HC/S2/06/22/A
Health Committee
22nd Meeting, 2006 (Session 2)
Tuesday 24 October 2006
The Committee will meet at 2.00 pm in Committee Room 1.
1. Items in private: The Committee will discuss whether to take items 4 and 6 in private.
2. Health Board Elections (Scotland) Bill: The Committee will take evidence on the Bill from:
Sir John Arbuthnott, Chair, NHS Greater Glasgow & Clyde; Professor William Stevely, Chair, NHS Ayrshire & Arran; Robert Anderson, Interim Chair, Lothian NHS Board; Richard Norris, Director, Scottish Health Council; Pat Watters, President, CoSLA; and Jane Kennedy, Team Leader - Health & Social Care, CoSLA.
3. Scottish Budget 2007-08: The Committee will take evidence from:
Andy Kerr MSP, Minister for Health and Community Care; and, Dr Kevin Woods, Chief Executive, NHS Scotland
4. Scottish Budget 2007-08: The Committee will discuss the evidence heard today.
5. Health Board Elections (Scotland) Bill (in private): The Committee will discuss the evidence heard today.
6. Committee Work Programme 2006-07: The Committee will discuss its work programme.
7. Adult Support and Protection (Scotland) Bill (in private): The Committee will consider a draft Report.
Simon Watkins/Karen O’Hanlon Joint Clerks to the Committee Room T3.40 Email: [email protected]
HC/S2/06/22/A
The following papers are attached for this meeting—
Agenda Item 2:
Health Board Elections (Scotland Bill) – Cover Sheet HC/S2/06/22/01
Witness Submissions HC/S2/06/22/02
Executive Summary of SPICe Briefing HC/S2/06/22/03
Agenda Item 3:
Scottish Budget 2007-08 HC/S2/06/22/04
Agenda Item 7:
PRIVATE PAPER: Adult Support and Protection (Scotland) Bill – HC/S2/06/22/05 Draft Report
Agenda item 2 HC/S2/06/22/01 24 October 2006
Health Board Elections (Scotland) Bill
1. The Committee will today begin taking evidence at Stage 1.
2. Paper HC/S2/06/22/02 contains the written evidence received from today’s panel of witnesses. Note, no submission was made by the Scottish Health Council.
3. Additionally, paper HC/S2/06/22/03 is an executive summary of the forthcoming SPICe briefing paper on this Bill, and includes an analysis of respondents to the call for evidence who were in favour or against the Bill.
Simon Watkins/Karen O’Hanlon Joint Clerks to the Committee
Agenda item 2 HC/S2/06/22/02 24 October 2006
SUBMISSION FROM LOTHIAN NHS BOARD
1. Do you support the general principles of the Bill and the proposals for direct elections to NHS Area Health Boards?
NHS Boards are by statute (Section 7 of the NHS Reform (Scotland) Act 2004) required to involve the public in the planning, development and operation of health services. The Statutory Guidance for Community Health Partnerships (CHPs) clearly sets out that CHPs would ‘most importantly involve the public, patients and carers in decisions concerning the delivery of health and social care for their communities’ and that Public Partnership Fora (PPF) would be key in engaging the public.
The PPF are only beginning to function and find their feet with local communities and there is a danger that they would be undermined by having directly elected members who would become ‘the voice’ for patients rather than Boards actively engaging with users and communities in a variety of ways to explore options, proposals and views. Such views also run the risk of being ‘issues of moment’ rather than looking to the wider health agenda whilst of course, embracing in a proactive way, the aspects of health that have an impact on the population as a whole and the specific issues of minority groups which require to be addressed.
We agree that Health Boards should be open, transparent and accountable to the communities they serve and we believe that NHS Lothian is achieving this in a number of ways - Patient Focus and Public Involvement work, Non Executive Directors who are elected representatives, Public Board Meetings and through the Public Annual Accountability Review held by the Minister for Health and Community Care.
2. Are there any omissions from the Bill that you would like to see added?
Not applicable.
3. What are your views on the quality of consultation, and the implementation of key concerns about the accountability of NHS Health Boards?
Quality of Consultation
• Scottish Health Council’s Annual Review 2005 – 2006 of Patient Focus and Public Involvement Performance Assessment of NHS Lothian (July 2006) commended ‘the variety of opportunities presented to patients, carers and the community to become involved in planning and developing services’ and the development of the Public Partnership Forum (PPF) in Midlothian, West Lothian and North and South Edinburgh were seen as a good examples of involving the public at an early stage (East Lothian PPF is in the process of being established).
The review noted that a significant amount of engagement work had been undertaken with people in each of the equality strands, including people with learning difficulties.
1 It was also recognised by the Scottish Health Council (SHC) that the Board has asked local communities how they wish to be involved e.g. Children and Young People’s Health and Healthcare Strategy, the development of Public Partnership Forums and that the work on engagement is an integral part of the early process of all new initiatives.
‘NHS Lothian has made every attempt to encourage participation at every level to meet its statutory and Patient Focus and Public Involvement responsibilities.’
As evidence please find attached the final report from Scottish Health Council and the Self Assessment submitted by NHS Lothian.
• Improving Care, Investing in Change – Public Consultation Process and Responses to Public Consultation
In June 2004, Lothian NHS Board confirmed its intention to undertake public consultation on a range of options for service change in acute services, older peoples services and mental health services. The whole consultation process was designed around a momentum of public, patient and staff involvement and is part of an ongoing process of informing and engaging, consultation and feedback that continues today, with the ICIC Steering Group including patient representatives.
The attached Board Paper provides information on the extent and quality of the consultation process and how the public informed and shaped the strategic programmes.
• NHS Lothian Strategic Context and Action Plan for Patient Focus and Public Involvement (PFPI)
We have also enclosed a copy of our PFPI Action Plan which sets out the work that NHS Lothian will undertake in the coming years. You will see from this comprehensive plan that we are committed to ensuring that PFPI becomes ‘as much about how we do things as what we do’.
• Development of Children and Young People’s Health and Health Services Strategy for Lothian 2006 - 2012
Between December 2005 - February 2006 children, young people and parents were involved in workshops and focus groups to gather their views about how Children and Young People’s Health Services might be improved from the user’s perspective. We sought to do this with a cross-section of children, young people, parents, staff and the voluntary sector with particular effort to reach out to vulnerable and ‘hard to reach’ groups.
Over the 3 months there were 23 meetings involving over 130 young people between 5 – 18 years, over 20 parents and 16 voluntary organisations. We also drew on findings from previous involvement work with young people. This work aligns with and takes account of the parallel initiatives being undertaken by the Royal Colleges, the voluntary sector and by the Scottish Child Commissioner for Children and Young People.
2 We are now in the process of holding a series of public and stakeholder workshops across Lothian and have distributed to all households in Lothian with the new BT phonebook a 4 page leaflet which outlines how we have improved and invested in services over the last year as well as covering the Children and Young People’s strategy.
In addition to this a Child and Family Advisory Board will be established as one of the five project groups for the reprovisioning of the Royal Hospital for Sick Children. This Board will be co-chaired by the RHSC Family Council and our Chief Nurse, and will have 2 young people representatives as well as representation from the voluntary sector, local authorities and health staff.
Accountability of NHS Health Boards
• NHS Lothian Scheme of Establishment / Public Partnership Fora
The Scheme of Establishment sets out that Public Partnership will be a core function of CHPs and as such will be integral to their development and planning across all agendas. The PPF functions would not only include those that were set out in the CHP guidance:
o Informing the public about a range of locations and services to promote a better understanding about how and where to access services; o Engaging local service users, carers and the public in discussion about how to improve health services; and o Support wider public involvement in planning and decision making to make public services more responsive and accountable to citizens and local communities.
But also those that sit within a broader social contract for engagement in health:
o Development and support for o Building community capacity; independent and collective o Supporting self help; advocacy; o Community based needs o Development of volunteering; assessment. o Policy development and scrutiny;
The Guidance set out that the CHPs establish an appointed representative of the PPF as a full CHP Committee Member. Lothian has gone beyond this and on each of its CHP Sub-Committees there are 2 PPF representatives. The process for appointing these members to the CHP Sub-Committees was one that was developed and agreed by the PPF itself within the parameters set out in the Statutory Guidance.
• Non-Executive Directors
The Non-Executive Directors retain an objective view of the needs of the local population through the ‘listening and responding function’ of the Board and the drive to utilise evidence to inform our developments, where appropriate. Amongst our Non-Executive Board Members there are also 5 local Councillors ensuring that each Community Health Partnership has local authority representation.
3 • Public Meetings
Each of the Board Meetings are advertised and held publicly. All Board Papers are available to members of the public at the meeting or on request and are published on our website.
Similarly, the Annual Review by the Minister for Health and Community Care is held publicly and the Self Assessment Report produced by NHS Lothian is available to the public.
• Public Involvement
There are various ways that patients, carers and the public can be involved in their local health services. Within Lothian there are a number of Councils, Fora and Networks:
o Family Council at the Royal Hospital for Sick Children o Patients Councils at both St John’s and Royal Edinburgh Hospitals o Patient and Public Partnership Network for the Royal Infirmary of Edinburgh, Western General Hospital, Liberton Hospital, Princess Alexandra Eye Pavilion and the Royal Victoria Hospital. o North Edinburgh Public Partnership Forum o South Edinburgh Public Partnership Forum o East Lothian Public Partnership Forum o Midlothian Public Partnership Forum o West Lothian Public Partnership Forum o Southeast Scotland Cancer Network (SCAN) o NHS Lothian Managed Clinical Networks for Coronary Heart Disease (CHD), Stroke, Opthalmology and Palliative Care. o The Lothian Diabetes Representative Group (Patient Group for the NHS Lothian Diabetes Managed Clinical Network) o Other Lothian / National voluntary sector organisations.
We also undertake a targeted approach whereby people will be asked to complete questionnaires, attend focus groups or workshops to tell us what they think of a particular service.
NHS Lothian has a dedicated team to ensure patient focus and public involvement is central to its work. The team consists of a Head of Patient Focus and Public Involvement and 5 Patient Involvement Workers working with each of the Community Health Partnerships.
• The National Standards for Community Engagement
As part of the Edinburgh Partnership, NHS Lothian has signed up to the National Standards and the principles that highlight the importance of equality and recognise the diversity of people and communities; have a clear sense of purpose; effective methods for achieving change; build on the skills and knowledge of all those involved and show a commitment to learning for continuous improvement.
4 4. Have you any comment on the practical implications of putting these provisions in place and the consideration of alternative approaches?
Practical Implications
• Disenfranchisement
The response by the City of Edinburgh Council to the inquiry into boundaries, voting and representation in Scotland highlighted a number of issues around the use of postal voting:
o The risk of confusion with papers being received away from polling stations and potential advice from polling staff. o It offers the opportunity for, or an increase in, the level of electors being “assisted to vote” by third parties. o 40% of adults are estimated to have a reading age of nine or less o Public confusion about the differing systems particularly by some elderly people, those with learning difficulties and / or those whose first language is not English.
• Cost
As one of the largest Health Boards in Scotland the cost to NHS Lothian would be substantial:
Turnout % Annual Cost Total Election Cost 30 39,881 159,523 40 53,174 212,697 50 66,468 265,871 60 79,761 319,045 Based on UK General Election Figures and using the information contained with the Financial Memorandum.
We believe the costs contained within the Financial Memorandum are underestimated. A more local example to consider would be the recent referendum by the City of Edinburgh Council on Transport in February 2005, which balloted circa 325,000 people by postal vote at a cost of £0.5million. This would put the cost per ballot closer to £1.53. On this basis the costs for Lothian would be:
Turnout % Annual Cost Total Election Cost £ £ 30 61,018 244,070 40 81,357 325,426 50 101,696 406,783 60 122,035 488,139
In a time when NHS Boards are expected to make year on year efficiency savings this would only add to our difficulties in meeting current targets as well as put additional pressure on clinical services.
The Financial Memorandum makes reference to savings that can be made by sending groups of ballots to households. We would question whether this would be
5 acceptable in terms of electoral procedure but with the number of single households increasing we would doubt whether the anticipated savings will be as much as 50%. Also the above costings do not take into consideration the changes to postal charges, advertising / publicity costs for the elections or the additional costs of ad hoc elections if a Non Executive Director should leave post mid-term.
Alternative approaches
Consideration could be given to promoting the role of the Non-Executive Directors, in particular our Local Authority Board Members, by making them more accessible to the general public. This should not just be limited to the areas that they represent given that so many of our patients are from out with Lothian.
However, we would in the main suggest that the NHS continues to support and strengthen the Public Partnership Forums and other user and carer networks to ensure that local communities, particularly those which are hard to reach, are engaged in the delivery and design of their health services.
6 v SUBMISSION FROM NHS GREATER GLASGOW AND CLYDE
Thank you for the opportunity to submit comments on the above Bill, as part of the Health Committee's evidence-gathering at Stage 1 of the Bill process.
NHS Greater Glasgow and Clyde opposes the Bill and set out below are the reasons for that position. I have summarised below our key points and then expanded on these in the body of this response.
1. Accountability - there is a clear line of accountability through the Minister for Health and Community Care to the Scottish Parliament - there cannot be dual accountability to local communities through directly elected members.
2. Democratic Representation - as well as the democratic oversight provided by Ministers the addition of local Councillors to NHS Boards and CHP Committees provides a substantial and direct democratic input to NHS business and reflects increasingly integrated decision making. If there were also directly elected Board members there is potential for confusion and conflict between members from different “electoral” systems.
