Scottish Budget: draft budget 2018-2019

Chapter 5: Health and Sport

Portfolio Responsibilities

The Health and Sport portfolio is responsible for maintaining and improving the health and wellbeing of Scotland. Its role is in providing the support to ensure that the NHS and wider health and social care services meet the health and care needs of the people of Scotland effectively and at the right time. Through this support, the portfolio is crucial in contributing directly to Scottish economic growth by helping people to live longer, healthier lives and in reducing the inequalities that continue to exist across parts of Scotland.

The portfolio must respond to the unprecedented challenges facing health services – demographic change, rising demand and expectations, and financial constraints. At the same time, it is working to take advantage of the opportunities that new medicines, procedures and technologies can offer.

The core of the Scottish Government’s approach to meeting both these challenges and opportunities is the Health and Social Care Delivery Plan, which was published in December 2016. The Delivery Plan sets out the framework of reform to ensure that health and social care services continue to provide high quality care while ensuring that prevention and early intervention improve healthy life expectancy.

Our Priorities

Next year our NHS is 70 years old and in that time it has continually evolved to reflect advances in medicine and the changing needs of our people. As we look to the future, our NHS will continue to evolve, delivering our vision that people live longer, healthier lives at home or in a homely setting.

As an important next step in the delivery of our commitment to increase the health resource budget by £2 billion by the end of this Parliament, the baseline budget for our frontline NHS Boards will increase by £179 million (1.9 per cent) in 2018-19. Together with an increase of £175 million in investment in reform, total additional funding for our frontline NHS Boards will amount to £354 million (3.7 per cent) which amounts to a real terms increase of £208 million (2.2 per cent).

This additional funding is provided as part of our twin approach of investment and reform, recognising the increasing demand and expectations placed upon our frontline services and being clear that the status quo is not an option. It is through this approach that we will deliver our triple aim of better care, better health and better value.

This investment will support our commitment that more than half of frontline spending will be in community health services by the end of this Parliament, and will allow us in 2018-19 to continue our progress in seeing the shift towards this balance of spending. In 2018-19 it will also support a further shift in the share of the frontline NHS budget dedicated to mental health and to primary, community, and social care.

Investment Area	2017-18 Investment in reform (£m)	2018-19 Investment in reform (£m)	Increase for 2018-19 (£m)
Transformational Change Fund	25.0	126.0	101.0
Primary Care	60.0	110.0	50.0
Mental Health and CAMHS	30.0	47.0	17.0
Trauma Networks	5.0	10.0	5.0
Cancer	8.0	10.0	2.0
Investment in reform	128.0	303.0	175.0

Delivering Better Care

Through our new Mental Health Strategy, we are shifting the balance of care towards mental health, increasing the level of investment in mental health services and improving support in the crucial period from birth to young adulthood. We are:

• re-designing primary and community services to meet the increasing demand for services;
• developing the skills and capacity of our workforce to support people with mental health problems, including delivery of an additional 800 workers over the next five years to ensure access to mental health professionals in A&E, GP practices, police custody units and prisons;
• improving transitions for young people moving from Child and Adolescent Mental Health Services ( CAMHS) to adult mental health services, including potential flexibility for those aged 18-25 to continue their care and treatment with CAMHS; and
• supporting the Rural Mental Health Forum to help people in rural areas maintain good mental health.

Primary and community care is where most healthcare interactions begin and end and our aim is to have as many people as possible receiving care at home or in a homely setting. We have negotiated a new GP contract with the British Medical Association which, subject to agreement from the profession, will come into effect in 2018-19. This will provide a stable, long-term foundation for general practice in Scotland, ensuring that people have access to improved quality services delivered by GPs leading and working as part of an extended primary care term. We are investing £110 million in 2018-19 to support implementation of the new proposed GP contract, if agreed; and to support the wider primary care reform.

