there may be an additional 400,000 people undertaking unpaid care as a result of COVID-19. The Scottish Government made a one‑off Coronavirus Carer's Allowance Supplement payment of £230. This was in addition to the regular six monthly Carer's Allowance Supplement, benefitting around 83,000 of Scotland's lowest income carers with some of the most intense caring roles. This additional payment, together with the existing six‑monthly Carers Allowance Supplement, will mean that eligible carers in Scotland in receipt of Carer's Allowance will receive an additional £690 this year on top of their Carer's Allowance.

Support for carers is key to protecting their wellbeing. During the pandemic, we provided £500,000 to carers services to support them in working remotely. We will work with these services to increase their capacity and ensure sharing of best practice and learning across settings, together with an additional £11.6 million for ongoing implementation of the Carers (Scotland) Act, provided to local authorities to deliver carers services this year, recognising the extra demands they may be under.

The pandemic has thrown into sharp focus the important role that unpaid carers play in our communities and we will continue to work to build on this public awareness to encourage those who are caring to take up the support that is available to them. We will provide tailored information to support carers to help them identify themselves, access routes for support and know their rights under the Carers Act. We will do this through a dedicated national campaign which will assist carers in identifying the support they need to look after their own health and wellbeing. Alongside publishing guidance to support the re‑opening of adult day care services, we will continue to deliver the £3 million voluntary‑sector Short Breaks fund, offering time off and away for carers. As part of this fund, carers services in every local authority area are able to provide small grants to carers to support them to take a break in a way that they choose.

Safeguarding staff and patients

The work of health and social care staff throughout the pandemic has been immeasurable and invaluable. They have faced the same family and societal challenges that we all have whilst also delivering vital care in incredibly difficult circumstances. We owe them an immense debt of gratitude. We must ensure we provide the necessary support and protection they need. We cannot restore services and achieve the reforms we want to see without them.

Work is underway with the Social Care Fair Work group to develop and implement proposals to embed fair work principles that will lead to better terms and conditions and more rewarding roles for people working in social care, including care homes, care at home, housing and other support. An interim report is due in September 2020, with fully developed proposals by the end of 2020.

Issues related to pay, reward and recognition of NHS staff are discussed in partnership with unions. This year the majority of NHS Scotland staff including nurses, ancillary, administration and Allied Health Professionals have received a 2.95% pay rise as part of our three‑year NHS Agenda for Change pay deal, which has delivered a minimum 9% pay increase for most staff over three years and over 27% for some staff still moving up their pay scale. NHS Scotland staff are the highest paid in the UK, and we will look to ensure that pay for NHS Scotland staff remains as fair as possible going forward.

As we are now in the last year of the three‑year Agenda for Change pay deal, we are working closely with NHS unions to agree a timetable to secure a new pay deal for 2021‑22. As part of this we are considering several options which take into account the efforts of NHS staff during the pandemic, and have not ruled out revisiting the final year of the current three‑year pay deal as part of that 2021‑22 deal.

We know that empowering staff at the front line and minimising bureaucracy was an important element in the success of the work across health and social care services in the early months of the pandemic response. We want to build on that approach as we remobilise, reform and improve services for the future.

We also know that many minority ethnic staff in health and care services felt anxious about protecting themselves and their families during the pandemic. To address this, we published occupational risk assessment guidance to help staff and managers consider the specific risk of COVID-19 in the workplace.

By the end of 2020 we will establish a national race equality network to produce an action plan with annual progress targets for health and social care employment at all levels of seniority in relation to minority ethnic groups. The national network will also review existing recruitment and promotion processes. Through our Leadership and Talent Management Programmes, we will increase the numbers of minority ethnic staff in senior and executive team roles. We will ensure new and existing minority ethnic staff networks in health and social care have a voice and influence to drive change, by introducing clear lines of governance and accountability, up to Board level. We will also work with staff networks and health and social care employers on a campaign to improve the accuracy of workforce ethnicity data.

As part of our efforts to improve support during the pandemic, we introduced a new, bespoke wellbeing hub for health and social care staff, and their families. This provides access to support, advice on self‑care and personal resilience, and will help staff to recognise their own 'warning signs'. All health and social care workers in Scotland now have access to mental health support 24 hours a day, seven days a week through a new national helpline.