3. Public Involvement - NHS Boards have a substantial emphasis on public involvement and engagement which is subject to clear performance management.
4. Responsibility - by what method would directly elected members be held accountable for their decisions if these are damaging to the public interest - will there be surcharges as there are for local Councillors?
Expanding these summarised points:-
1. Accountability
We believe there are clear and effective accountability arrangements at present.
NHS Boards are clearly accountable to Scottish Ministers on behalf of the Scottish Parliament and the public. NHS Boards are set up as agents of Scottish Ministers and are empowered to locally implement Ministerially-approved national strategies and initiatives.
Scottish Ministers have the responsibility for taking decisions on NHS Board plans that have been consulted upon. There is a clear obligation on Boards to consult with all interested parties on proposals that entail major service changes, transfer of services, or hospital closures.
Scottish Ministers appoint all Non-Executive and Executive Members of an NHS Board - all nominations having previously been subject to an open and competitive process which identifies those who can make a valuable contribution to the work of NHS Scotland. Non-Executive Members are expected to tackle a wide range of demanding responsibilities, balancing national priorities while addressing the health priorities and healthcare needs of their area. They are expected to demonstrate a
7 strong personal commitment to the NHS and an understanding of, and interest in, government health problems and how they impact locally.
Accountability to Scottish Ministers is achieved in a variety of ways and covers:-
(a) Local implementation of national strategies, directives, guidance and good practice.
(b) Robust performance management arrangements covering key health indicator targets, guarantees (waiting times) and priorities. Monthly and quarterly reporting mechanisms are in place to consistently monitor an NHS Board's performance across all performance targets.
(c) Regular meetings between the Minister and NHS Board Chairs cover issues of performance and developing policy issues.
(d) The Annual Review meeting, for each NHS Board, held in public and chaired by the Minister for Health & Community Care. These meetings scrutinise an NHS Board's performance over the previous year and the Minister's assessment is made available in a public letter and included NHS Boards' Annual Reports, to let the public see the outcome of the performance of each NHS Board. The review is preceded by a Board submission covering all elements of its performance.
2. Democratic Representation
It is not correct to suggest that NHS Boards as presently constructed have no democratic representation. In addition to line responsibility to Ministers and the Parliament, the following have ensured democratic accountability.
“Our National Health - A Plan for Action A Plan for Change” in 2001 introduced representation from Senior Councillors, with a lead responsibility for health from each Local Authority in an NHS Board's area, to sit as Non-Executive Members on the NHS Board. NHS Greater Glasgow and Clyde has 7 Local Authority Councillor Members - more than 25% of the Non-Executive cohort on the NHS Board. This has been an extremely useful addition to the NHS Board and the Councillors represent the NHS Greater Glasgow and Clyde area as Non-Executive Directors and not just their own Councils or ward areas. Like all non-executive Directors they are appraised annually.
The White Paper 'Partnership for Care' introduced, for the first time, Community Health Partnerships. The initial model has been developed further within NHS Greater Glasgow and Clyde and currently six Community Health & Social Care Partnerships (CHCPs) have been set up - five in Glasgow City and one in East Renfrewshire.
Each CHCP Committee is chaired by a Local Authority Councillor and each Committee has four additional Councillors as Members. This, therefore, involves 30 locally-elected Councillors sharing responsibility with healthcare professionals, staff and public representatives for the development and evolvement of integrated community-based health and social care for these areas.
8 Local Authority Councillors are used to taking 'big picture' and difficult decisions and being accountable for them. They understand the need to take decisions within the legislative framework and the need to avoid surcharging for incompetent/negligent decisions. They also sign up to and adhere to the Codes of Conduct embedded in the Ethical Standards in Public Life etc. (Scotland) Act 2000.
3. Public Involvement
The recent steps taken nationally, to place more emphasis on earlier and better engagement with the public, has been put in place as a result of criticism of NHS Boards' performance in this area in the past.
The Patient Focused Public Involvement (PFPI) efforts have developed significantly within NHS Boards in the last few years and national annual assessments are undertaken by the SEHD; these clearly show that improvements have been made in this area.
The NHS Reform (Scotland) Act 2004 places a statutory duty on NHS Boards to involve the public and the establishment of the independent Scottish Health Council (SHC) and local advisory council has lead to NHS Boards' engagement with the public being more independently scrutinised and assessed.
The SHC monitors the effectiveness of the NHS Boards' public involvement and has a role in commenting on the adherence to national guidance when consulting the public on service change. If the SHC is not satisfied with the public involvement process, it can recommend to Scottish Ministers that the consultation be improved and undertaken again.
As part of the initiatives to respond to the statutory duty to involve the public, NHS Greater Glasgow and Clyde appointed a Community Engagement Team to make contacts with Community Council groups interested in health and other stakeholders, to involve them in developing healthcare strategies and increase involvement in implementing change by taking account of local services and needs. There has been a significantly increased visibility, within local communities, of the Community Engagement Team and a greater sharing of views and local healthcare plans. The Head of Community Engagement has direct contact at all levels of the Board’s operations. The Board holds regular “Our Health” public events that attract upwards of 200 attendees. There is a contact base of over 3,000 actively interested individuals and groups who receive regular communications. The Board’s newspaper “Health News” is distributed to over 300,000 people at least once per quarter.
In setting up Community Health (and Care) Partnerships (CH(C)Ps), the regulations require the establishment of Public Partnership Forums for each CH(C)P (10 in NHS Greater Glasgow and Clyde), in order to strengthen patient and local community involvement in the planning and operation of the locally-based Community Health (and Social Care) services. We expect these to provide highly effective local engagement.
The Freedom of Information (Scotland) Act 2002 has provided the public with greater rights to information on health services. 9
4. Responsibility
NHS Board members can be removed with immediate effect by the Minister if their conduct is inappropriate. Local Councillors can be surcharged if their decisions do not properly meet their responsibilities. The proposals within the Bill are not clear about how directly elected members who act against the public interest and fail to cooperate with key Board responsibilities - for example to set a balanced budget - will be dealt with.
5. Membership of NHS Board
If the Bill was introduced and if NHS Boards are to retain the representation currently achieved within their composition, then NHS Boards may need to further increase in size. Currently, Greater Glasgow and Clyde NHS Board comprises 32 Members (27 Non-Executive Members and 5 Executive Members). Of that number, 17 existing appointments are currently mandatory (Chair, Employee Director, representatives of the University, Clinical Forum, CH(C)P Professional Committee, 7 Local Authority Councillors, Chief Executive, Medical Director, Nurse Director, Director of Public Health and Director of Finance) and, therefore, 18/19 elected representatives would require to be elected under the proposals in this Bill. This would lead to an NHS Board of 35/36 members and, at the same time, not retain any of the experience of the 15 independent Non-Executive Members currently sitting on the NHS Board.
To even retain 5/6 independent Non-Executive Members would take the NHS Board to over 40 Members - an unworkable number in terms of conducting effective business at Board level.
6. Finance
The Financial Memorandum sets out the annual estimated costs for the first elections under the Bill as between £600,000 and £1.2m.
Currently none of this expenditure is budgeted for and, therefore, any costs of introducing Health Board elections would require to be found at the expense of services to patients and, therefore, would have a detrimental effect on patient services.
7. National Health Service
The NHS is a national health service delivered on a local basis, with national targets, guarantees, strategies, initiatives and policies which require to be delivered by all NHS Boards for the good and benefit of the population of NHS Scotland. Under the proposals, locally-elected NHS Boards might take decisions which do not accord with national policy and this could lead to different services in different areas, post- code services and a skew in performance against national targets.
The elections could encourage 'single issue' candidates who are not able to represent people on the full range of NHS services or the full NHS Greater Glasgow and Clyde area. The big picture and national concept of the service could be lost and could lead to the detriment of some services to patients. There is no single issue solution and pressure/campaign groups could engineer significant 10 representations at the elections which could result in such groups having a significant proportion of places on the NHS Board at the expense of consideration of the wider health issues.
8. Wider Public Sector Reform
The Bill proposes a piecemeal change for one part of a large service interconnected with many other public sector organisations. It sits out of context with the broader picture contained in the recently published 'Transforming Public Services - The Next Phase Of Reform'.
The NHS is part of a wider spectrum of public service and other organisations delivering joined-up services to the public; with these interconnections and partnerships come responsibilities for delivering high-quality, sustainable and safe services. It is very clear that the service works best when acting in concert with partner authorities.
9. Conclusion
NHS Greater Glasgow and Clyde does not support this Bill for the reasons set out above.
PROFESSOR SIR JOHN P. ARBUTHNOTT Chairman
11 SUBMISSION FROM NHS AYRSHIRE AND ARRAN
Thank you for the opportunity to comment on the above Bill. This response represents the views of NHS Ayrshire and Arran, as expressed by both Executive and Non-Executive Members during a discussion of the proposals and underlying principles contained within the Bill. NHS Ayrshire and Arran would not support the introduction of the Bill being considered.
There are 2 clearly stated objectives of the Bill, viz.:
1. Improving the accountability of Health Boards; and 2. Providing the public with a mechanism to influence health care delivery.
Dealing with the first, NHS Boards are currently accountable to the Minister for Health and Community Care, which provides a direct line of responsibility for the implementation of nationally determined policy by the Scottish Parliament, and indeed, the Health Committee. There is a direct link between the concerns of the public and the operation of the NHS through the public election of members of the Scottish Parliament.
Additionally, a key aspect of the NHS in Scotland is its national nature, the proposed Bill would not necessarily improve accountability, merely change it from a national framework to a local one.
Indeed the Bill is unclear with respect to the implications there would inevitably be for the operation of the Minister, the Chief Executive of NHS Scotland, the Scottish Parliament and the Health Committee.
Turning to public influence on health care delivery, there is a range of requirements on NHS Boards with respect to consultation. The relatively recent creation of the Scottish Health Council will embed a role on behalf of the Minister to ensure that these mechanisms are adequately pursued and executed by NHS systems. These requirements operate in relation to major service change as well as on an ongoing basis. In addition the PPFs that have been created under Community Health Partnerships offer a real opportunity to deliver close collaboration and partnership with local communities.
I would also highlight the every significant role health and the NHS play in national election campaigns and the prominence given by political parties to plans for the NHS within their manifestos.
Turning to the specific questions posed by the Committee:
1. Do you support the general principles of the Bill and the proposals for direct elections to NHS Area Health Boards?
NHS Ayrshire & Arran does not support the general principles for a variety of reasons:
1. The Bill, if enacted, would result in a change rather than an increase in accountability for NHS systems; 2. There would be a potential to create postcode prescribing and services as local elected members took particular decisions, thereby undermining the national framework of the NHS. There is the potential for this Bill to actually return the
12 organisation of health care to a pre-1947 model of administration where local Boards decided care provision in isolation from one another; 3. Elections are likely to be costly, with low levels of turnout (given the recent electoral results in local government); and 4. The Bill would not replace the need for consultation and engagement with service users and carers on particular issues and hence there would be no reductions in the levels of resources applied anywhere else in the system
2. Are there any omissions from the Bill that you would like to see added?
A number of issues of detail are absent, such as:
• the future for Stakeholder Non-Executive Members; • the likely cost of elections; • the absence of skills and expertise to run elections within NHS Boards; and • the impact on Ministerial and Scottish Parliament responsibilities in relation to health.
3. What are your views on the quality of consultation, and the implementation of key concerns about the accountability of NHS Health Boards?
In recent years, most notably since the creation of the Scottish Parliament, there has been a significant increase in the accountability and scrutiny of NHS Boards. As well as the Scottish Parliament and the Health Committee, Annual Reviews are now led by the Minister and held in public, CHPs have been established with PPFs and the Scottish Health Council has been created. Controversial change will always be challenging and complex – changing the mechanisms for accountability will not make it any easier to devise solutions to the ongoing need to adapt and review care provision. There is a strong set of checks and balances currently in place for NHS Boards.
There are also significant mechanisms that NHS Boards are required to participate in to ensure local responsiveness (Community Planning) and regional / national coherence (Regional and National Planning). The benefits of these joint approaches could be undone with the inevitable pull on Board members to consider NHS provision in very local constituency areas.
4. Have you any comment on the practical implications of putting these provisions in place and the consideration of alternative approaches?
How would the accountability of the Chief Executive be affected and what would the responsibility of elected members be in this regard?
There is no evidence that there is significant public appetite to stand for such elections – there is no pattern of huge over subscription to Non Executive places on NHS Boards. This would be further exacerbated by the proposal to provide no remuneration to elected members.
This Bill would represent a very significant administrative burden for (inexperienced) NHS Boards. The allocation of resources to elections would divert funds from direct patient care. This is against a set of proposals where the turnout is likely to be low (<50% at 2003 local government elections) and the impact on the quality of decision-making unknown. 13 Moreover, there have been significant recent changes, such as the creation of the Scottish Health Council. Our view would be that these mechanisms should be allowed to develop and the situation monitored and reviewed at a future date by the Health Committee.
The Bill would also create the potential for a ‘yo-yoing’ of decisions in health care every 4 years as elected members change. This would be particularly true if political block votes were exercised at NHS Board meetings and decisions. Within this context the responsibilities for clinical and financial governance of NHS systems would become problematic. An inevitable question posed by such scenarios is the issue of revenue raising powers for systems. Such politicisation of the NHS, which delivers a very large element of the public sector that contains a number of very significant inherent risks, is not a desirable move.