In acute and secondary care, we are driving quality improvements by building resilience in elective services. In particular, we are:

• developing a new National Improvement Collaborative with clinical specialists, to support the way elective services are configured to improve quality and meet demand;
• investing in the Modern Outpatients Programme, to reduce unnecessary attendances and referrals to hospital outpatient services;
• investing £100 million in our Cancer Strategy for earlier detection and diagnosis, and quicker treatment and post-treatment support;
• continuing the national clinically-led six Essential Actions improvement work in unscheduled care;
• continuing the Detect Cancer Early programme focusing on breast, bowel and lung cancer to contribute further to improvement in survival outcomes; and
• improving outcomes for people with a range of long-term conditions including heart disease, stroke, cancer, diabetes and rare diseases through our focus on the whole patient pathway, earlier referral, speedier diagnosis and clinically effective treatments and follow up.

We will progress our £200 million commitment to expand the Golden Jubilee Hospital and develop five elective care centres in Aberdeen, Dundee, Edinburgh, Inverness and Livingston. This will allow us to meet the increasing demand for hip and knee replacements and cataract operations, while dedicated elective capacity will help tackle the knock-on effect that peaks in demand from unscheduled, emergency patients can have on planned, elective care.

The implementation of the Scottish Trauma Network has begun with £5 million already allocated in 2017-18 to enhance trauma services across Scotland. The steering group is expected to complete a national trauma network implementation plan, phased over five years, by the end of 2017. Further funding of £10 million will be made available in 2018-19, to continue to implement the plan and enhance the Trauma Network further.

We will continue to progress implementation of our commitment to increase access
to life-changing technology for people living with Type 1 diabetes. We will invest
£2 million in 2018-19, to enable more people than ever before to benefit from insulin pump therapy and continuous glucose monitors.

Overall, there will be continued focus on using capital investment to support the delivery of the National Clinical Strategy and the Delivery Plan. We will do this by maintaining the NHS estate, replacing and updating medical equipment, refreshing information management and technology and replacing key vehicles such as ambulances, providing over £200 million of investment in these areas. We will also invest in primary and community care facilities including £30 million to support GP premises over three years.

In addition, through the hub investment programme, we will continue the construction of the following projects:

• NHS Forth Valley – Stirling Care Village;
• NHS Grampian – Inverurie Health Care Hub and Foresterhill Health Centre;
• NHS Greater Glasgow and Clyde – Gorbals Health Centre;
• NHS Greater Glasgow and Clyde – Woodside Health Centre
• NHSScotland Pharmaceutical Service; and
• NHS Lothian – East Lothian Community Hospital.

It is also essential that we continue to invest in our workforce, who are core to health and care services across Scotland. We will do so through:

• recruiting Community Link Workers, building on the 53 already in post as part of our commitment to recruit 250 Community Links Workers during the lifetime of this Parliament;
• continuing to recruit 1,000 new paramedics; over the last two years, 400 have already been recruited;
• delivering an additional 800 workers over the next five years to ensure access to mental health professionals in A&Es, GP practices, police custody units and prisons;
• increasing the number of pharmacists with advanced clinical skills working in general practice, training more paramedics, health visitors and a further 500 advanced nurse practitioners;
• investing £2 million in additional training for GP nurses;
• delivering an estimated 2,600 more training places for nurses and midwives;
• investing an additional £3 million to increase the number of radiology trainees in Scotland by at least 50 over the next five years, helping to improve waiting times for diagnosis and treatment of cancer patients in Scotland;
• 50-100 extra medical undergraduate places promised in Part 1 of the National Health and Social Care Workforce Plan over the parliamentary term; and
• recruiting at least 800 more GPs over the next 10 years.

In addition, as set out in the Programme for Government, we are lifting the public sector pay cap for NHS and other public sector workers from 2018-19.

