Scottish Budget 2019-2020

Chapter 5 - Health and Sport

Portfolio Responsibilities

The Health and Sport portfolio is responsible for ensuring the people of Scotland get the right care and support, in the right place, and at the right time. The portfolio is crucial in delivering the following key National Outcomes:

• We are healthy and active.
• We grow up loved, safe and respected so that we realise our full potential.

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

In our ‘Health and Social Care Medium Term Financial Framework’ we set out the financial environment to 2023-24 and the potential initiatives required to deliver a sustainable health and social care system with a wide range of partners. It set out that our NHS, and the wider health and social care system, must continue to adapt, recognising changing demands and that people are living longer, thanks in no small part to the NHS and the care and treatment it has provided.

By supporting these outcomes, the portfolio is contributing directly to inclusive economic growth by helping people to have healthier and more active lives and reducing inequalities across Scotland.

Portfolio Priorities

In a year when our NHS celebrated its 70th anniversary, health and social care services have been adapting to the changing needs of people living longer, often with more complex health and care needs. We have been pursuing longer-term sustainable change alongside shorter-term action in critical areas requiring urgent improvement.

The UK Government, earlier this year, set out the health resource consequentials that should accrue to our budget as a result of their spending plans. The Financial Framework was predicated on the understanding that the UK Government would honour this commitment as a true net benefit to Scotland’s budget. However, at the UK Autumn Budget 2018 it was outlined that the health resource consequentials had been reduced by £55 million in 2019-20.

In order that our health and care services are not impacted by this shortfall we have taken the necessary steps to reinstate the reduction of £55 million applied by the UK Government. This will see headline additional resource funding for the Health and Sport portfolio of £729 million (5.5 per cent). These increases mean that since 2016-17 the health resource budget has increased by £754 million over and above inflation. 

Over the last year we have maintained record investment in our NHS and have awarded 147,000 Agenda for Change staff earning under £80,000 a minimum pay rise of at least 9 per cent over three years. We are taking forward major new investments, with new trauma centres opening in Aberdeen and Dundee and construction on elective care centres at the Golden Jubilee expansion and at Raigmore Hospital. There remain the challenges arising from a highly uncertain environment – not least, the UK’s exit from the EU – but that has not daunted our determination to act.

This budget delivers a further shift in the balance of spend towards mental health and primary, community and social care. This supports our commitment that by the end of this Parliament, more than half of spending will be in community health services. In 2019-20 we are continuing to prioritise front-line services. Our additional funding for front-line NHS Boards will amount to £281 million.[1] Along with increased investment for improving patient outcomes set out below, this will take additional investment in our front-line Boards to amount to £430 million (4.2 per cent). 

Table 5.01 – Investment in improving patient outcomes

Improving patient outcomes	2018-19 Investment in reform (£m)	2019-20 Investment in reform (£m)	Increase for 2019-20 (£m)
Primary Care	120	155	35
Waiting Times	56	146	90
Mental Health and CAMHS	47	61	14
Trauma Networks	10	18	8
Cancer	10	12	2
TOTAL	243	392	149

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 disabled people and recognise the vital role unpaid carers play. 

This package of investment will see £120 million transferred from the health portfolio to the local government settlement in-year and paid directly to local authorities for investment in integration and school counselling services. The investment package also sees an additional £40 million of funding included in the local government settlement to extend free personal care to under 65s as set out in the Programme for Government and for the continued implementation of the Carers (Scotland) Act 2016.

Capital investment in 2019-20 will amount to £336 million. This will include investment in the Baird Family Hospital and the ANCHOR Centre in Aberdeen, and will support increasing elective capacity across Scotland. A detailed capital investment strategy will be published in the coming months, setting out an investment framework over the longer term, including primary and community care projects.

Access to Healthcare Priorities

Our Waiting Times Improvement Plan will lead to sustainable, substantial improvements to performance, including 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 specialties 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 £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 are investing £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.

We will support the continuing development of genomic medicine in Scotland, which will include investment in improved genomic tests, collaboration in the 100,000 genomes programme, improved data analysis, and workforce training and development.