In conclusion, NHS Ayrshire and Arran would not support the introduction of this Bill. Our view is that it would change and confuse rather than increase accountability. It would be likely to undermine the operation of a national NHS. There is no evidence that it would increase the quality of decision-making. The administrative and financial burden would be significant.
I trust these views and observations are of assistance to the Committee in its deliberations.
Kind regards
Professor William Stevely CBE Interim Chair
14
SUBMISSION FROM COSLA
I refer to the invitation to submit evidence to the Health Committee in connection with the above-mentioned Bill.
This matter was considered by COSLA Leaders at their meeting today when it was agreed that the Health Committee be advised that:- a) COSLA remains of the view previously indicated to Bill Butler MSP in response to his initial consultation, namely that the case has not been made for the introduction of direct elections to Health Boards; b) The role of elected members on Health Boards is capable of expansion to strengthen links with the existing democratic process; and c) The matter is one that requires to be considered in the wider context of public sector reform, and particularly the current debate initiated by Tom McCabe, Minister for Finance and Public Sector Reform.
COSLA will be undertaking some detail work on how exactly the local authority elected member role could be expanded and how this could link with the broader public sector reform agenda. I will arrange for the outcome of this work to be forwarded to you when available.
Sylvia Murray Policy Manager
15 Agenda item 2 HC/S2/06/22/03 24 October 2006
EXECUTIVE SUMMARY OF SPICe BRIEFING ON THE HEALTH BOARD ELECTIONS (SCOTLAND) BILL
Background and Current System • The Bill seeks to redress public dissatisfaction with NHS decision making by allowing for the majority of the area NHS Board members to be elected by the public. • Since the inception of the NHS, management and decision making has been devolved from central government to regional bodies (in various forms) with accountability to the Secretary of State/Ministers. Debates about central or local governance of the NHS have continued since this time. • Among the reasons for having non-departmental public bodies is that they can operate with a degree of independence from Ministers and provide expert independent advice on technical, scientific or other complex and sensitive issues. • Existing avenues of accountability and public involvement in the NHS include annual Board reviews with the Health Minister; a statutory duty to involve the public; the Public Partnership Forums of Community Health Partnerships, the presence of local authority members on Boards and the Scottish Health Council to oversee the quality of consultation in the NHS. • At present, NHS Board members are either appointed by Ministers (non-executive members, including the Chair) or hold a place by virtue of their position (executive members). Appointments are made via an open and competitive process. At present, there are a total of 194 non-executive members (lay = 117, stakeholder = 77) and 100 executive members on the 14 NHS Boards. • A survey in 2004 found that 73% of the public felt that they had little or no influence over the way the NHS is run. This was up from 57% in 2000.
Main provisions of the Bill The Bill proposes that: • 50% plus no more than two Board positions should be directly elected by the public. Board Chairs would still be appointed by Ministers. The Bill would not cover Special Health Boards. • Elections would take place every four years (outwith the local government and Scottish Parliament election cycle), with the first elections on 1st May 2008. • Each elector would have one vote and those elected would be the top ranking candidates equal to the number of posts available (e.g. if there were five places, the five candidates with the highest number of votes would be elected). • Constituency areas would mirror the 14 existing area NHS Board boundaries. • In order to stand for election, candidates should be eligible to vote in local government elections for wards within the Board area, registered at an address within the Board area and should receive 10 nominations from local community members. • Campaign expenses would be limited to £500 for each candidate and £250 for third parties. Each candidate will be allowed to produce a 250 word communication for each elector’s household. • Elected members would receive no remuneration. • A person would be entitled to vote if they are registered to vote in a local government election in an area which falls within the Board area, and they are entered on the local government register at an address within the Health Board area. • Voting would be by post only. • The Returning Officer for an election would be the Returning Officer for the largest local authority within the Board area. Funding for elections would come from Board budgets.
1
Reactions and Responses • 85% (n=136/160) of responses to Bill Butler’s consultation on his Bill proposal, supported the principle of the Bill. • 52% (n=17/33) of responses to the Health Committee’s call for evidence on the Bill, supported the principle of the Bill.
Arguments for the principle of the Bill Among the main arguments for the Bill were: • High levels of public expenditure require democratic accountability. Those in charge of such large amounts of taxpayer’s money should be directly answerable to the public. • Elected members would represent the public and not Ministers. • Elected Boards would improve public involvement and consultation. • It would depoliticise the NHS by freeing Boards from central dictat, allowing them to establish their own priorities in line with the needs of their local populations. • There is no need for Boards to be at arms length of government as they do not have a regulatory or semi-judicial role.
Arguments against the principle of the Bill Among the main arguments against the Bill were: • NHS Boards are already accountable to Ministers and the Scottish Parliament. • NHS Boards are already improving public involvement and consultation in the NHS and the changes need time to bed in (e.g. Community Health Partnerships, statutory duty to involve the public, the Scottish Health Council). • Elections will politicise the NHS, lead to short-term decision making, single issue candidates, distort priorities and delay difficult decisions from having to be made. • Elections could lead to ‘postcode lotteries of care’ and undermine the planning of regional services. • The NHS is complex and Boards benefit from having members chosen for particular skills and experience. • Voter turnout may be low which could undermine the legitimacy of the Boards. • May not improve public satisfaction, as in the case of when local authorities close services and face public anger e.g. school closures. • Elections could be costly and remove money from frontline services.
Specific Issues with aspects of the Bill Some specific issues raised about the practicalities of the Bill include: • Although the policy memorandum describes the voting system in the Bill as ‘First-past-the-post’, respondents to the Committee’s call for evidence claim this is not the case, and that it is in fact the ‘Single Non-transferable Vote’. • Postal voting may exclude people with disabilities and those who do not speak English. • As the posts are not remunerated, this may narrow candidates to those who are retired and affluent. • The size of NHS Boards may either have to increase significantly to accommodate a simple majority of elected members, or a number of existing positions will have to be removed and replaced with those who are elected. The Bill does not specify which. • The size of the electoral area (i.e. the whole Board area) may lead to under-representation of people from rural areas.
2 Experience from Other Countries New Zealand District Health Board Elections • In 2001, New Zealand held its first elections for membership on its District Health Boards. • The elections are held using the single transferable vote system and the electoral constituency is the whole board area. This is a change from the first set of elections in 2001 where first-past-the- post system was used and the Board was broken down into smaller electoral wards. • Seven of the eleven places on Boards are elected by the public and members receive remuneration of NZ$24,000 per annum. • Boards are primarily responsible to central government as they do not set their own objectives and Ministers can impose sanctions for poor performance. • Turnout for the 2001 elections was 50% falling to 42% by 2004. However, in 2004 the turnout was skewed by 15% of ballot papers being filled in incorrectly or being left blank. • The number of candidates per seat in 2001 was 7.4 falling to 3.5 candidates per seat in 2004. • Woman and Maoris are under-represented among elected members. • Most of those elected in 2001 came from a professional background (e.g. health, business, law). 10.9% had a background in community work or advocacy.
English Foundation Trusts Elections • Foundation Trusts’ Board of Governors are elected by patients and the public. To vote you must be a member of the Trust (this is usually done by opting in). • In the first wave of elections the average voter turnout for Trusts with an opt-in membership was 52%. This compares favourably to turnout at English local government elections (37%). However, it is questionable as to whether this turnout gives an indication as to likely turnout at Scottish Board elections as the electorate had opted in and are therefore likely to have a higher interest in health services. • At the one trust where all patients were assumed to be members unless they opted out, the turnout was 18%. • 85% of public posts and 73% of patient posts had more than one candidate. Conversely, this means that 15% of public posts and 27% of patient posts had only one candidate. • A review of the elections by the Healthcare Commission found no evidence that single-issue pressure groups were ‘disproportionately represented’. • Women are underrepresented on Boards of Governors, holding 45.5% of posts. • A high proportion of governors representing the public were drawn from the retired population. • No significant differences were found between Foundation Trusts and NHS Trusts in relation to patient experience, the attitude of staff and the provision of services, although this may change with time. • The review concluded that it is too early to assess the impact of the Trusts and whether there is greater accountability.
Cost • The Bill estimates that with a turnout of 30%, elections would cost £1.2m (£0.3m per annum) and with a turnout of 60%, elections would cost £2.4m (£0.6m per annum). This is based on the experiences of Stevenage Borough Council which has piloted ‘postal vote only’ elections. • The Financial memorandum does not include an estimate of costs that may be incurred on general publicity for elections. • There is also no consideration of potential savings that may be made from the remuneration paid to existing Board members, as members elected under the Bill would not be remunerated. At present, expenditure on non-executive member’s remuneration (excluding chairs) is approximately £1.28m per annum. However, as it is unclear what the final configuration of the Boards would be (e.g. whether the non-executive stakeholder members would remain on the Board and still be remunerated), the total potential saving cannot be calculated.
3
Summary of Written Evidence – Health Committee Consultation on the Health Board Elections (Scotland) Bill
Submissions in Favour of the Bill 1. UNISON – Would aid openness, transparency and accountability which is essential for bodies in charge of £7bn of taxpayers money – Would decentralise power to local areas 2. Fife Council – Elections will establish a transparent process which will give local people a real voice 3. John Winton – Appointed members become ‘yes men’ for fear of removal from their position 4. Cowal Against – Elected members should be paid similarly to the appointed non- the Cuts in the executive members Health Services – Bill would ensure greater public involvement, more truthful (CATCHES) communications and genuine consultation – Voting system may not ensure geographical representation – Would like clarification on whether members of the Public Partnership Forum can be elected 5. Socialist Health – Democratic structure will ensure that Boards are more open, Association transparent and accountable – Campaigns over hospital closures show that people want to be involved in planning – Will change the culture of health boards from top-down to one where the public are partners – Will provide greater accountability while retaining necessary expertise
6. Scottish Health – The NHS as a political football has inevitably reflected the views Campaigns Network of the party in power – Non-Exec members are perceived as individuals who support current govt policy – The Bill would increase democracy – Elected Board members would not tolerate decisions being taken without proper and meaningful discussion – Remuneration should be the same as current non-exec members – Appointed members should not be allowed to stand for election – The Bill will depoliticise the NHS 7. Orkney Islands – No comment, just outlines its support for the Bill Council 8. STUC – The Bill would help improve the openness, transparency, accountability and opportunity for participation – It would improve confidence in the decision making processes of the NHS while retaining expertise – Proposals support the wider agenda of public sector reform by decentralising power to local areas – Local campaigns are evidence that people are willing to give their time and energy
4 Submissions in Favour of the Bill 9. Optometry – No comment, just outlines its support for the Bill Scotland 10. Voluntary Health – Accountability for public spending must lie equally with taxpayers Scotland and government – Direct elections would be a more accessible means of promoting local voices and accelerate ‘Patient Focus, Public Involvement’ – Representation in existing fora for public involvement usually comes from ‘more affluent, older indigenous sections of the population’ – Concerns that the nomination process could miss particular groups (e.g. ethnic groups, people with disabilities) – Remuneration should be the same as that for Non-Exec members – Favour postal votes 11. Lanarkshire – Would assuage perceptions of cronyism and that the public are Health United not really consulted – If passed would need to be widely publicised – No disqualification for someone with shareholder interests in PFI projects 12. Henry McCubbin – Boards currently protect sectional interests of health professionals 13. Royal College of – Support the idea of elections to health boards Psychiatrists
Submissions Against the Bill 1. British Medical – Already poor voter turnout in SP and LG elections, Foundation Association Trust Elections in England have had extremely low turnouts – Costly and will be paid out of Health Board budgets at the expense of frontline services – Will politicise the NHS, lead to short-term decision making – Stifle innovation and development in services as Boards will put off making difficult decisions – Board membership requires specific skills and experience – Boards are already accountable to Ministers 2. Royal College of – A significant amount of work has already been taken to address Nursing the problems of how the public is involved in, these changes should be given time to bed in – Could result in short-term decision making or avoiding decisions in the run-up to elections – Probability of low voter turnout – Appointments allow for an appropriate skill set – Currently able to take decisions based on clinical and cost- effectiveness for all people, not just sectional interests – Addition of Councillors to Boards has added a democratic element – Some of the RCN’s concerns may be abated by having a minority of members elected, or by strengthening existing guidance by introducing statutory regulations 3. NHS Forth Valley – National Health Service provision is complex, members should be selected for their skills and experience – Current method of selection involves an open, transparent and competitive process – Councillors bring a democratic element without politicising the NHS