Child and Maternal Health

The Scottish Government has set out clearly its priority for ensuring the best start for every child. We begin by focusing on supporting mothers and families from before conception through pregnancy and into those critically important first few days. To do this we will implement the recommendations of the Best Start Maternity and Neonatal Review. Increasing health visitor numbers to 500 more in place by the end of 2018 and also increasing Family Nurse Partnership provision (available to all eligible mothers on the mainland, a world first) will extend access to professional support throughout those critical early months and years of a child’s life.

Getting it Right for Every Child remains the foundation for building a stronger, healthier Scotland, with an emphasis on prevention and early intervention to ensure the best outcomes for Scotland’s children and young people. We will take forward an increasing focus on preventing adverse childhood experiences ( ACEs), such as abuse, neglect and parental drug and alcohol misuse, and mitigating the negative impacts where ACEs occur.

2018 is also the Year of Young People and it is appropriate that it will be in this year that we will publish our Child and Adolescent Health and Wellbeing Action Plan, which will set out our concrete actions to support all children to become and remain healthy and successful.

Nursing and Midwifery, and Allied Health Professionals

We are investing £3 million over the next four years to train additional Advanced Nurse Practitioners ( ANPs) with the first intake beginning training in 2017-18. This will provide ANPs with the skills to manage the complete clinical care of their patients, including assessing, diagnosing and treating and thereby ensuring better outcomes for their patients.

We will further enhance our commitment to nursing and midwifery in Scotland by commissioning an additional 1,600 training places in this Parliament, this is on top of the 1,000 additional places already announced.

At a total investment of £144 million, we will continue to maintain free tuition for nursing and midwifery students, retain the nursing and midwifery student bursary at least at its current level and consider how best the bursary can enable wider participation and increased retention, including through the £1 million discretionary fund. We will take forward a range of other actions to widen participation in nursing and midwifery education and careers in line with the recommendations of CNO Commission published on 7 December 2017.

We will invest £1 million to support Allied Health Professionals ( AHPs), working in partnership with fellow health and social care staff, to deliver the Active and Independent Living Programme across health and care settings, including improving support for self-management, improving awareness of AHP services, and rehabilitation and enablement services.

We will also contribute to the delivery of safe, person-centred and effective care in health and social care by supporting the implementation of legislation regarding the provision of safe and effective staffing. In the NHS this will require the use of a rigorous, evidence-based approach to workload and workforce planning, initially for nurses and midwives, ensuring key principles relating to professional judgement, local context and quality measures underpin workload and workforce planning.

Delivering Better Public Health

Our focus is on delivering an early intervention and prevention approach to public health, balanced by efforts to support everyone to lead healthier lives regardless of their circumstances. We are consulting on a new diet and obesity strategy, and we are progressing measures to limit the marketing of products high in fat, sugar and salt, which disproportionately contribute to ill health and obesity.

As part of our commitment to deliver the health prevention agenda we will also build on the work underway to develop a Diabetes Prevention Framework to identify people at high risk of Type 2 diabetes and focus activity to increase health and weight management interventions.

Addressing the use and impact of drugs is a challenge that is not unique to Scotland, but it is one we are determined to meet. We have begun an overhaul of our drug strategy, guided by a principle of ensuring the best health outcomes for people who are, or have been, drug users. We will expand its scope to set out a new vision for alcohol and drug treatment together. In 2018 we will deliver a refreshed alcohol framework to continue to take on Scotland’s often problematic relationship with alcohol misuse. Following the unanimous UK Supreme Court judgment on minimum unit pricing, we intend to implement the policy from 1 May 2018. This renewed focus on alcohol and drugs will be backed by additional investment of £20 million in treatment and support services.

This activity will form part of a set of overarching public health priorities, which will be agreed with local government to direct improvement across Scotland. It will be backed by preparation to establish a new, single, national population health improvement body by 2019.

Our vision is of a Scotland where more people are more active, more often. The Active Scotland Outcomes Framework sets out our ambitions for achieving that, and is underpinned by a commitment to equality. We will work with sportscotland to protect sport investment and mitigate the impact of continued reductions in lottery income. Along with an additional £2 million to the budget, we will underwrite the potential shortfall in funding of up to £3.4 million for sportscotland in 2018-19 and will continue to encourage the UK Government to take the appropriate action required to address lottery reductions.