We will implement a number of services to support improved mental health among health and social care staff, backed initially by £5 million of funding. This includes development of a Health and Social Care (HSC) Mental Health Network, to enhance existing mental healthcare provision, and to supplement support which has already been instigated on behalf of health and social care staff locally and nationally. This will support staff working across public services as well as the independent and third sectors. We will also expand and enhance the digital resources available to staff, including deployment of large scale psychological interventions accessible via the National Wellbeing Hub.

We will provide Boards with additional funding to support and further the work they have already undertaken to support and provide therapeutic intervention for health and social care staff when it is needed. It will supplement the wide range of offerings that are being provided at a local level. In addition, we will implement a Workforce Specialist Service, the most comprehensive of its kind in the UK, which will provide confidential assessment and treatment for mental ill-health, offering specialism in the complexities of treating and supporting professionals who work in regulated environments, delivered through a multi‑disciplinary team of mental health care providers, and supported by the continued delivery of digital wellbeing resources through the National Wellbeing Hub and the National Wellbeing Helpline.

For patients, our world-leading Scottish Patient Safety Programme (SPSP) continues to deliver significant improvements in the quality and safety of patient care. The SPSP launched in January 2008 as the first patient safety programme to be introduced nationally anywhere in the world. An initial aim was set to reduce hospital mortality by 15% by December 2012, extended to a 20% reduction by December 2015, and revised to secure a further 10% by quarter ending December 2018. We have met all of those goals, meaning tens of thousands fewer than expected deaths.

The ongoing success of the programme is testament to the hard work of staff across the country, improving the safety of healthcare wherever it is delivered, and ensuring better outcomes for some of our most vulnerable people. That is even more pressing at a time when our NHS is treating more people with more complex needs, and as we seek to recover from the current pandemic - we continue to learn and adapt, and will take action where necessary. There has been much to learn from the pandemic which will feed into the further work of the safety programme. This will include the development of the essentials of safe care across health and care services with a particular focus on care and support in the community and care homes.

In 2019, the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Julia Cumberlege, set out a range of recommendations to improve patient safety, including the establishment of a Patient Safety Commissioner to be a national advocate for patients. We are considering the full recommendations made, but are committed to the establishment of a Patient Safety Commissioner.

Improvements to population health

COVID-19 has both exposed and exacerbated health inequalities in Scotland. The disproportionate harm caused by COVID-19 to older people, minority ethnic groups, people living in greatest deprivation, and those with obesity, diabetes and respiratory and cardiovascular disease has highlighted new vulnerabilities and underscored existing health inequalities.

Older people have been significantly impacted by the health, economic and social harms of the coronavirus pandemic. As we move forward, we will identify and work to reduce barriers that older people face when accessing health and social care services - no matter whether those service are provided by the NHS, local government, or third and independent sectors - to ensure they can live longer and healthier lives, and our communities benefit from the contributions older people can make.

The restrictions which have been put in place to stop the spread of the virus have also had a disproportionate impact on women, people in manual or lower‑paid jobs, young people, and those without reliable access to the internet. We know that often health inequalities are driven by, and more deeply rooted in, wider social inequalities.

To tackle heath inequalities and support those most in need we will take a cross‑government approach to further developing our policies to support high-risk groups, including groups whose risks have become more evident in light of the COVID-19 pandemic. We will focus on our six public health priorities developed in partnership with COSLA as we take this programme of work forward:

• We live in vibrant, healthy and safe places and communities
• We flourish in our early years
• We have good mental wellbeing
• We reduce the use of and harm from alcohol, tobacco and other drugs
• We have a sustainable, inclusive economy with equality of outcomes for all
• We eat well, have a healthy weight and are physically active

In line with our cross Government focus, actions to tackle health inequalities can be found in our work on a national mission to create new jobs, good jobs and green jobs, and on promoting equality and helping our young people grasp their potential.

A core part of our work to reduce health inequalities must include how we support people and communities to make change that is important to them, threading community interventions, mutual aid and the voice of lived experience throughout our strategies and frameworks to ensure care and support are truly person‑centred. We will strengthen existing work with partner organisations to support people to manage their own health conditions.

Health inequalities are often linked to poor health literacy, and we will work through the Health Literacy Action Plan to improve health literacy, ensuring that information about care and support is delivered by professionals in a way that is accessible and easy to understand.