5 Submissions Against the Bill – Proposals would involve reducing some of the existing members or significantly increasing the size of the Board – Already a number of measures being implemented to improve public involvement (e.g. CHPs, creation of the Scottish Health Council) – Boards already accountable to Ministers and scrutiny has been enhanced by the Scottish Parliament – Could increase postcode lotteries of care due to a move away from National approaches – Will reduce funding for frontline services – Likely to be poor voter turnout 4. Scottish – Boards are already accountable to Ministers and Parliament Executive Health – It is accepted that public involvement by NHS Boards needs to Department be improved and a number of measures have been introduced to do this – The Bill takes no account of the impact it would have on the remaining membership of the Board, who are there on the basis of the contribution they can make – Would make no difference to the achievement of the NHS’ aims (delivering high quality, sustainable and safe health services ) and could in fact distract Boards instead – Cost could be higher than that set out in the financial memo and the cost is not budgeted for, would be at the expense of patient services. – Could result in postcode delivery of services 5. NHS Shetland – Any changes should improve services and the patient’s experience, the Bill will remove resources from front line services and be detrimental to patients – Boards are already accountable to Ministers and Parliament – Recent reforms have already addressed some of the acknowledged problems in accountability and involvement – The timing of the Bill does not complement the current ‘Transforming Public Services’ consultation 6. NHS Greater – Boards are already accountable to Parliament through the Glasgow & Clyde Minister – Democratic representation is provided by both the Minister and local councillors on NHS Boards and Community Health and Social Care Partnership Committees
– Recent reforms have enhanced public involvement in NHS NHS Greater decision making (e.g. NHS Reform Act, Patient Focus, Scottish Glasgow & Clyde Health Council) Cont’d – How would elected members be held responsible? Current members can be removed by the Minister – Boards may need to increase in size – The cost would be detrimental to services – Could lead to postcode lottery of care – Could encourage single issue candidates who would not represent people on the full range of services – Sits out of context with the recently published ‘Transforming Public Services’ consultation 7. NHS Ayrshire & – Would not increase accountability. Would only change the Arran accountability framework from a national one to a local one – Could create postcode service delivery – Elections likely to be costly with poor voter turnout,
6 Submissions Against the Bill – Would remove funds from patient care with no evidence of the effect on the quality of decision making – No evidence there would be enough candidates willing to stand – It would not reduce the need for consultation and engagement with the public therefore resources would not be reduced elsewhere – Raise a number of questions about some of the practical implications of the Bill, including who would run the election, the position of stakeholder members 8. CoSLA – No case for direct elections, would prefer the role of elected members on NHS Boards to be expanded – Needs to be considered in the wider context of public sector reform 9. NHS Highland – Already accountable – Elections will increase the likelihood of a postcode lottery of care – Another tier of elected members will obscure lines of accountability – Community Health Partnerships already addressing some of the issues the Bill is aiming to address, the Bill would undermine the development of CHPs 10. NHS Lothian – Believes Boards are already open, transparent and accountable in a number of ways, outlines numerous examples (Public Partnership Forums, councillors on Boards, accountable to the Minister) – Raise some issues in relation to postal voting, including accessibility to people with poor literary skills – Calculate own estimate of cost which is much higher than that set out in the bill 11. George J – Boards are already accountable to the Scottish Executive Cunningham – Doesn’t think the cost would be justifiable to the public as the best use of money in the NHS 12. Steve Renwick – – Candidates need to have an extensive skill base, not be NHS Lothian enthusiastic amateurs – Remuneration would need to be enough to attract the right calibre of candidate as commitment is extensive – Would elected members be willing to take on the personal liability of endowed monies, as current non-execs do? – Where is the evidence that the public want a greater say in the strategy of the health board? – Where is the evidence that the current system is sub-optimal? 13. Dr David Price – Boards are already fully accountable, open, transparent and inclusive through a variety of means – Many suitable candidates will be put off by an election system – Will attract ‘single-issue’ candidates – Most of the public are happy with their local NHS, any problems are usually due to difficulties dealing with change which is natural and occurs in all aspects of life – Voter turnout will be abysmally low 14. Chairman of – Pre-empts the Transforming Public Services consultation NHS Lanarkshire – Lines of accountability are already clear – to ministers and parliament – Domination of local issues will undermine the national service and could lead to a post-code lottery of care – Cost of elections would divert resources from frontline services
7 Submissions Against the Bill – Boards already have elected members on them – It will not lead to an improved service 15. Fife NHS Board – No democratic deficit as Boards are clearly accountable no Chairman Ministers and Parliament – Direct elections may put off difficult decisions being made thus affecting services – Decision taking place prior to the completion of transforming public services – Problems with public engagement which have prompted the bill have been improved in the last 2 years e.g. Scottish Health Council, National Standards for Community Engagement (PFPI?) – Need for a national and regional perspective – avoid post-code lotteries of care – Mentions report by Prof David Hands ‘Organising for Care – The design of a New NHS for Wales’ 16. NHS Grampian – Already accountable – Councillors already sit on Boards – NHS reform act placed a duty on NHS Boards to involve the public, this is independently scrutinised by the Scottish Health Council – Cost would come out of direct patient care
No Position on the General Principles of the Bill/Specific Issues 1. Fairshare – The voting system proposed within the Bill should be changed to the Single Transferable Vote to allow for proportional representation – Highlight that the proposed system is not ‘First-past-the-post’ but is actually the ‘Single Non-Transferable Vote’ – Experience of the Single Non-Transferable Vote is that it provides potential for tactical voting and parties and organised groups engage in ‘voter management’ 2. Association of – Other non-postal elections are already held the first Thursday in Electoral May therefore there could be confusion among electors if Administrators (AEA) another election was to take place on the same day, suggest changing the day Society of Local – They have ‘considerable views’ on the practical implications of Authority Chief putting the provisions in place but do not go into detail Executives and – Procedures could follow those for National Park Board and Senior Managers Local Government elections (SOLACE)
Society of Local Authority Lawyers and Administrators in Scotland (SOLAR) 3. Electoral – Do not feel they are in a position to comment on the principles Commission of the bill 4. Scottish – Concerned about the disqualifier which would rule out people Independent who have mental or physical incapacity Advocacy Alliance
Kathleen Robson Senior Research Specialist SPICe
8 Agenda item 3 HC/S2/06/22/04 24 October 2006
Scottish Executive Draft Budget 2007- 08
1. The Committee will hear evidence from the Minister for Health and Community Care at today’s meeting.
2. Last year the Committee focussed on the Efficient Government Initiative. In September the Convener wrote to the Minister for an update on the initiative. His response is attached as Annex A.
3. Members have already taken evidence from the Deputy Minister on mental health expenditure over this period. This session allows members to look at the overall budget process.
4. The purpose of the evidence session is to:
• obtain further information on the Executive’s plans for achieving savings through the Efficient Government initiative.
• obtain further information on the Executive’s proposals for the 2007- 8 budget;
• consider the issues identified by the Finance Committee for scrutiny; and
5. The following documents are provided to inform this evidence session:
• Letter from the Minister for Health and Community Care on the Efficient Government initiative. (Annex A);
• Paper from the Dr Kevin Woods on the Efficient Government initiative. (Annex B);
• Paper produced by Professor Arthur Midwinter, Budget adviser to the Finance Committee - “Budget Process 2007 – 08: Draft Budget Guidance to Subject Committees” (Annex C);
• SPICe briefing on the Draft Budget. (Annex D); and
• Scottish Executive Health and Community Care Draft Budget for 2007-08. (Annex E)
Simon Watkins/Karen O’Hanlon Joint Clerks to the Committee SCOTTISH EXECUTIVE
Minister for Health &.. Community Care St Andrew's House Andy Kerr MSP Regent Road Edinburgh EH1 3DG
Roseanna Cunningham MSP Health Committee Convener Telephone: 08457741741 The Scottish Parliament [email protected] EDINBURGH http://www.scotland.gov.uk EH99 1SP
2b September 2006
Thank you for your letter of 7 September 2006 about the Scottish Executive Draft Budget 2007-08 - Efficient Government Initiative.
You know that my portfolio has an extensive and ambitious set of plans that support the Efficient Government Initiative, and there has been a significant level - some £176.8m - of efficiencies secured in 2005-06, predominantly cash-releasing. The delivered saving exceeds the Health Departments original "Building a Better Scotland' plan by £llm. Added to this is around £42m on non-recurrent cash savings reported by NHS Boards. I was encouraged by that and see it as a good outcome for the Initiative and for the Health Department. I would like to stress that this is about achieving more for patients with the available resources and every pound saved will be reinvested for the delivery of care for patients and communities.
The Health portfolio target was set to deliver cash efficiencies of £ 166m in 2005-06 and to make progress towards the achievement of £173.3m time releasing savings by 2007-08. I can confirm that action is being taken to ensure the delivery of planned time savings by 31 March 2008.
In the current year, 2006-07, published planned cash savings rise from £169.lm to £240.5m. We expect to, working with colleagues in the Health Department and particularly in the NHS Boards, where Chief Executives are fully committed to this initiative, deliver the bulk of that plan and make significant progress in 2006-07 towards the achievement of £173.3m time releasing savings by year ending 2007-08.
You asked for specific updates on progress towards each of the efficiency plans; I have provided this at Appendix 1, together with a tabular picture of the original "Building a Better Scotland' savings plan, the March 2006 published revised savings plan and 2005-06 outturn position.
~~
) ANDY KERR Appendix 1 CASH RELEASING SAVINGS
NHS Procurement - 2005-06 Plan £33m Savings from the NHS Procurement initiative continue to be delivered as per plan and the £33.3m planned savings for 2005-06 has been achieved. This initiative is on track to meet its 2006-07 planned savings.
Support Services Reform - 2005-06 Plan £0 The Outline Business Case is now being taken forward to Full Business Casso Weare working on a number of important areas surrounding this initiative.
NUS Logistics - 2005-06 Plan £0 NHS Logistics is progressing well. Two NHS Boards are now receiving supplies from the interim distribution centre and the third implementation is due to take place in October 2006. The development of the National Distribution Centre continues to progress according to plan. In addition, following the successful pilot of a new Ward Product Management system at NHS Ayrshire & Arran, this new system will be rolled out across NHSScotland.
Improved Prescribing and Drug Purchasing - 2005-06 Combined Plan £47m Cash savings from Improved Prescribing and Drug Purchasing initiatives reported savings of £59.6m for 2005-06. Further savings of £4m for 2005-06 have only recently been reported, bringing total savings from Improved Prescribing and Drug Purchasing to £63.6m. As a result, these initiatives have met and exceeded their overall combined planned savings of £62million by 31 March 2008. NHS Boards are continuing to apply the Improved Prescribing initiatives established during 2005-06 and as a result small residual savings may continue to accrue.
NHS 1% Efficiency Savings - 2005-06 Plan £88m With regard to the NHS Efficiency initiative, non-recurring savings of £42m were reported by Boards for 2005-06 over and above recurring savings of £71m reported. Although it is recognised that these types of savings fall outside the definition of planned efficiency, they are without doubt savings through efficiencies in spending by Boards. The Scottish Executive Efficient Government Delivery Group acknowledge that some non-recurrent savings might turn out to be recurrent in due course; consequently they see merit in capturing non-recurrent savings and welcome that transparency on the part ofNHS Boards and SEHD.
Facilities Management Systems - 2005-06 Plan £O.lm The Facilities Management System (FMS) Plan remains at pilot study stage at NHS Tayside and has not been rolled out for implementation across the service, this initiative has exceeded its 2005-06 £0.1 m planned savings by £40k.
Care Commission - 2005-06 Plan £lm Savings from the Care Commission have been made through streamlining of the Commission's joint inspection arrangements for early year's services and were embedded in the Commissions budget for 2005-06. Additional savings were also reported as being achieved in 2005-06 as a result of the Commission's Organisational Structure Review, which saw a net reduction of eight middle management posts. The Commission also funded increases in non-staff prices from efficiency savings elsewhere in it's budget. These additional efficiency savings amounted to £0.5m. Efficiency savings of a further £0.6m are embedded in the Commission's budget for 2006-07. Appendix 1
TIME RELEASING SAVINGS
The Health Department Ministerial target was originally set to deliver cash efficiencies savings in 2005/06 and make progress towards the achievement of time releasing savings by year ending 2007- 08. In 2005-06 we delivered £11.3m of time savings and are making significant progress towards the achievement of our £ 173.3m planned time savings by 31st March 2008.
Reduction in Absence - 2005-06 Plan £16.3m A Reduction in Sickness Absence of 0.15% has been achieved during 2005-06 compared to 2004-05 rates and current trends continue to fall. This equates to estimated actual savings of £5.85m for 2005-06. NHS Boards were only given official direction in the form of a Health Department Letter in November 2005 of action required with regard to this Plan and consequently the savings reported for 2005-06 are the result of work over a 5 month period.
Increasing Consultant Productivity - 2005-06 Plan £21.1m The existing measure for the Increasing Consultant Productivity plan is currently being reconsidered. Given concerns that the current measure is a narrow activity rather than productivity measure, a strong case emerged for a broader range of measurers which better reflect the complexities involved, avoid over reliance on a single measure, are better aligned with key policy and plans, enable meaningful comparison with England, support benchmarking activities and better reflect challenges in the Atkinson review. The necessary work to develop more appropriate measures to describe progress against this plan is being undertaken as a priority and this work will be finalised very shortly. Forecasted savings will be confirmed following the completion this work, however it is anticipated that significant efficiency gains will be delivered.
Scottish Primary Care Collaborative - 2005-06 Plan £6.5m Scottish Primary Care Collaborative reported savings of £3.1m against planned savings of £6.5m for 2005-06. Evidence trom GP practices who joined the Collaborative suggest that they have seen a reduction in DNAs as a result of the improvements they have made trom participating in the programme. There has also been a favourable impact on the need to employ locum cover for GP absence.
Outpatient Programme - Speciality Redesign - 2005-06 Plan £0.9m For 2005-06 the Outpatient Programme - Specialty Redesign initiative reported savings of £I.25m, which exceeds the total planned savings of £0.9m by 31sl March 2008. Data continues to be collected on the new roles created by this initiative and it is anticipated that further savings will be delivered for 2006-07.