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, including the work of the Task Force on Children and Young People’s Mental Health Improvement. Actions will include:

• providing 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:

• trialling 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 and therapies in rural areas; and
• enhancing the handling of 111 calls through specialist mental health training.

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.

Workforce priorities

Supporting the workforce is critical to delivering our priorities. Portfolio spend will focus on key workforce issues, including provision of:

• 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; and
• 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. With a greater emphasis on community-based and more joined-up, anticipatory and preventative care, integration aims to improve care and support for those who use health and social care services and equips our services for the challenges the future will bring. 

Social care provides vital support for thousands of people in Scotland. We are working with the Convention of Scottish Local Authorities (COSLA), Health and Social Care Partnerships, people who use social care, and a wide range of partners to ensure the growing demand for social care and support is met. We recognise the importance for many in being able to live independently and participate in society. Actions will include:

• implementing our commitment to extend free personal care to all those under 65 who need it with our investment of £30 million;
• implementation of self-directed support;
• reforming the Independent Living Fund Scotland charging policy to improve the disposable incomes of disabled people;
• continuing to support delivery of the Living Wage for social care staff working in adult services;
• working with key partners, including COSLA, to support workforce planning for integrated social care services;
• continuing to work to embed the recently established rights for Scotland’s unpaid carers with an additional £10.5 million;
• improving access to support for survivors of abuse experienced while growing up in care; 
• supporting improvements in adult support and protection;
• delivering the provision of communication equipment and support to children and adults who have lost their voice or have difficulty speaking; 
• considering evidence for, and views on, a potential new national scheme to provide extra financial support to people with the highest social care needs; and
• enabling an increase in payments for Free Personal and Nursing Care.

Community Health Services priorities

In 2019-20 we are supporting primary care with an investment of £941 million. The first entirely Scottish GP contract came into effect on 1 April 2018, focusing on the role of Scotland’s GPs 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.

We are also determined to deliver our ambition to make community pharmacy the first point of access for care and advice for more people. In 2019-20, we will invest £192 million to support the delivery of important core community pharmacy services such as the Minor Ailment Service, Chronic Medication Service and Public Health Service. We are strengthening the Chronic Medication Service to enable community pharmacists to provide personalised care for people with stable long-term conditions and for those on long-term medication.

On dental care, we will introduce a new scheme to ensure people in care homes receive appropriate dental care, and over time, expand this 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.

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. 

Reforming Health Services 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. As part of this wider agenda, work continues in developing plans by NHS Boards and their partners to identify which services would better provide for patients if delivered at regional and national level. As these plans are put into place, we will be supporting NHS Boards to accelerate regional and national collaboration in service design and delivery. This will ensure that services bring real change in immediate priorities such as access to care as well as achieve longer-term sustainability and reform. 

Digital Health and Care priorities 

The wider use of digital actively supports, and 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. 

The Strategy sets the six key areas of work that must be developed in order for us to realise our ambition. This includes the National Digital Platform, a new approach that facilitates the availability and exchange of information of existing and new health and care systems and applications. In early 2019 we will produce an overall plan setting out our programme of work over the next five years. 

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. Our vision is that ‘by 2025, everyone who provides healthcare in Scotland will demonstrate their professionalism through the approaches, behaviours and attitudes of 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 and 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. It 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 investment of £20 million per annum to support alcohol and drug treatment will also continue.

We will increase our support for children and families affected by Foetal 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. In addition, we will:

• 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.

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 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 women’s 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 the 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.