A Scotland where we eat well, have a healthy weight and are physically active

We will work with Food Standards Scotland and Public Health Scotland to support a targeted approach to improve healthier eating for people with low incomes. We will continue to improve, expand and increase access to weight management services for people with, or at risk of, Type 2 Diabetes, or with prediabetes, and extend access to weight management services to everyone living with obesity. We will raise awareness of weight management services and self‑help tools in a non‑stigmatising way.

We will progress legislation on Restricting Foods Promotions as soon as possible, having taken into account the impact of the COVID-19 pandemic. This will include consideration of whether a more wide‑ranging Bill is required. Work on the evidence base to underpin the proposals is continuing and we will engage with other administrations in the UK to explore the scope for the alignment of policy and legislation. We will build on the positive sport and physical activity behaviour changes we have seen during the COVID-19 pandemic, such as increased walking and cycling, and build wider community participation particularly within disadvantaged and under-represented communities. This will link with our work on communities, particularly our ambitions for 20 minute neighbourhoods and increased low carbon active travel, discussed in the next chapter.

We will work with sportscotland and Scottish Governing Bodies of Sport to rebuild membership and participation levels following the negative impacts of COVID-19. And we will work with the newly appointed Scottish Daily Mile Coordinator to encourage physical activity in a number of settings to support long-term behaviour change and specifically tackle the challenges around physical and mental health created by COVID-19.

We will establish a short life working group to examine social prescribing of physical activity - identify and communicate examples of best practice and co‑produce resources for practitioners in the many roles which make up the overall system. In addition we will support the delivery of health and care services to address inequalities by building on examples of innovation and best practice developed to address the impacts of the COVID-19 pandemic on sexual health services, by developing a Recovery Framework for Sexual Health and Blood Borne Viruses. We will also learn from the successful approach already taken by NHS Tayside in collaboration with the University of Dundee, which has offered treatment for Hepatitis C to people who inject drugs without waiting until they joined a recovery programme or stopped using drugs. In late 2019, Tayside met the World Health Organisation's (WHO) 2030 target for reducing prevalence of the virus 11 years early. We will work with the Scottish Health Protection Network, third sector and people who use services to understand how this approach can progress our ambition to eliminate Hepatitis C across Scotland by 2024. This work will be supported by investment from our Inclusive Scotland Fund.

We will review the focus of funding to tackle inequalities in the national population screening programmes. This will help address the impacts of COVID--19 on uptake of, and access to, screening as the programmes resume following a temporary pause due to the pandemic. We will also complete implementation of the Human Tissue (Authorisation) (Scotland) Act 2019 - to introduce an opt-out system of organ and tissue donation - by the end of March 2021.

A Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs

Scotland faces substantial public health challenges from the use of alcohol, tobacco and other substances. The way we address that must be through a public health response. In recognition of the importance of people in recovery from alcohol and drug problems being able to support each other, we have lifted certain COVID-19 restrictions to allow face‑to‑face peer support to take place under guidance. We also plan to further support the development of recovery communities across Scotland by providing £300,000 from our Inclusive Scotland Fund to the Scottish Recovery Consortium.

The Drug Deaths Taskforce has highlighted that stigma is one of the main factors preventing people from seeking treatment for drug problems. As a result a new strategy to tackle stigma has been published to encourage a more informed and compassionate approach towards people who use drugs and their families.

The taskforce has now announced the Scottish Government funding for research and front‑line services to help tackle the drug deaths public health emergency over the next year, including £1 million for 10 research projects examining different approaches to the drugs death public emergency, and £3 million for Scotland's Alcohol and Drug Partnerships to deliver on the six evidence‑based strategies set out by the Taskforce to reduce deaths and harms. The Scottish Government has also published the Rights, Respect and Recovery Action Plan, setting out how we will respond to drugs and alcohol as public health issues first and foremost, and help people by treating wider problems such as housing and employment, and supporting their families.

During the lockdown and response to COVID-19, drug and alcohol support services as well as smoking cessation support have been maintained as priority services. We have secured a temporary arrangement with the Crown Office and Procurator Fiscal Service (COPFS) to enable non‑drug treatment services who may be supporting people at risk of opioid overdose, such as hostels, to distribute Naloxone to people who use drugs, and their families and friends. We will be seeking to make this arrangement permanent, either through the UK Government making the required changes in legislation or by transferring the required powers to the Scottish Government, and will consult on drug law reform to support this. Alongside this we have asked Health Boards to include the prescribing of Buvidal (a long acting form of opiate substitute treatment) in prison settings to ensure continuity of treatment is available during the pandemic. A national protocol on Buvidal prescribing will be developed to enable greater treatment choice for people in both prison and community settings.