Outpatient Programme - Patient Focussed Booking - 2005-06 Plan £2.6m Outpatient Programme - Patient Focussed Booking (PFB) programme has reported savings of £1.1 m against planned savings of £2.6m for 2005-06. This project has reported difficulties measuring the impact and assigning cost savings to many benefits resulting trom PFB including more efficient waiting lists, improved validation, routine patients being seen in turn and reduced hospital cancellations. Consequently, these savings have been excluded trom the reported savings, but the programme team aim to implement a new reporting tool during 2006-07 which will recover the position stated. The Planned Care Improvement Programme will lead measurement and implementation of PFB for the remaining appropriate new and return outpatient appointments trom October 2006.
(-) ~..> <,.V
I:\\'ESTOR 1:\ I'MWLE Appendix 1
Electronic Transmission of Lab Results to GPs - 2005-06 Plan £4m Technical work for the Electronic Transmission of Lab Results to GPs system is nearing completion, having been delayed due to requirements to modify GP systems to support the new GP contract. Revised software is due for testing in November 2006, and is it expected that some NHS Boards will commence installation of software during January - March 2007, with all Boards using it by April.
Digital X-rays/Picture Archive Computer System (PACS) - 2005-06 Plan £3.3m The contract with the Digital X-rays/Picture Archive Computer System (PACS) supplier is now signed. The first implementation of the system in an NHS Board is now underway and the first site (Southern General Hospital) went live earlier this month. It is considered that the end point for this project will not change and that the savings position will be recovered over the remaining years. Tabular Information Appendix 1
HEALTH & COMMUNITY CARE PORTFOLIO EFFICIENCY SAVINGS PLAN TO 2007-08 Original Published Revised Cash Plans "Building Cash Project Reference & Description a Better Outturn Scotland" Savings Cash Plan 2005-06 2006-07 2007-08 2005-06 £'m £'m £'m £'m £'m HlC 1 NHS Procurement 50.0 33.0 50.0 60.0 33.3
HlC2 Support Services Reform 10.0 0 0 10.0 0
H/C3 NHS Logistics 10.0 0 2.5 7.5 0
H/C4 Improved Prescribing 20.0 5.0 10.0 20.0 21.6
H/C7 NHS Efficiency Savings 75.0 88.0 134.0 208.0 71.0
HlC8 Facilities Management Systems 1.0 0.1 0.4 0.8 0.1
H/C9 Drug Purchasing 0 42.0 42.0 42.0 38.0
H/C 10 Care Commission 0 1.0 1.6 1.6 1.5
CASH TOTAL 166.0 169.1 240.5 349.9 165.5
Original Published Revised Time Plans "Building Time Project Reference & Description a Better Outturn Scotland" Savings Time Plan 2005-06 2006-07 2007-08 2005-06 £'m £'m £'m £'m £'m H/T 1 Reduction in Absence 0 16.3 34.5 54.8 5.9
HlT2 Increasing Consultant Productivity 0 21.1 45.6 73.0 0
H/T3 Scottish Primary Care Collaborative 0 6.5 6.5 6.5 3.1
HlT4 Outpatient Programme/ Specialty 0 0.9 0.9 0.9 1.2 Redesign
HlT5 Outpatient Programme/ Patient Focussed 0 2.6 2.6 2.6 1.1 Booking
H/T6 Electronic Transmission of Lab Results to 0 4.0 8.0 12 0 GPs
HlT9 Digital X-Rays/ PACS 0 3.3 13.4 23.5 0
TIME TOTAL 0 54.7 111.5 173.3 11.3
I HEALTH TOTAL 166.0 l 223.8 352.0 523.2 176.8 ~r" ~"'_C:!
I'E,.<;TOR IS I'EOPLE Annex B
Health & Community Care
Head of Department Statement of Efficiency Savings
As Head of Department, I am aware of the overall need to ensure the delivery of government services as efficiently as possible. In terms of the Efficient Government Plan (Building A Better Scotland: Efficient Government - Securing Efficiency, Effectiveness and Productivity) I acknowledge my responsibility to plan accordingly to achieve £169.1million of cash releasing savings in 2005-06 and make progress in 2005-06 towards the achievement of £173.3million time releasing savings by year ending 2007-08.
I am satisfied, subject to NHS Boards ensuring that evidence is held locally of savings claimed for H/C7 NHS Efficiency Savings, on the basis of project managers statements of assurance that, in the case of cash-releasing savings, the costs of the activities in question have been reduced by the amounts shown below without material detriment to the quality or quantity of service provided; and that, in the case of time releasing savings, the amounts shown below are a fair estimate of the value of time released from the activities in question for other productive purposes.
I confirm that the actual saving achieved was £165.5million of cash releasing and £11.3million of time releasing savings for the year ended 2005-06. The attached table shows outturn against target and records any changes to the target since the first publication of the relevant Efficiency Technical Notes. The delivered saving exceeds my original target by £11million. Our time releasing gains have accrued more slowly than our plans showed but we continue to make progress towards the 2007-08 target. In addition to the figures shown, non-recurrent cash releasing savings of £42million have been reported by NHS Boards. I can confirm that action has been taken to ensure the delivery of the savings for 2006-07 in full.
I am satisfied that the savings identified fall within the published definition of an efficiency gain.
Kevin Woods
28 June 2006
EFFICIENT GOVERNMENT: DELIVERY OF EFFICIENT GOVERNMENT SAVINGS
PORTFOLIO OUTTURN SUMMARY: Health
Published Agreed Project Outturn Project Number and Cash Planned Saving amended Saving (£m) 05- Title or Time (£m) 05-06 target 06 H/C1 - NHS Cash 33.0 No change 33.3 Procurement H/C4 - Improved Cash 5.0 No change 21.6 Prescribing H/C7 - NHS Efficiency Cash 88.0 No change 71.0 Savings H/C8 - Estates and Cash 0.1 No change 0.14 facilities management H/C9 - Drug purchasing Cash 42.0 No change 38.0 H/C10 - Care Cash 1.0 No change 1.5 Commission Total Cash Releasing 169.1 165.54 Savings H/T1 - Reduction in Time 16.3 No change 5.85 absence H/T2 - Increasing Time 21.1 No change 0.0 consultant productivity H/T3 - Scottish Primary Time 6.5 No change 3.112 Care Collaborative H/T4 - Specialty Time 0.9 No change 1.249 redesign projects H/T5 - Outpatient : Patient focussed Time 2.6 No change 1.12 booking H/T6 - Electronic transmission of lab Time 4.0 No change 0.0 results to GPs H/C9 - Digital Time 3.3 No change 0.0 Rays/PACS Total Time Releasing 54.7 11.331 Savings Total 223.8 176.871
Annex C
Budget Process 2007 – 08 - Draft Budget Guidance to Subject Committees: Paper by the Budget Adviser
1. The budget process this year is again a short one, because of the postponement of the Spending Review until 2007, there has been no Stage One.
2. Members will also be aware from the figures that this is the tightest budgetary context in this Parliament with spending growing by 2.4 % in real terms over 2006-7.
3. Therefore, there is no need for Committees to make recommendations for additional spending, but proposals to reorder priorities within portfolios would be considered.
4. The document also highlights changes in plans since last year, and Committee comments on these would be helpful.
5. This is the last budget in the current Parliament. The Finance Committee has put considerable effort into improving the quality of financial information in the document. Concerns remain over the Executive’s ‘objectives and targets’ approach. It would be helpful if Committees could reflect on the usefulness of the financial and performance information to them, and suggest ways of improving the presentation of the budget in the next Parliament.
6. In addition, Committees may also feel able to reflect on spending priorities within their portfolios and recommend any programmes they feel need to be prioritised for the next Parliament.
7. Last year, Committees were asked for views on the Executive’s Efficient Government Initiative. The Executive has recently published an Outturn Report for 2005-06 and the Finance Committee would be interested in any observations that subject committees may have on Efficient Government within their remit.
8. With these comments in mind, the Finance Committee would welcome responses on the undernoted key topics:
a) Is the Committee satisfied with the responses from Ministers to its recommendations for the 2006-7 budget? b) Does the Committee wish to make any comments on the budgetary changes reported in the “New Resources” section? c) Does the Committee wish to recommend any transfers of funding between programmes within its portfolio, with an explanation for the proposal?
1
d) Does the Committee have any proposals for improving the quality and relevance of financial and performance information in the Draft Budget which could be considered after the 2007 election? e) Does the Committee wish to make any recommendations in budget proposals to its successors in 200x7? Is there any programme with a clear need for additional expenditure, or which members think is overfunded?
Professor Arthur Midwinter September 2006
2 Annex D SPICe DRAFT BUDGET 2007-08: HEALTH AND briefing
COMMUNITY CARE 5 October 2006
JIM DEWAR AND KATHLEEN ROBSON 06/72
This briefing has been prepared to assist the Scottish Parliament’s Health Committee in scrutinising the Draft Budget 2007-08. It provides general information on the Draft Budget 2007-08 and specific information on Health and Community Care covering
• trends over the six years 2002-08 • changes since last year • provisional outturn • progress on objectives and targets • progress on efficiency savings
Scottish Parliament Information Centre (SPICe) Briefings are compiled for the benefit of the Members of the Parliament and their personal staff. Authors are available to discuss the contents of these papers with MSPs and their staff who should contact Jim Dewar on extension 85377, email [email protected] or Kathleen Robson on extension 85371, email [email protected] Members of the public or external organisations may comment on this briefing by emailing us at [email protected]. However, researchers are unable to enter into personal discussion in relation to SPICe Briefing Papers. If you have any general questions about the work of the Parliament you can email the Parliament’s Public Information Service at [email protected].
Every effort is made to ensure that the information contained in SPICe briefings is correct at the time of publication. Readers should be aware however that briefings are not necessarily updated or otherwise amended to reflect subsequent changes. www.scottish.parliament.uk
1 CONTENTS
KEY POINTS ...... 3
INTRODUCTION ...... 4
HEALTH AND COMMUNITY CARE SPENDING PLANS...... 6
TRENDS 2002-08 ...... 6 CHANGES IN PLANNED SPEND BETWEEN 2006-07 AND 2007-08...... 7 CHANGES IN PLANNED SPEND 2007- 08 SINCE DRAFT BUDGET 2006-07...... 8 PROVISIONAL OUTTURN AND END YEAR FLEXIBILITY 2005-06...... 8 OBJECTIVES AND TARGETS...... 8
THE EFFICIENT GOVERNMENT INITIATIVE...... 11
EFFICIENCY PLANS NOT ON TARGET ...... 11 GUIDANCE FROM BUDGET ADVISER...... 13
SOURCES ...... 15
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KEY POINTS • The Draft Budget 2007-08 increases total planned spend for 2007-08 across all portfolios by almost £600m compared with the plans announced last year for 2007-08
• The increase arises mainly from changes in responsibilities (Network Rail +£338m) and funding of pensions liabilities (Scottish Public Pensions Agency +£571m) offset in part by changes in accounting (EC receipts -£497m)
• The year on year increase in real terms in Total Managed Expenditure (TME) in 2007-08 is £725m (2.4%) with the bulk of the increase (£483m) going to Health and Community Care
• The largest percentage increases in real terms are in Education and Young People (+£45m, +7.8%), Health and Community Care (+£483m, +5.1%) and Tourism, Culture and Sport (+£12m, 4.2%)
• Over the period 2002-08 spending on Health and Community Care will have increased in real terms by 39.3% compared with an increase in TME of 28.2% while Health and Community Care’s share of TME will have increased from 30.2% to 32.8%
• There are only minor changes in planned spend for 2007-08 compared with last year’s plans for the same year
• The provisional outturn for 2005-06 shows no over or under spend in the Health and Community Care budget
• The Objectives and Targets remain the same as those included in last year’s Draft Budget
• The Executive has made significant progress on a number of targets (e.g. reducing deaths from coronary heart disease and stroke) but other targets have not had the same level of progress (e.g. reducing teenage pregnancies in deprived communities)
• Actual Efficiency Savings in 2005-06 were £176.8m but this was £47m less than planned
• Most of the cash release efficiency savings were met, resulting in a shortfall of £3.6m out of a possible £169.1m.
• Just one of the six planned time-release savings was met, resulting in a shortfall of £43.4m out of a possible £54.7m. The most significant shortfall was in relation to improving Consultant Productivity (£21.1m) although the Executive attributes this to a revision in the measure used.
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INTRODUCTION Spending Review 2004 (Scottish Executive 2004a) set out the Executive’s spending plans for the three financial years to 2007-08. The Draft Budget 2007 - 08 (Scottish Executive 2006a) published on 8 September 2006, updates the Executive’s spending plans for 2007-08. These plans incorporate new money coming to Scotland as a result of the UK Budget of 22 March 2006 (HM Treasury 2006).
The figures in the Draft Budget 2007-08 are “largely the same as those published in ‘Draft Budget 2006-07’, with explanations given for any significant changes” (Scottish Executive 2006, p7). Some significant changes in spending plan figures for 2007-08 are proposed but these reflect changes in responsibilities and accounting rather than real changes in the allocation of resources.
Table 1 compares planned spend by portfolio in 2007-08 as published in Draft Budget 2006-07 and Draft Budget 2007-08.