Spending Plans

Table 5.02: Spending Plans (Level 2)

Level 2	2017-18 Budget £m	2018-19 Budget £m	2019-20 Budget £m
Health and Sport	13,210.6	13,583.8	14,307.2
of which:
NHS Territorial Boards (restated)	9,446.5	9,718.2	10,090.1
NHS National Boards	1,168.6	1,184.3	1,225.6
Community Health Services	1,575.1	1,647.7	1,853.6
Departmental Allocations (restated)[2]	1,020.4	1,033.6	1,137.9
Food Standards Scotland	15.3	15.3	16.0
Total Health and Sport	13,225.9	13,599.1	14,323.2
of which:
Total Fiscal Resource	12,444.7	12,874.8	13,603.5
of which Operating Costs*	–	–	53.9
Non-cash	273.1	273.1	273.3
Capital	408.1	341.2	336.0
Financial Transactions	–	10.0	10.0
UK Funded AME	100.0	100.0	100.4

* In 2019-20, there is a change to the way that Scottish Government staffing budgets are presented and total operating costs are now included within portfolio budgets. This is set out in more detail in the Annex on operating costs.

Level 2	2017-18 Budget £m	2018-19 Budget £m	2019-20 Budget £m
Presentational Adjustments for Scottish Parliament Approval
sportscotland (NDPB Non-cash)	(1.2)	(1.3)	(1.2)
Food Standards Scotland - shown separately	(15.3)	(15.3)	(16.0)
PPP/PFI Adjustments	96.2	88.0	138.0
Total Health and Sport	13,305.6	13,670.5	14,444.0
Total Limit on Income (accruing resources)	2,050.0

What the Health and Sport budget does

The Health budget helps the people of Scotland to live longer and healthier lives, through focusing on early intervention and prevention, reducing health inequalities and providing sustainable, high quality and continually improving health and care services locally, regionally and nationally. It supports the triple aim of better care, better health and better value.

The Sport budget supports the people of Scotland to get more physically active as part of our efforts to prevent ill health and improve our wellbeing, whilst delivering world-class sporting performances.

Table 5.03: Health and Sport Spending Plans (Level 3)

Level 3	2017-18 Budget  £m	2018-19 Budget £m	2019-20 Budget £m
Resource
NHS Territorial Boards (restated)	9,446.5	9,718.2	10,090.1
NHS National Boards	1,168.6	1,184.3	1,225.6
Community Health Services
Primary Care Services	821.4	870.5	931.2
Community Pharmaceutical Services	184.5	184.8	191.9
General Dental Services	414.0	414.8	416.6
General Ophthalmic Services	102.0	107.4	108.4
Mental Health Services	53.2	70.2	85.5
Additional Support for Social Care	–	–	120.0
Departmental Allocations
Outcomes Framework	68.0	66.2	62.9
Workforce and Nursing	176.4	193.1	216.2
Health Improvement and Protection	46.1	62.7	78.0
Sportscotland	29.7	31.7	32.6
Active, Healthy Lives	12.7	12.8	13.4
Care, Support and Rights	116.7	112.1	128.2
eHealth	90.4	92.9	88.9
Early Years	56.6	67.7	72.7
Quality and Improvement	15.1	13.2	18.7
Miscellaneous Other Services (restated)	(129.2)	(114.7)	(69.7)
Revenue consequences of NPD	29.8	44.7	50.0
Total Resource	12,702.5	13,132.6	13,861.2
Capital
Investment	428.1	361.2	356.0
Financial Transactions	–	10.0	10.0
Income	(20.0)	(20.0)	(20.0)
Total Capital	408.1	351.2	346.0
Annually Managed Expenditure
NHS Impairments	100.0	100.0	100.0
Total Health	13,210.6	13,583.8	14,307.2
of which:
Fiscal Resource	12,429.6	12,859.7	13,588.1
Non-cash	272.9	272.9	273.1
Capital	408.1	341.2	336.0
Financial Transactions	–	10.0	10.0
UK Funded AME	100.0	100.0	100.0

See footnote on operating costs in Table 5.02.