The pandemic has placed greater pressures on Scotland's residential rehabilitation services, so we are working with providers to identify ways to resolve these. We have established a short life working group, working with partners to consider the most appropriate longer‑term approach to sustainable residential services based on the needs of those who would benefit from them. We want to ensure there is improved access and greater choice for people - enabling them to achieve their recovery. As a first step, during the pandemic we established a pathway from prison to residential rehabilitation to provide better continuity of care and guard against any transmission of COVID-19 in the event of their being a resurgence of the virus in prisons.

In the coming year we will also consult on restricting the advertising and promotion of alcohol and e‑cigarettes, and legislating on e‑cigarette restrictions and on smoking outside hospitals. Removing smoking from outside hospitals will further help protect staff and patients from the known dangers from second‑hand smoking.

A Scotland where we have good mental wellbeing

Loneliness, isolation, grief and psychological trauma have taken a toll on our mental health, particularly amongst the young and those who already experienced mental health issues before COVID-19. Whilst mental health services were one of the first to be remobilised following the easing of lockdown, we need to now scale up our support for mental health and wellbeing.

We're already made significant commitments to improving mental health. In 2017, we launched our ten year plan for mental health, backed by an initial £150 million over the course of this Parliament. In 2018, we committed to invest a further £250 million in mental health over the next five years to improve services for children, young people and adults.

However, the COVID-19 pandemic has affected everyone in Scotland. All of us have experienced uncertainty. Some of us will have been anxious or worried about our health, our family and friends, our jobs, and our way of life. Some of us will have been able to adjust to strange new circumstances. Others will have found the past few months much tougher. That's why we now need to go further, faster and ensure the right help and support is available for mental health when it's needed most.

Responding to the additional mental health needs associated with the pandemic

To set out how we will ensure our action on mental health recognises, learns from, and responds to the challenges of COVID-19, we will publish a Mental Health Transition and Recovery Plan in autumn 2020. We are working with communities and partners across Scotland and are being guided by the lessons we have learned so far. We will equip individuals, families and communities to support their own, and each other's, mental wellbeing. This will require approaches that go beyond the traditional remit of health. Our approach will consider everything that influences our mental health and wellbeing, considering the needs of different groups, and seeking to reduce inequalities across the Scottish population.

We know that there are those whose circumstances as a result of the pandemic are more likely to have experiences which contribute to poorer mental health, such as poverty, isolation, and loneliness. We will work closely with these groups and stakeholders to best reflect their circumstances and needs in the plan.

We will ensure that our response focuses on the importance of meaningful employment, and seeks to mitigate the impacts on mental health of unemployment (or the risk of unemployment), redundancy and unhealthy workplace practices.

People who have been in the shielding category (and their families) are among those most likely to be affected adversely by the COVID-19 restrictions. We will support them to maintain their mental wellbeing as they navigate the changing guidelines and supports put in place.

We recognise the pandemic has been challenging for carers, in particular young carers. We will work with carer representative bodies to understand, and respond to, the mental health impacts of COVID-19 and lockdown on carers, recognising in particular the disproportionate burden experienced by female carers.

As a long‑term response to the COVID-19 crisis, evidence and expert opinion is telling us that a trauma‑informed approach to recovery should be a key component of remobilisation. We are expanding the National Trauma Training Programme by a further two years (to 2022/23) to ensure that our workforce has the resources they need to help raise awareness of the different ways in which traumatic experiences and stress affects people.

Focusing on good mental wellbeing at a population level

We want the population of Scotland to be well informed about wellbeing, mental health and mental ill‑health. This includes being aware of the importance of mental health on their lives, and those around them, what help is available, and the language we use to talk about it.

During the pandemic, we launched 'Clear Your Head', providing advice to support mental health and ensure people have the information they need to get the care they need. We will build on the success of this campaign by encouraging people to keep up any new active habits they may have started during the pandemic. We particularly want to see people getting outside and doing one thing, however big or small, to feel calmer and more in control.