We will continue to increase the number of Community Sports Hubs and are on track to deliver 200 by 2020. Future hubs will have an explicit focus on addressing inequality and be focused on areas of deprivation in recognition that being active is an important factor to support health and wellbeing.

As part of our commitment to equality, we will build on our work ensuring programmes and interventions support under-represented groups using forums such as the Women and Girls advisory board to guide our thinking and ensure we deliver at pace and scale.

We will continue to embed our Legacy from the Commonwealth Games 2014 and use the Gold Coast Games to highlight the success of both performance and participatory sport and physical activity.

Alongside what we are doing on active travel, we will launch a new Active Scotland Delivery Plan with a wide range of actions across all sectors, including:

• strengthening Community Sport Hubs, improving opportunities for older people in care to be physically active and ensuring Scotland becomes the first ‘Daily Mile’ nation;
• encouraging more women and girls to take up sport by maintaining our Sporting Equality Fund with a £0.3 million investment;
• drawing on the expertise within the Women and Girls in Sport Advisory Group to help shape our future actions; and
• showcasing the contributions of football clubs to delivering positive outcomes, including the Football Fans in Training programme and Walking Football.

Delivering Better Services

In the last year new structures have been put in place which will support the implementation of the National Clinical Strategy and the Health and Social Care Delivery Plan. These include:

• developing regional plans involving NHS Territorial Boards and local partners to set out services which can best be planned and delivered at regional level as well as support services which can best be delivered closer to home;
• supporting NHS Special Boards to develop a plan to focus improvement in national services, including advancing a ‘Once for Scotland’ approach;
• examining opportunities for greater sharing of support services away from the delivery of frontline care; and
• developing a Digital Care Strategy to support a digitally-active population and workforce and make better use of the opportunities of modern technology.

Evidence from across the globe consistently shows that research is a cornerstone of all high-performing health systems, leading to better targeted and more personalised treatment and to improved patient outcomes. Research and innovation is central, and vital, to our health and social care services in Scotland, both in terms of discovering and implementing solutions to the health challenges posed by living longer lives, as well as catalysing development of our life sciences, digital health and manufacturing industries. We will invest an additional £3 million to promote and spread health innovation; and we will continue to invest in research and development infrastructure and capacity building, supporting vital collaborative working between the NHS, academia, industry and the medical research charities. This will deepen Scotland’s global reputation as a destination of choice for health science, at the forefront of new developments, including in precision medicine and genomics.

Realistic Medicine aims to deal with the dual challenge of providing care that has greater worth to individuals (through proper identification of their preferences and shared decision making), while also addressing the need to improve health and wellbeing at a population level. This will require an effective and co-ordinated approach that builds on the good work underway to improve service quality, safety and efficiency.

Health and Social Care Integration

We continue to support Integration Authorities to improve outcomes across health and social care. In particular, we are providing support for effective commissioning of new and better models of care, with improved data and opportunities for different areas to learn from one another’s experience of redesigning services.

We are enhancing the social care sector’s ability to meet increased demand and provide better services, including adult social care reform, jointly delivered with local government and Integration Authorities.

In 2018-19 an additional £66 million is included in the Local Government settlement allocations to support additional expenditure by local government on social care in recognition of a range of pressures they and integration authorities are facing, including support for the implementation of the Carers (Scotland) Act 2016, maintaining our joint commitment to the Living Wage (including our agreement to now extend it to cover sleepovers following the further work we have undertaken) and an increase in the Free Personal and Nursing Care payments.

This will take the Scottish Government’s overall package of additional direct investment in social care and integration to over £550 million in 2018-19.