Table 1 Changes in planned spend 2007- 08 since Draft Budget 2006-07 £m Sept 2005 Sept 2006 Change Explanation for change Environment and Rural Reclassification of EC receipts Development 1328.3 915.0 -413.3 of £497m Communities 1313.1 1327.9 14.8 Education and Young People 665.4 641.8 -23.6 Tourism, Culture and Sport 290.9 310.9 20.0 Enterprise and Lifelong Learning 2914.9 2950.5 35.6 Network Rail £338m, transfer Transport from DoT £17m and 1897.5 2335.3 437.9 concessionary fares £79m Scottish Public Pensions Finance and Public Service Reform 10374.5 10942.9 568.4 Agency additional £571m Health and Community Care 10279.4 10247.2 -32.2 Justice 1100.7 1132.1 31.4 Administration 263.7 261.2 -2.5 COPFS 100.6 100.8 0.2 Food Standards Agency 10.8 10.8 0.0 Scottish Parliament and Audit Scotland 107.2 106.9 -0.2 Contingency Fund 41.0 -41.0 Total 30687.9 31283.6 595.6
Total Managed Expenditure (TME) in 2007-08 is set to increase on 2006-07 in real terms by £725m, or 2.4%. In converting cash to real terms the Executive have used a deflator which assumes an increase in prices of 2.66% between 2006-07 and 2007-08. This is in line with Treasury forecasts.
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Table 2 Changes between Budget 2006-07 and Plans 2007-08: real terms (2006-07 prices) £m 2006-07 2007-08 Change Change Budget Plans £m % Environment and Rural Development 874.0 891.3 17.4 2.0 Communities 1283.3 1293.5 10.2 0.8 Education and Young People 580.2 625.2 45.0 7.8 Tourism, Culture and Sport 290.7 302.8 12.2 4.2 Enterprise and Lifelong Learning 2843.7 2874.1 30.4 1.1 Transport 2247.8 2274.9 27.1 1.2 Finance and Public Service Reform 10576.8 10659.6 82.8 0.8 Health and Community Care 9499.0 9981.9 483.0 5.1 Justice 1079.9 1102.8 22.9 2.1 Administration 260.9 254.5 -6.5 -2.5 COPFS 99.3 98.2 -1.1 -1.1 Food Standards Agency 10.3 10.5 0.2 2.2
Scottish Parliament and Audit Scotland 102.3 104.2 1.9 1.8 Total 29748.1 30473.6 725.4 2.4
The largest absolute increase in spend is the Health portfolio which increases in real terms by £483m or 5.1%, representing two-thirds of the total real terms increase. The budget for the Education and Young People portfolio increases by 7.8% in real terms.1 The only other budget line to increase above the overall rate of budget growth (2.4%) is Tourism, Culture and Sport, which will increase by 4.2% in real terms.
Environment and Rural Development (+2.0%); Communities (+0.8%); Enterprise and Lifelong Learning (+1.1%); Transport (+1.2%); Finance and Public Service Reform (+0.8%) and Justice (+2.1%) portfolios are all set to increase by less than the overall budget increase of 2.4% in real terms.
Administration (-2.5%) and Crown Office and Procurator Fiscal Service (COPFS) (-1.1%) portfolios are set to see their budgets shrink in real terms over the next financial year.
The next UK Spending Review has been postponed until 2007. As a result this year’s Draft Budget makes only minor changes to last year’s spending plans. Next year’s Draft Budget will incorporate the outcome of the spending review and roll forward spending plans to March 2011.
1 The Education and Young People budget line is relatively small and made up of specific grants. The vast majority of education spend comes out of the Lifelong Learning and Local Government Budget lines.
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HEALTH AND COMMUNITY CARE SPENDING PLANS
TRENDS 2002-08 Table 3 shows the budget and planned spend over the six years from 2002-03 to 2007-08 by Level 2 heading in cash terms
Table 3 Categories of spending (Level 2) Cash 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £m Budget Budget Budget Budget Budget Plans
National Health Service 6382.7 7101.8 7903.9 8629.1 9329.9 10072.4 Other Health Services 32.0 37.4 42.0 44.8 43.1 45.5 Health Improvement 51.0 69.2 79.9 107.0 108.1 110.5
Community Care 8.8 18.3 21.9 19.1 17.9 18.9
Total 6474.5 7226.7 8047.7 8799.9 9499.0 10247.2 Mental Health Specific Grant 13.3 14.0 14.0 14.0 14.0 14.0 Total Managed Expenditure 21478.7 23643.6 25520.1 27389.9 29748.1 31283.6
H&CC as % of TME 30.2 30.6 31.6 32.2 32.0 32.8
Table 4 shows the budget and planned spend in real terms expressed in 2006-07 prices
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Table 4 Categories of spending (Level 2) real terms 2006-07 prices % £m 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 Increase Budget Budget Budget Budget Budget Plans on 2006- 07
National Health Service 7,063.0 7,631.9 8,268.6 8,839.9 9,329.9 9,811.6 5.2 Other Health Services 35.4 40.2 43.9 45.9 43.1 44.3 2.8 Health Improvement 56.4 74.4 83.6 109.6 108.1 107.6 -0.5
Community Care 9.7 19.7 23.0 19.5 17.9 18.5 3.4
Total 7,164.5 7,766.1 8,419.0 9,014.9 9,499.0 9,981.9 5.1 Mental Health Specific Grant 14.7 15.0 14.6 14.3 14.0 13.6 -2.9 Total Managed Expenditure 23,767.9 25,408.2 26,697.5 28,059.1 29,748.1 30,473.6 2.4 H&CC as % of TME 30.2 30.6 31.6 32.2 32.0 32.8
Over the period 2002-08 total spending on Health and Community Care will have increased by 39.3% which compares with an increase in TME of 28.2%. As a result Health and Community Care’s share of total spend has increased from 30.2% to 32.8%.
CHANGES IN PLANNED SPEND BETWEEN 2006-07 AND 2007-08 Between 2006-07 and 2007-08 planned spending on Health and Community Care increases in real terms by £483m (5.1%) with virtually all of the extra resources going to the NHS. This compares with an increase for TME of 2.4%.
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CHANGES IN PLANNED SPEND 2007- 08 SINCE DRAFT BUDGET 2006-07 Table 5 compares the planned spend in 2007-08 as stated in the latest Draft Budget and the figures published last year.
Table 5: Changes in planned spend on Health and Community Care 2007-08 since Draft Budget 2006-07 (Level 2) Sept 2005 Sept 2006 Change Change £m £m %
National Health Service 10092.6 10072.4 -20.2 -0.2
Other Health Services 73.6 45.5 -28.1 -61.9
Health Improvement 94.3 110.5 16.2 14.6
Community Care 18.9 18.9 0.0 0.0 Total 10279.4 10247.2 -32.2 -0.3
Mental Health Specific Grant 14.0 14.0 0.0 0.0
These changes are explained in the Draft Budget as the transfer of the Welfare Foods budget from Other Health Services to Health Improvement and the transfer of £31m from the Health budget to the Justice portfolio which now has lead responsibility for drug policy.
PROVISIONAL OUTTURN AND END YEAR FLEXIBILITY 2005-06 Provisional Outturn and End Year Flexibility 2005-06 (Scottish Executive 2006b) shows no over or under spend in the Health and Community Care budget. This compares with an under spend in 2003-04 of £74m and in 2004-05 of £59m.
OBJECTIVES AND TARGETS The overall aim of the Health and Community Care portfolio is
“to improve the health and the quality of life of the people of Scotland and to deliver integrated health and community care services making sure there is support and protection for those members of society who are in greatest need.”
This aim is supported by four objectives and eight targets as set out in Table 5. The objectives and targets published in the Draft Budget 2007-08 are unchanged from those published last year.
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Table 6: Health and Community Care Objectives and Targets Objective 1
Working across Scottish Executive Departments and with other delivery partners to improve the health of everyone in Scotland and reduce the health gap between people living in the most affluent and most deprived communities.
By health improvement action to tackle diet, physical activity, smoking and alcohol consumption, by action to ensure early detection and improved
access to treatment and care we will reduce the mortality rates for those 1. Between 1995 and 2005, there has been a 14.8% aged under 75, between 1995 and reduction in the rate of cancer deaths 2010 Target 1 2. Between 1995 and 2005, there has been a 45.8% By 2010 we will reduce: reduction in the rate of Coronary Heart Disease deaths
1. deaths due to Cancer by 20% 3. Between 1995 and 2005, there has been a 45.1% reduction in the rate of Stroke deaths 2. Coronary Heart Disease by 60%; and
3. Stroke by 50%
Reduce health inequalities by Adults: increasing the rate of improvement across a range of indicators for the 1. Between 2003 and 2005, Coronary Heart Disease most deprived communities by 15%, by mortality rates in the most deprived communities have 2008. been reduced by 12.7%
For adults – 2. Between 2003 and 2005, Cancer death rates in the most deprived communities has been reduced by 7.4% 1. coronary heart disease, 3. Between 2004 and 2005, smoking in the most deprived Target 2 2. cancer, communities has been reduced by 7.65%
3. adults smoking, 4. Between 2003 and 2005, smoking in pregnancy in the most deprived communities has been reduced by 11% 4. smoking during pregnancy Young People And for young people – 5. Between 2000-02 and 2002-04, the rate of teenage 5. teenage pregnancy pregnancies in the most deprived communities has decreased by 0.8% 6. suicides in young people Between 2001-03 and 2003-05, the rate of suicides in 10-24 year olds has decreased by 16.4%
Objective 2
To seek and take into account the views and experiences of patients, carers and communities in designing, planning and improving healthcare services.
All NHS Boards will achieve year on year improvements in the involvement of the public in the planning and The Scottish Health Council annual reports for each NHS delivery of NHS services to 2008 and Board contains information in qualitative format only, thus it Target 3 in the involvement of patients in is not easily summarised. Each report highlights areas decisions about their own health care where progress has been made as well as areas requiring and the development of services, as further improvement. reflected in reports by the Scottish Health Council.
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Objective 3
To improve the quality of NHS services to better meet the needs of patients, with particular priority to cancer, coronary heart disease, stroke and mental health.
An interim review of the standards in June 2005, gave a national overview on the progress of NHS Boards. Part of its conclusion read:
“This review shows that NHSScotland takes clinical All NHS Boards will demonstrate governance and risk management seriously, and is regular and sustained improvement, as committed to providing this assurance. It was also clear that reflected in the reports by NHS Quality clinical governance is beginning to develop from its relatively Improvement Scotland (QIS) in informal beginnings into a much more structured and performance against the Healthcare cohesive system with the patient at the core of all activities. Governance standards set by NHSQIS. Target 4 Clinical governance and risk management have taken root and if this commitment is maintained, NHSScotland will be able to demonstrate continual clinical improvement that results in better outcomes and better experiences for patients.”
Objective 4
Ensure patients receive healthcare at the right time, in the right place and in the right way.
By the end of 2007:
1. no patient will wait more than 1. At the end of June 2006, figures show that on average 18 weeks from GP referral to 79.6% of new outpatients were seen in 18 weeks an outpatient appointment;
2. no patient will wait more than 18 weeks from a decision to 2. At the end of June 2006, figures show that 5.8% of undertake treatment to the patients waited more than 18 weeks for inpatient/day start of that treatment - down case treatment. No-one waited more than 26 weeks. from the current 9 month maximum wait guarantee; and
Patients will be able to rely on shorter maximum waits for specific conditions:
Target 5 3. 18 weeks from referral to completion of treatment for 3. No data available for cataract surgery. Currently being cataract surgery; developed by ISD Scotland and the Scottish Executive and should be available at the beginning of 2007 4. 4 hours from arrival to discharge or transfer for 4. In 2006 12% of patients spent more than 4 hours in accident and emergency accident and emergency. Main reasons for waiting more treatment; than 4 hours included waiting for a bed (31%) and waiting for first assessment (20%)
5. 24 hours from admission to a 5. No data available for hip surgery. Currently being specialist unit for hip surgery developed by ISD Scotland and the Scottish Executive following fracture; and and should be available at the beginning of 2007
6. 16 weeks from GP referral through a rapid access chest 6. No data available for cardiac interventions. Currently pain clinic or equivalent, to being developed by ISD Scotland and the Scottish cardiac intervention. Executive and should be available at the beginning of 2007
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We will reduce the number of people waiting to be discharged from hospital In July 2005, there were 753 patients awaiting discharge. In into a more appropriate care setting by July 2006 this was 627. Target 6 20% year on year between 2005 and the end of 2008, cutting to a minimum This is an annual reduction of 16.7% the number of people waiting more than 6 weeks to be discharged.
By 2008, increase the number of older At 31st March 2005, the proportion of all older people people receiving intensive home care Target 7 receiving long term care who were receiving intensive home to 30% of all older people receiving care was 28.3% long term care.
By 2008-09, we will reduce the proportion of older people (aged 65+) Target 8 who are admitted as an emergency Data not yet available for 2005/06 inpatient two or more times in a single year by 20% compared with 2004-05.
THE EFFICIENT GOVERNMENT INITIATIVE The Minister for Finance and Public Services launched the Executive’s Efficient Government Plan ‘Building a Better Scotland – Efficient Government – Securing Efficiency, Effectiveness and Productivity’ (Scottish Executive 2004b) in November 2004. This document outlined a total of £405m savings in 2005-06, rising to £745m recurring cash savings and £300m recurring time savings by 2007-08.
Revised Efficiency Technical Notes were published in March 2006 (Scottish Executive 2006c) and an Efficiency Outturn Report for 2005/06 in September 2006 (Scottish Executive 2006d). The planned and actual to date savings in the Health and Community Care portfolio are shown in Table 6.
Most of the cash releasing savings planned for 2005-06 have been achieved (£165.5 compared with £169.1m = £3.6m shortfall) with Improved Prescribing achieving savings four times greater than the plan. However, actual time releasing savings have fallen well short of the plan (£11.3m compared with £54.7m= £43.4m shortfall) with no savings being recorded for three of the programmes. The gap between planned and actual savings has been most significant in Increasing Consultant Productivity (£21.1m), and Reduction in Absence (£10.4m). The total shortfall for all targets is £47m.