Evidence indicates that the impacts of lockdown and COVID-19 have had more of a negative impact on women than on other groups. We will engage with women's organisations in order to identify, and take action to support women and girls' mental health on an individual and structural level. This will include work to support women and their families in the perinatal period through the Perinatal and Infant Mental Health Programme Board. We will also build on existing research into the causes of poorer mental health for teenage girls and take action to address the impact of social media and body image on young women. We'll also act to address the mental health impact on those living with domestic violence, abuse, coercive control and toxic masculinity. We also know that women tend to have greater carer responsibilities, which the pandemic has exacerbated. Our dedicated national campaign will ensure carers can identify the right support and advice they need for their own health and wellbeing.

Focusing on our response to distress

For years, our priority has been to improve responses to people who present in distress to emergency services but who do not need clinical intervention. In 2017, a pilot project was started in four areas (Lanarkshire, Borders, Inverness, and Aberdeen) called the Distress Brief Intervention (DBI) programme. DBI is a programme for people who turn to emergency services in emotional distress but do not need an emergency response. Frontline services, including Police Scotland, Scottish Ambulance Service, and primary care, assess the needs of the person and, if appropriate, refer them to a local third sector agency who will be in contact within 24 hours and offer support over a two week period to manage distress. Since its inception in June 2017, over 9,000 people have been referred to the DBI. During COVID-19, the DBI has now become nationwide through NHS 24. This was designed to help people in distress and the interim evaluation of the programme showed that the DBI approach is helping to save lives. However, at the moment it isn't reaching everyone and is limited to people over the age of 16. During the pandemic, we expanded the programme to include an NHS24 pathway, and this has already shown very positive results which it's vital we maintain. We will now extend the DBI programme across Scotland, for a transitional period to 2024, at which point we expect it to be fully embedded by Boards.

While we continue to scale up our digital offer, we know that a significant number of people experiencing mental health problems and distress visit Emergency Departments. They might not always be able to get the most appropriate help there, and their visits also increase waiting times. Early into the pandemic, we asked Boards providing services for a larger number of people to put in place arrangements to redirect emergency mental health presentations away from Emergency Departments by establishing Mental Health Assessment Centres. The establishment of these centres has allowed quicker access to specialist services for those that need them and access to other interventions such as Distress Brief Intervention where appropriate. This has had a positive impact for people presenting with mental health needs, ensuring they receive the right support at the right time while also alleviating pressure on Emergency Departments. We will work with Boards to retain, develop and support Mental Health Assessment Centres, as part of a broader approach to improving access to appropriate help as quickly as possible for people with mental health needs or distress.

Suicide may become an even more pressing concern as the pandemic's longer‑term impacts on the general population, the economy, and vulnerable groups are felt. We want to promote an evidence‑based suicide prevention response, in partnership with the National Suicide Prevention Leadership Group (NSPLG), to deliver interventions where they will make a difference. This work will continue to deliver the ten actions in the Suicide Prevention Plan. In response to the pandemic, we are working with Public Health Scotland to improve reporting on suicide rates. A new public awareness campaign will launch in September. We will also progress work to ensure support for suicidal crisis and to make recommendations to service providers. We will work with COSLA and other partners to develop a future longer‑term suicide prevention strategy.

Supporting children and young people

Children and young people are not immune to the impacts of COVID-19, and many have faced unique challenges which may not be immediately evident and may be long‑lasting. As we develop and deliver our mental health response to COVID-19, the voices and experiences of children, young people and their families will remain central. We will also ensure they are clearly and quickly signposted to the right help and support where it's needed. We will enhance and build on digital support developed during lockdown, such as Aye Feel, and Parent Club.

Schools can play a unique and important role in supporting children's health and wellbeing and education authorities have prioritised this both during the COVID-19 pandemic and in their plans for school return. In particular, they are continuing to implement previous commitments on ensuring provision of school counsellors, and training for school staff in mental health and wellbeing.

All education authorities have an implementation plan in place for providing school counsellors and many have accelerated the implementation of their plans in response to COVID-19. We expect counsellors to be in place by the end of October 2020. We will also increase the school nursing workforce by an additional 250 school nurses by the end of 2022. We will continue to deliver on our 2018 Programme for Government commitment for more than 80 additional counsellors in colleges and universities over four years and are currently over two‑thirds of the way to meeting that commitment.