We will also:

• through Independent Living Fund Scotland ( ILF), continue to deliver payments to support severely disabled people, to enable them to live independently in the community;
• work with stakeholders to prepare for the implementation of our commitment to extend free personal care to all those under 65 who need it;
• invest £22.3 million in the Care Inspectorate to regulate and support improvement of registered services, bringing to life the new Health and Social Care Standards which focus on people’s experience of care;
• continue to invest in supporting people with long-term conditions to self manage through the £2 million Self Management Fund to enable third sector partners across Scotland to support people in our communities to live well with the health conditions they have;
• further embed Self-directed Support as our mainstream approach to social care by investing £9.2 million in system change to enable more people to have choice and control of their care and support;
• support the Survivor Support Innovation and Development Fund to improve access for all adult survivors of child abuse to a wide range of services, and the In Care Survivor Support Fund with £13.5 million over the next five years for survivors of child abuse and the services that support them; and
• continue to work with stakeholders to deliver the priorities and vision in the Scottish Government’s See Hear Strategy for people with sight loss, deafness and dual sensory loss in Scotland.

Health And Sport

Table 5.01: Spending Plans (Level 2)

Level 2	2016-17 Budget £m	2017-18 Budget £m	2018-19 Draft Budget £m
Health	13,023.0	13,210.6	13,583.7
of which:
NHS Territorial Boards	9,122.3	9,392.6	9,667.2
NHS Special Boards	1,099.7	1,168.6	1,184.3
Community Health Services	1,514.7	1,575.1	1,647.7
Departmental Allocations	1,286.3	1,074.3	1,084.5
Food Standards Scotland	15.3	15.3	15.3
Total Level 2	13,038.3	13,225.9	13,599.0
of which:
Fiscal Resource	12,131.4	12,444.7	12,874.7
Non-cash	272.9	273.1	273.1
Capital	529.0	408.1	341.2
Financial Transactions	5.0	-	10.0
AME	100.0	100.0	100.0

Table 5.02: Health and Sport Spending Plans (Level 2 real terms) at 2017-18 prices

Level 2	2016-17 Budget £m	2017-18 Budget £m	2018-19 Draft Budget £m
Health	13,221.3	13,210.6	13,385.6
of which:
NHS Territorial Boards	9,261.2	9,392.6	9,526.2
NHS Special Boards	1,116.4	1,168.6	1,167.0
Community Health Services	1,537.8	1,575.1	1,623.5
Departmental Allocations	1,305.9	1,074.3	1,068.9
Food Standards Scotland	15.5	15.3	15.1
Total Level 2	13,236.8	13,225.9	13,400.7
of which:
Fiscal Resource	12,316.1	12,444.7	12,686.9
Non-cash	277.1	273.1	269.1
Capital	537.0	408.1	336.3
Financial Transactions	5.1	-	9.9
AME	101.5	100.0	98.5

Health and Sport

Table 5.03: More Detailed Spending Plans (Level 3)

Level 3	2016-17 Budget £m	2017-18 Budget £m	2018-19 Draft Budget £m
Resource
NHS Territorial Boards	9,122.3	9,392.6	9,667.2
NHS Special Boards	1,099.7	1,168.6	1,184.3
Community Health Services*
General Medical Services	783.0	821.4	870.5
Pharmaceutical Services Contractors' Remuneration	184.2	184.5	184.8
General Dental Services	407.1	414.0	414.8
General Ophthalmic Services	100.0	102.0	107.4
Mental Health Services	40.4	53.2	70.2
Departmental Allocations
Outcomes Framework	131.0	68.0	66.2
Workforce and Nursing	171.1	176.4	193.1
Health Improvement and Protection	103.4	46.1	62.7
SportScotland	32.9	29.7	31.7
Active, Healthy Lives	12.7	12.7	12.7
Care, Support and Rights	115.5	116.7	112.1
e-Health	83.5	90.4	92.9
Early Years	41.5	56.6	67.7
Performance and Delivery	72.0	65.9	69.9
Quality and Improvement	11.3	15.1	13.2
Miscellaneous Other Services and resource income	(140.6)	(141.2)	(133.6)
Revenue Consequences of NPD Schemes	18.0	29.8	44.7
Total Resource	12,389.0	12,702.5	13,132.5
Capital
Investment	549.9	428.1	361.2
Financial Transactions	5.0	-	10.0
Income	(20.9)	(20.0)	(20.0)
Total Capital	534.0	408.1	351.2
Annually Managed Expenditure
NHS Impairments	100.0	100.0	100.0
Total Health	13,023.0	13,210.6	13,583.7
of which:
Fiscal Resource	12,116.3	12,429.6	12,859.6
Non-cash	272.7	272.9	272.9
Capital	529.0	408.1	341.2
Financial Transactions	5.0	-	10.0
AME	100.0	100.0	100.0