EFFICIENCY PLANS NOT ON TARGET On 26 September 2006, the Health Minister wrote to the Health Committee of the Scottish Parliament providing an update on progress towards the efficiency plans (Scottish Executive, 2006e). The following outlines a summary of the Minister’s update on each area that did not reach its target.
NHS Efficiency Savings (Cash release saving - £17m short of target)
Although this plan fell short of the £88m target, according to the Minister’s letter, NHS Boards did report a further £42m worth of non-recurrent savings which technically fall outwith the definition of planned efficiency but which the Executive considers to have come through efficiencies in spending by Boards.
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Table 6: Planned and actual efficiency savings 2005-06 2005-06 2006-07 2007-08 £m Planned Actual Planned Planned
Cash Release Savings
NHS Procurement 33.0 33.3 50.0 63.8
NHS Support Services Reform 0.0 0.0 0.0 10.0
NHS Logistics 0.0 0.0 2.5 9.7
Improved Prescribing 5.0 21.6 10.0 20.0
NHS Efficiency Savings 88.0 71.0 134.0 208.0
Facilities Management Systems 0.1 0.1 0.4 0.8
Drug Purchasing 42.0 38.0 42.0 42.0
Care Commission Efficiency Savings 1.0 1.5 1.6 1.6
Total Cash Releasing Savings 169.1 165.5 240.5 355.8 Time Release Savings
Reduction in Absence 16.3 5.9 34.5 54.8
Increasing Consultant Productivity 21.1 0.0 45.6 73.0
Scottish Primary Care Collaborative 6.5 3.1 6.5 6.5
Specialty Redesign Projects 0.9 1.2 0.9 0.9
Patient Focussed Booking 2.6 1.1 2.6 2.6 Electronic Transmission of Lab Results to GPs 4.0 0.0 8.0 12.0
Digital X-rays/ PACS 3.3 0.0 13.4 23.5
Total Time Releasing Savings 54.7 11.3 111.5 173.3 Countering NHS Fraud (tbc) 0.0 0.0 0.0 2.0 Total Savings 223.8 176.8 352.0 531.1
Drug Purchasing (Cash release saving - £4m short of target)
Although the planned saving for drug purchasing fell short of its target, the Minister’s letter reports on it together with ‘Improved Prescribing’ which exceeded it’s target by £16.6m. The Minister therefore considers this target (in combination with improved prescribing) to have been exceeded.
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Reduction in Absence (Time release saving - £12.4m short of target)
Compared to 2004-05, a reduction in sickness absence of 0.15% was achieved in 2005-06. Although the target falls short, the Minister’s letter outlines that NHS Boards were only issued official direction on this target in November 2005, therefore the £5.85m savings achieved relates only to five months worth of work.
Increase Consultant Productivity (Time release saving - £21.1m short of target)
The Minister’s letter reports that the measure for Consultant Productivity is being revised to better reflect the complexity of consultant productivity. The letter does not make it clear whether any effort has been made to measure progress using the existing measure, or if this is on hold until a new measure is approved.
Scottish Primary Care Collaborative (Time release saving - £2.6m short of target)
The letter does not provide an explanation of why this plan is not on target. Instead it outlines that it has had the effect of reducing ‘no-shows’ at GP practices and a reduction in the need to employ locum cover for GP absences.
Patient Focused Bookings (Time release saving - £1.5m short of target)
The letter highlights the difficulties in measuring the impact and assigning cost savings to a number of benefits to arise from the initiative. These have reportedly included more efficient waiting lists and reduced cancellations of hospital appointments. Consequently, these savings have been excluded from the reported savings, but the programme team is aiming to implement a new reporting tool during 2006-07 which it is hoped will recover the position stated.
Electronic Transmission of Lab Results to GPs (Time release saving - £4m short of target)
The technical work for this programme was delayed due to modification of the GP system in order to support the new GP contract.
Digital X-Rays/PACS (Time release saving - £3.3m short of target)
The first site for implementing this system went live at the beginning of September. Although behind target, it is anticipated that the savings target will be recovered over the remaining years.
GUIDANCE FROM BUDGET ADVISER
The Finance Committee’s Budget adviser, Arthur Midwinter, has produced guidance for the subject committees, in terms of their scrutiny of this year’s Draft Budget. This guidance can be summarised into the following points and members are invited to keep these in mind when considering their approach:
• Is the Committee satisfied with the response to its recommendations for the 2006-07 budget? • Does the Committee wish to make any comment on the budgetary changes reported in the “new resources and transfers” section? • Does the Committee wish to recommend transfers of funding between programmes within its budgetary portfolio? providing research and information services to the Scottish Parliament 13
• Does the Committee have any proposal for improving the quality and relevance of the financial and performance information contained in the Draft Budget? • Does the Committee have any recommendations on budget proposals for its successor Committee? For instance, is there any programme which the Committee believes requires additional or less expenditure?
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SOURCES HM Treasury. (2006) Budget 2006: A Strong and Strengthening Economy: Investing in Britain’s Future. London: HM Treasury. Available at: http://www.hm-treasury.gov.uk/budget/budget_06/bud_bud06_index.cfm
Scottish Executive. (2004a) Building a Better Scotland – Spending Proposals 2005-2008: Enterprise, Opportunity, Fairness. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2004/09/19984/43685
Scottish Executive. (2004b) Building a Better Scotland – Efficient Government – Securing Efficiency, Effectiveness and Productivity. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2004/11/20318/47372
Scottish Executive (2005) Draft Budget 2006-07. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2005/09/06112356/23573
Scottish Executive. (2006a) Draft Budget 2007-08. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2006/09/05131713/0
Scottish Executive. (2006b) Provisional Outturn and End Year Flexibility. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/News/News-Extras/outturneyf
Scottish Executive. (2006c) Efficiency Technical Notes March 2006. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2006/03/31095821/0
Scottish Executive. (2006d) Efficient Government: Efficiency Outturn Report for 2005-06. Edinburgh: Scottish Executive. Available at: http://www.scotland.gov.uk/Publications/2006/09/efficientgovernment
Scottish Executive. (2006e) Ministerial Letter to the Health Committee: SE Draft Budget 2007- 08 Efficient Government Initiative - 26 September 2006. Edinburgh, Scottish Executive. Available online: http://www.scottish.parliament.uk/business/committees/health/index.htm (Committee papers for Tuesday 24th October 2006)
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Annex E
Scottish Executive Draft Budget 2007-08
Health and Community Care
To improve the health and the quality of life of the people of Scotland and to deliver integrated health and community care services making sure there is support and protection for those members of society who are in greatest need.
Objectives and Targets
Working across Scottish Executive Departments and with other Objective delivery partners to improve the health of everyone in Scotland
1 and reduce the health gap between people living in the most affluent and most deprived communities. Reduce the mortality rates for those aged under 75, between 1995 and 2010 by health improvement action to tackle diet, physical activity, smoking and alcohol consumption, by action to Target 1 ensure early detection and improved access to treatment and care. We will reduce deaths due to cancer by 20%; coronary heart disease by 60%; and stroke by 50% by 2010. Reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15%, by 2008. (The range of indicators has been selected Target 2 from the 23 recommended indicators of health inequality. For adults - coronary heart disease, cancer, adults smoking, smoking during pregnancy, and for young people - teenage pregnancy and suicides in young people.) To seek and take into account the views and experiences of patients, Objective
2 carers and communities in designing, planning and improving healthcare services. All NHS Boards will achieve year on year improvements in the involvement of the public in the planning and delivery of NHS Target 3 services to 2008 and in the involvement of patients in decisions about their own health care and the development of services, as reflected in reports by the Scottish Health Council. Objective To improve the quality of NHS services to better meet the needs
3 of patients, with particular priority to cancer, coronary heart disease, stroke and mental health. All NHS Boards will demonstrate regular and sustained improvement, as reflected in the reports by NHS Quality Target 4 Improvement Scotland ( QIS) in performance against the Healthcare Governance standards set by NHSQIS. Objective Ensure patients receive healthcare at the right time, in the right
4 place and in the right way. By the end of 2007:
• no patient will wait more than 18 weeks from GP referral to an outpatient appointment; • no patient will wait more than 18 weeks from a decision to undertake treatment to the start of that treatment - down from the current 9 month maximum wait guarantee; and • patients will be able to rely on shorter maximum waits for specific conditions: Target 5 • 18 weeks from referral to completion of treatment for cataract surgery; • 4 hours from arrival to discharge or transfer for accident and emergency treatment; • 24 hours from admission to a specialist unit for hip surgery following fracture; and • 16 weeks from GP referral through a rapid access chest pain clinic or equivalent, to cardiac intervention.
We will reduce the number of people waiting to be discharged from hospital into a more appropriate care setting by 20% year Target 6 on year between 2005 and the end of 2008, cutting to a minimum the number of people waiting more than 6 weeks to be discharged. By 2008, increase the number of older people receiving intensive Target 7 home care to 30% of all older people receiving long term care. By 2008-09, we will reduce the proportion of older people (aged Target 8 65+) who are admitted as an emergency inpatient two or more times in a single year by 20% compared with 2004-05.
Note: The Objectives and Targets set as part of the 2006-07 Health Department Delivery Plan are set out in Annex A Spending plans 2002-08
Table 8.01 Categories of spending (Level 2)
2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £000s Budget Budget Budget Budget Budget Plans National Health 6,382,724 7,101,824 7,903,887 8,629,072 9,329,929 10,072,374 Service Other Health 31,986 37,367 41,969 44,780 43,073 45,461 Services Health 50,999 69,187 79,882 106,989 108,074 110,456 Improvement Community 8,762 18,349 21,942 19,052 17,880 18,940 Care Total 6,474,471 7,226,727 8,047,680 8,799,893 9,498,956 10,247,231 Mental Health 13,300 14,000 14,000 14,000 14,000 14,000 Specific Grant
Note: Welfare Foods budget transferred from Other Health Services to Health Improvement for all years
Table 8.02 Categories of spending (Level 2 real terms)at 2006-07 prices
2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £000s Budget Budget Budget Budget Budget Plans National Health 7,063,012 7,631,883 8,268,551 8,839,880 9,329,929 9,811,576 Service Other Health 35,395 40,156 43,905 45,874 43,073 44,284 Services Health 56,435 74,351 83,568 109,603 108,074 107,596 Improvement Community 9,696 19,719 22,954 19,517 17,880 18,450 Care Total 7,164,538 7,766,109 8,418,979 9,014,874 9,498,956 9,981,906 Mental Health 14,718 15,045 14,646 14,342 14,000 13,638 Specific Grant What the budget does
The Health portfolio's aim to improve the physical and mental health and wellbeing of the people of Scotland contributes to many of the Executive's key aims, e.g. to encourage economic growth, to improve educational attainment, whilst also promoting equality and closing the opportunity gap between the most and the least affluent. We will also ensure that our activities are sustainable and delivered in partnership.
Scotland's health is improving, but it remains relatively poor when compared to other European countries. In addition there is a substantial, growing gap in life expectancy and healthy life expectancy between the most and least affluent men and women in Scotland. The challenge of improving health outcomes in Scotland is one which faces the Scottish Executive as a whole. We set out in Improving Health in Scotland: The Challenge a strategic approach, drawing together actions and resources across a wide range of the Executive's responsibilities. The Challenge aims for action on three linked levels:
• life circumstances - promoting social inclusion, employability and closing the opportunity gap; • lifestyles - diet, alcohol misuse, smoking and lack of physical activity; and • health topics - tackling biggest killers and contributors to poor quality of life such as coronary heart disease, mental health and cancer.
We will focus on health improvement delivery, which will include anticipatory care, approach for people at risk of preventable ill-health in deprived communities, developing a healthy weight policy which builds upon existing work on physical activity and diet, and a framework for local health improvement actions by community planning partners.
Aspects of health improvement work (e.g. Mental Well-being, Diet and Physical Activity) have been commended by the World Health Organisation. We plan to celebrate the successes to date whilst also increasing the rate of improvement in population health.
In 2007-08 we will continue to do all we can to reduce smoking prevalence by building upon the benefits flowing from the smoke-free places introduced by the Smoking, Health and Social Care (Scotland) Act 2005. In addition to continuing to invest in smoking cessation services we will use the recommendations of the Smoking Prevention Working Group - expected to report in Autumn 2006 - to develop a new long term strategy to guide smoking prevention activity at national and local levels.
We will also drive forward Delivering for Health, our programme of action for the NHS which will see us shift the balance of care from reliance on episodic, acute care in hospitals towards a system which emphasises a wider effort to improve health and well being, through preventative medicine, support for self care, delivering services in the community and greater targeting of resources to those most risk.
We are committed to an approach which:
• places the patient at the centre of planning and delivery; • reduces waiting; and • raises the quality of care and promotes patient safety.
NHS Quality Improvement Scotland is at the heart of our efforts to improve quality and standards in the NHS in Scotland through developing standards, guidelines and reporting publicly on performance. It has recently concluded that the arrangements now being put in place by the NHS to protect the quality of patient care are more robust and coherent than at any time in the history of the service. The new Scottish Health Council will help to ensure that NHS Boards are communicating effectively with and listening to patients and the public, and that there is a clear patient-focused approach to the delivery of services.