Table 5.04: Health and Sport Spending Plans (Level 4)

Level 4	2017-18 Budget  £m	2018-19 Budget £m	2019-20 Budget £m
Improving Outcomes and Reform[3]	91.9	196.7	209.2
Territorial Boards
NHS Ayrshire and Arran	683.6	694.9	720.0
NHS Borders	197.7	200.6	207.7
NHS Dumfries and Galloway	284.9	289.1	299.1
NHS Fife	624.7	636.6	661.4
NHS Forth Valley	496.7	506.8	527.0
NHS Grampian	902.4	920.6	957.9
NHS Greater Glasgow and Clyde	2,123.5	2,154.5	2,231.2
NHS Highland	592.6	604.3	627.5
NHS Lanarkshire	1,135.9	1,156.1	1,199.3
NHS Lothian	1,356.0	1,384.3	1,441.5
NHS Orkney	46.7	47.7	49.6
NHS Shetland	47.5	48.7	50.6
NHS Tayside	721.3	734.8	762.9
NHS Western Isles	71.6	73.0	75.7
Total	9,285.1	9,452.0	9,811.4
National Boards
NHS Waiting Times Centre	51.9	54.0	54.2
NHS Scottish Ambulance Service	229.3	237.9	259.9
NHS National Services Scotland	324.7	328.2	338.5
Healthcare Improvement Scotland	24.7	24.7	24.9
NHS State Hospital	34.4	34.8	35.3
NHS 24	65.2	66.3	68.6
NHS Education for Scotland	420.0	420.0	425.9
NHS Health Scotland	18.4	18.4	18.3
Total	1,168.6	1,184.3	1,225.6
Other Income	69.5	69.5	69.5
Total Territorial and National Boards	10,615.1	10,902.5	11,315.7

Food Standards Scotland Priorities

The vision of Food Standards Scotland (FSS) is to deliver a food and drink environment in Scotland that benefits, protects and is trusted by consumers. FSS launched its first strategy in 2016, which set out the high-level direction until 2021. In 2019-20, this strategy, which contributes to the delivery of several of the Government’s National Outcomes, will be delivered through a corporate plan outlining the priorities and key activities to be taken forward using an outcomes-based approach.

The budget will also enable FSS, to a very limited degree, to initiate some of the work required to manage the impact of EU exit. As the central regulatory body for food and feed, FSS will be significantly affected by EU exit, due to the current regulatory framework deriving from EU law. FSS will also need to help businesses and local authorities be ready for legislative and regulatory change as a consequence of the UK’s exit from the EU.

What the Food Standards Scotland budget does 

The budget of Food Standards Scotland supports consumer protection – making sure that food is safe to eat, ensuring consumers know what they are eating and improving health through better diet.

The objectives of Food Standards Scotland (FSS) as set out in the Food (Scotland) Act 2015 are to:

• protect the public from risks which may arise in connection with the consumption of food;
• improve the extent to which members of the public have diets which are conducive to good health; and
• protect the other interests of consumers in relation to food.

Table 5.05: Food Standards Scotland Spending (Level 3)

Level 3	2017-18 Budget  £m	2018-19 Budget £m	2019-20 Budget £m
Administration	15.3	15.3	16.0
Capital Expenditure	–	–	–
Total Food Standards Scotland	15.3	15.3	16.0
of which:
Fiscal Resource	15.1	15.1	15.4
Non-cash	0.2	0.2	0.2
Capital	–	–	–
Financial Transactions	–	–	–
UK Funded AME	–	–	0.4
	15.3	15.3	16.0

Footnotes

This adjusts for funding in 2018-19 for NHS Pay awards (£95 million for all NHS Boards) that will be applied to the health portfolio resource budget as part of the Scottish Government’s Spring Budget Revision 2018-19. It also adjusts for recurring allocations to Boards that have been baselined for NHS Boards since the Budget Bill 2018-19 (£16.9 million for all NHS Boards).

In 2019 departmental allocations include initial funding from HM Treasury of £122 million to meet costs arising from the actuarial valuation of the NHS Pension Scheme. Work is ongoing in finalising the valuation. We expect the final arrangements and settlement to be confirmed by the UK Government in early 2019 and we will then allocate this funding to NHS Boards.

Investment of up to £40 million will be accelerated from 2019-20 to 2018-19 to support the Scottish Government’s Waiting Times Improvement Plan. This is reflected in the funding figure for 2019-20, and will be processed in 2018-19 as part of the Scottish Government’s Spring Budget Revision.