Note:
* Allocations for 2018-19 for Primary and Community Care Services are still to be decided and are subject to UK pay negotiations with the professional groups concerned.

Table 5.04: Territorial and Special Health Boards Spending Plans (Level 4)

Level 4	2016-17 Budget £m	2017-18 Budget £m	2018-19 Draft Budget £m
Transformation Change**	20.0	38.0	145.7
Territorial Boards
NHS Ayrshire and Arran	669.0	683.6	694.9
NHS Borders	193.9	197.7	200.6
NHS Dumfries and Galloway	279.4	284.9	289.1
NHS Fife	604.3	624.7	636.6
NHS Forth Valley	485.2	496.7	506.8
NHS Grampian	882.3	902.4	920.6
NHS Greater Glasgow and Clyde	2,079.1	2,123.5	2,154.5
NHS Highland	577.5	592.6	604.3
NHS Lanarkshire	1,107.0	1,135.9	1,156.1
NHS Lothian	1,303.4	1,356.0	1,384.3
NHS Orkney	43.2	46.7	47.7
NHS Shetland	42.6	47.5	48.7
NHS Tayside	699.1	721.3	734.8
NHS Western Isles	66.6	71.6	73.0
Total	9,032.6	9,285.1	9,452.0
Special Boards
NHS Waiting Times Centre	46.5	51.9	54.0
NHS Scottish Ambulance Service	218.5	229.3	237.9
NHS National Services Scotland	293.4	324.7	328.2
Healthcare Improvement Scotland	15.5	24.7	24.7
NHS State Hospital	34.3	34.4	34.8
NHS 24	64.6	65.2	66.3
NHS Education for Scotland	408.7	420.0	420.0
NHS Health Scotland	18.2	18.4	18.4
Total	1,099.7	1,168.6	1,184.3
Other Income	69.7	69.5	69.5
Total Territorial and Special Boards	10,222.0	10,561.2	10,851.5

Note:
** This represents funding included within Level 3 budgets that will be allocated to Boards in year to support the delivery of transformational change. This funding comprises the Transformational Change Fund, Trauma Networks and Cancer funding set out in the priorities section above.

What the Health and Sport budget does

The budget enables our health and care services to help people in 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.

The Sport budget enables people in Scotland to become more active, more often. This allows people to be more physically active which contributes to personal, community and national wellbeing.

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 2018-19, this strategy, which contributes to the delivery of seven 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 initiate the work required to prepare for leaving the EU. As the central regulatory body for food and feed, FSS will be significantly affected by Brexit, due to the current regulatory framework deriving from EU law. FSS will also need to help businesses and local authorities be ready for legislative and regulatory change as a consequence of leaving the EU.

Table 5.05: Food Standards Scotland more Detailed Spending Plans (Level 3)

Level 3	2016-17 Budget £m	2017-18 Budget £m	2018-19 Draft Budget £m
Food Safety	10.3	10.3	10.3
Eating for Health	3.0	3.0	3.0
Choice (making it easier for consumers to make informed choices)	2.0	2.0	2.0
Total	15.3	15.3	15.3
of which:
Fiscal Resource	15.1	15.1	15.1
Non cash	0.2	0.2	0.2
Capital	-	-	-

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.