In collaboration with the Mental Health in Schools Working Group, we will develop and deliver a new mental health training and learning resource for all school staff. This resource will include learning for school staff to respond to the impact of COVID-19 on children and young people's mental wellbeing. To support schools and educational practitioners, we will provide a framework on implementing, developing and evaluating a whole school approach to support children and young people's mental health and wellbeing.

Delivering better mental health services

We are prioritising remobilising mental health services in our wider NHS remobilisation and we will support NHS Boards and their partners to recover stronger and better, building on the innovations and new service designs which have emerged as a response to COVID-19. This will require a continued focus on access, improvement and quality, and it will involve partners and services across the whole landscape. The involvement of patients and the mental health workforce will be critically important. Even before the current crisis, we recognised the urgency of ensuring that everyone who needs support can get access to appropriate services. We anticipate that demand for mental health services will grow in the coming months, due both to the pandemic and the likely impacts of the economic downturn. We have prioritised mental health services in our remobilisation of NHS services but we know that there is still more work to do. We will renew our efforts to drive down waiting times for Child and Adolescent Mental Health Services (CAMHS) and psychological therapies, and to address rejected referrals.

Spend on CAMHS in Scotland has increased year‑on‑year since 2011 and by 182.7% since 2006. Despite this, we know that too few Boards are meeting their required targets and too many children and young people - and adults within psychological therapies - are waiting an unacceptably long time to start treatment. Our investments have helped to substantially increase the CAMHS and psychological therapies workforce but the impact on performance has been slower and less comprehensive than expected and needed.

We published a full progress update on the Audit of Rejected Referrals as part of the last Annual Report on the Mental Health Strategy. In response to the Audit's recommendations, we published a CAMHS Service Specification which outlines the provisions that children, young people and their families can expect from mental health services - regardless of where they live. We will be closely monitoring the Specification's implementation over the coming months and will work closely with Boards on their plans to remobilise CAMHS services. This will result in an agreed plan with each Health Board to meet the CAMHS standards

We want to remobilise services to meet the anticipated demand in a way that builds on the innovations and work undertaken at local level through the crisis. All Boards have been asked to set out their approach to the remobilisation, recovery and redesign of services for the remainder of this financial year in the next iteration of their remobilisation plans. We will develop a recovery plan and programme for mental health services, including CAMHS, to support the recovery process.

We know it is vitally important that people can access support close to home. We have provided £2 million for Local Authorities to support the introduction of new Community Mental Health and Wellbeing Services, with further funding to come. While the pandemic has had an impact on the planning and development of those services, we are working with local authorities to ensure they are ready to start supporting children, young people and their families as soon as possible. The first services will be in place by the end of the year with support available across all 32 local authorities in 2021.

As well as ensuring people are able to access services, we will also ensure services are of the highest standard and delivered safely - not least for those who may be most vulnerable or at‑risk.

In 2020, we established a Quality and Safety Board for Mental Health Services in response to the Report of the Independent Inquiry into Mental Health Services in Tayside. An initial meeting was held in February 2020. The Board will consider a wide range of issues that impact upon the quality and delivery of safe and effective services, including in inpatient and community settings. It will also respond to the recommendation in the inquiry's report for a review of the assurance and scrutiny of mental health services across Scotland, including the powers of Healthcare Improvement Scotland and the Mental Welfare Commission.

There is no consistent adult ADHD diagnostic service across Scotland and many NHS Boards do not currently provide any adult ADHD diagnostic services, leading to inequality of access. A draft adult ADHD pathway has been developed in partnership with the National Autism Implementation Team and the Royal College of Physiatrists and we will engage with NHS Boards to consider the practical consequences of implementing the National Clinical Pathway for ADHD.

We also know we need to improve the service response for people with personality disorders. Early work had started on ways to address this with the Royal College of Psychiatrists - this was paused due to the pandemic but will now be resumed at pace. As part of this work, we will establish a Personality Disorder Managed Network which will make recommendations on how to improve services and support a national roll-out of patient self‑management training.

Finally, we will continue our national action on dementia prevention, which is backed by our world‑leading government commitment on brain health. Earlier this year, we established Brain Health Scotland, hosted by Alzheimer Scotland - the first national programme of its kind. It will lead work to ensure that optimal brain health, and as a consequence dementia prevention, is central to our future public health strategies, research and clinical practice. As part of this, we will develop and deliver the first Brain Health and Dementia Prevention Strategy, to be published in 2021.