Scotland's health policy can be represented pictorially as:
Statement of Priorities
Our immediate priority, will be to meet the targets set out in 'Delivering for Health', in particular:
• improving health and targeting action to address inequalities in health; • meeting waiting times targets; • a national strategy for the care of long term conditions; • e-health review of emergency retrieving services; • plans for the establishment of planned care services; • development of a model of Rural General Hospitals; • publication of a National Delivery Plan for Mental Health Services; • managed Clinical Networks for tertiary paediatric care; • we have initiated a National Review of Specialist Children's Services which is aiming to produce a National Delivery Plan for Specialist Children's Services in Scotland by the autumn of 2007 which will include building two new children's hospitals in Edinburgh and Glasgow. • continuing investment in research ensuring that expenditure is as well- focused as possible to achieve the objectives of improving health and health services for the people of Scotland.
New Resources and transfers
In 2007-08 we are planning to spend more than £748m more on healthcare services in Scotland than we are doing in the current year. We will be using this additional funding to seek major improvements in performance through a sustained programme of reform and service redesign and through investment in capacity. We expect Community Health Partnerships ( CHPs) to help take reform forward and to strengthen the voice of healthcare at a local level. The CHPs will promote health and tackle health inequalities, together with better integration of primary care services with the specialist services in hospitals and with the social care services of local authorities.
We continue to invest to increase the capacity of the NHS, with Partnership Agreement targets to increase the number of doctors, nurses and other health professionals; with the largest programme of spending on hospitals and community health centres; and with a strategy to improve the use of information technology and telemedicine techniques. We are funding major reforms to modernise the pay and conditions of Health Service staff in support of the required redesign of services, providing a platform for new ways of working, delivery of higher quality care to patients, and the development of new roles for staff. Although the independent healthcare sector in Scotland is small, we will make increasing use of such independent providers, where this offers value for money and improvements in the patient's experience.
This investment in the NHS needs to be matched by a sustained commitment to redesign the way services are delivered, so as to shorten the patient's pathway of care and provide the right care in the right place and at the right time. Such redesign will mean major changes in the way healthcare is delivered in future: for example, more support for people with chronic conditions and their carers through primary care teams and local health centres, making full use of the professional skills of community nurses and pharmacists; more services to raise health standards delivered through local communities and voluntary bodies; more nurse-led clinics and day-care services; more investment in local diagnostic facilities; and clinically appropriate use of hospital-based services and care.
We will continue to invest in modernising community care services, through local authorities and the voluntary sector to meet the needs of Scotland's older people and younger adults who need care. Our aim is to deliver a wider variety of flexible, person-centred services, delivered through partnership arrangements to help more people to live independently for longer in their own homes or in sheltered housing, and to reduce inappropriate admissions and inappropriate length of stay in hospitals.
In 2006-07 and 2007-08, £31m was transferred to the Justice Portfolio who now have lead responsibility on drug policy.
Growing the economy
Although the main role of NHSScotland is to look after the health of the Scottish population, the health portfolio does contribute both directly and indirectly to help grow the Scottish economy.
Direct Contribution
• Employment - Public sector health and care services in Scotland are major contributors to the Scottish economy. Employment in the NHS in Scotland in September 2005 represented 6 per cent of the Scottish workforce. Furthermore, NHSScotland recognises its responsibility as a large employer and has formed strong partnerships with Jobcentre Plus to ensure that its vacancies are promoted to people who are currently out of work and that opportunities for NHS pre-employment training exist for potential candidates who do not hold the necessary skills to compete at interview. • Expenditure - Pay represents the major component of expenditure on health and care services. The provision of employment opportunities and spending power results in indirect multiplier effects that further increase the contribution of the NHS to the economy. • Equity - In rural and remote regions of Scotland the NHS provides work and spending power, thereby contributing to the local economy and helping to mitigate the effects of depopulation. • Investment in Scotland to support involvement in the United Kingdom Clinical Research Collaboration ( UKCRC), has been influential in helping to attract recent investment of c.£33m by Wyeth Pharmaceuticals, in a translational medicine initiative involving the Universities of Aberdeen, Dundee, Edinburgh and Glasgow and the NHS. It has also attracted an additional investment of up to £17m from Scottish Enterprise. • The collaboration will create the world's first 'Translational Medicine Research Collaboration' in Scotland and provide the impetus for Scotland to lead the world in medical research and bring lifesaving new drugs to patients more quickly. The collaboration will create 50 jobs at a state-of-the-art Laboratory in Dundee in the first instance, rising to as many as 120 over 5 years. • A recent UK Health Research Analysis report published by the UKCRC confirms that Scotland attracts a disproportionate amount of directly funded research (13.1%) when compared to regions in England. A separate survey indicates that Scottish healthcare research is the most productive in the World.
Indirect Contribution
• The main drivers of economic growth are the quantity (and quality) of an economy's factors of production. The quality of that labour force is a major contributor to an economy's international competitiveness. The health service provides a vital role in ensuring that the labour force remains healthy and available for work.
• Public health care available free at the point of use has a significant effect on the labour force. Better health enhances labour productivity by reducing: o the number of working days lost due to illness; o the number of early retirements; and o the number of premature deaths amongst those of working age because of treatable illness. • Although not all output lost through absenteeism is preventable through increased health expenditure, particular programmes of health expenditure are clearly more relevant than others. For example, it is estimated that approximately 35 per cent of absences from work are caused by mental health problems 1. Figures for Scotland suggest that 72 per cent of people with mental health problems are unemployed - the highest of all the disability groups - yet 80 per cent go on to make a complete recovery. • Another example of health expenditure that has the potential to improve economic performance is health improvement. Health improvement in Scotland is a multi-agency, multi-stranded approach which ranges from action focused on key settings (workplace, homes, communities and schools) to mental health, suicide reduction, sexually transmitted diseases, alcohol, tobacco and drugs misuse to programmes aimed at healthier eating and physical activity. This is particularly important in preventing (or reducing) the prevalence of diseases such as cancer, coronary heart disease and stroke. The effect on economic and social productivity of these problems should not be under-estimated, in particular alcohol and drug misuse. For example, a study commissioned by the Scottish Executive Health Department ( SEHD) in 2001 estimated that the total economic cost of alcohol misuse to the Scottish economy was in excess of £400m per annum. Nearly 50 per cent of this loss was because of premature mortality and the remainder through unemployment and absenteeism from work. • The indirect costs of supporting research in the NHS in Scotland is met from the Health Budget. It is estimated that every £1 of this support generates another £6 of direct research funding through charities and other research organisations. This spending contributes towards the continued advances in medicines, leading ultimately to improved services for patients. It also provides an incentive to leading medical practitioners to remain (or to relocate) in Scotland, improving the overall quality of the economic output. • It is estimated that the introduction of new smoke free laws could save up to 1,000 lives through reduced exposure to second hand smoke in addition to lives saved by people giving up smoking as a result of the ban. Reductions in smoking prevalence could also potentially lead to savings for the NHS in Scotland which is estimated to spend £200m a year on treating smoking related diseases. A Regulatory Impact Assessment was published by the Executive in 2005, which suggested that the benefits of a ban on smoking over a 30 year period would amount to over £4bn in NPV terms, compared to the option of continuing with a voluntary approach to prohibiting smoking in public places.
The main role of public expenditure on health should be to provide clinical and community care to all those in need of these services. This is and will continue to be the main aim for NHS Scotland in the future. However, in addition to providing these essential services, the health service has and does play a key role in maintaining and improving the productive potential of Scotland's population and in so doing, contributing to ensure a solid base for the future economic growth of Scotland.
Closing the Opportunity Gap/Promoting Equality
Closing the opportunity gap
• A high level Closing the Opportunity Gap objective for health was announced in July 2004: to increase the rate of improvement of the health status of people living in the most deprived communities, in order to improve their quality of life, including their employability prospects. • Supporting this Closing the Opportunity Gap objective, a specific health inequalities target was agreed as one of the Health and Community Care targets for SR2004: to reduce health inequalities by increasing the rate of improvement across a range of indicators for the most deprived communities by 15% by 2008. Six key indicators have been selected: o under 75 CHD mortality; o under 75 cancer mortality; o adults smoking; o smoking during pregnancy; o teenage pregnancy (aged 13 - 15); and o suicides in young people (aged 10- 24).
These targets are ambitious and stretching given that recent evidence points to an increasing health inequalities gap between most and least affluent, and will require concerted and effective action at local and national level.
• We are currently developing Prevention 2010, this takes forward the recommendations in the Kerr report: that we identify people at risk in deprived communities and actively recruit them into interventions programmes and follow them to ensure progress is effective. The Prevention 2010 Programme will aim to deliver effective health interventions through enhancing primary care services in deprived communities in the context of the new Community Health Partnerships, and will seek to demonstrate that it is possible to engage with people in deprived communities with the long-term aim of reducing deaths and hospital admissions from conditions such as stroke and CHD. The World Health Organisation has stressed the importance of preventing obesity through combined action to tackle the problems of lack of physical activity and poor diet. Scotland is responding to this by driving forward an integrated multi-sectoral implementation of our national Physical Activity and the Scottish Diet Action Plan and the World health Organisation has strongly commended Scotland in adopting this preventive approach and developing a healthy weight policy advice to tackle the rising obesity epidemic, and developing a framework for local health improvement actions by community planning partners. • Smoking, poor diet, poor mental health, high levels of alcohol consumption and low rates of physical activity are all major contributory factors to chronic ill health and the major causes of morbidity and mortality. National guidelines and programmes will support local partnerships to have a particular focus on positive outcomes around these factors. Action plans on each of these areas have already been published by the Executive and a ban on smoking in public places came into force in spring 2006. In addition to driving forward implementation of smoke-free areas legislation, efforts will be stepped up to reduce the number of smokers in the general population and to close the gap in smoking prevalence between the poorest and the most affluent groups. • We will devote specific resources as follows: o £1m per annum until 2009-10 for the Glasgow Centre for Population Health; o £9m for 2005-08 for Phase 2 of the three National Health Demonstration Projects and associated Learning Networks, all with a clear focus on tackling health inequalities; o Up to £25m for 2005-08 for the Prevention 2010 Programme, providing additional resources to strengthen primary care in deprived communities and national support for the Programme; o £6m between 2006-08 for implementation of smoke-free legislation o £20m between 2006-08 for smoking cessation activity • Health improvement activity is funded through a range of SEHD and Executive programmes, many of which will impact both directly and indirectly on tackling health inequalities.
Promoting equality
• In addition to traditional health improvement activity, NHSScotland also recognises that employment is a key contributor to good health. This factor coupled with a genuine recruitment need has led a number of NHSScotland employers, with the support of SEHD, to develop structured routes to employment for economically inactive citizens. Current schemes target claimants of Incapacity Benefit, Income Support, Jobseekers allowance and people with refugee status, but are open to any one who is not working or is in low paid/low skilled work. The courses are designed to enable participants to compete for vacancies on a level playing field. NHS Boards are being encouraged to develop courses appropriate to their local circumstances to ensure that equality of employment opportunity exists. • Closing the Opportunity Gap also means that the NHS needs to respond effectively to the individual circumstances of people's lives - including age, gender, ethnicity, disability, religion, sexual orientation, mental health, economic, location or other circumstance - so that all individuals are treated in a fair and sensitive way, and can access the right health services for their needs. This is central to our commitment to social justice and the need to bridge the opportunity gap for all. • The Fair for All approach was initially developed to ensure that the needs of ethnic minorities and refugees were effectively met. We are committed to ensuring an effective approach across the NHS to delivering all of the equality strands, including race, disability, gender and sexual orientation, to ensure that health services respond sensitively to individual needs. The NHS Reform (Scotland) Act 2004 now underpins this commitment by placing a specific duty on NHS Boards to promote equality of opportunity. • We will raise awareness of equality and diversity issues in the workplace and promote accessible recruitment methods. This will allow us to offer improved equality of employment opportunity. Attracting a wider pool of talent for NHS vacancies and improving retention rates will help us ensure that the workforce reflects the local community which in turn assists in the delivery of a culturally sensitive service which is responsive to the needs of the public and our patients. • By 2008 we will increase the number of older people receiving intensive home care to 30% of all people receiving long term care. • Our National Health: A Plan for Action, a Plan for Change describes how "we will achieve over time, our core aims of building a national effort to improve health, reduce inequalities in health and make the NHS a national health service not a national illness service". This is an integral part of sustainable development. To help develop a sustainable workforce the Health Portfolio is encouraging men to take a greater interest in their own health by providing support services including the development of well man clinics. • Initial analysis of the data identified in the pilot on smoking prevention and cessation underlines a marked difference in the response of girls and boys. Since 2000, the number of 15 year old boys smoking has remained significantly lower, at around 15%, than that of girls at around 24%. Our commitment to equality will be enhanced by utilising information from the pilots to identify gender differences and inform resource allocation. In addition, by making the link between objectives like smoking prevention and cessation and increasing participation in sport, we will be better able to link policy priorities, resource allocation and implementation strategies.
Sustainable Development
• NHSScotland has a target for 2% per annum reduction in climatically adjusted energy consumption over the 9 year period 2001-2010. The NHSScotland Property and Environment Forum are introducing web- based environment data gathering software which will facilitate the benchmarking of water and effluent consumption. Indications are that savings of up to £3m may be achievable if benchmark consumption levels are met. • Our commitment is to develop Scotland as a health improving environment, including the Health Promoting NHS, identified in the Health Improvement Challenge which complements and can add value to sustainable development. These agendas combine to deliver shared goals such as providing opportunities for walking and cycling and influencing food distribution and food provision outcomes. The NHS has a major role to play as an exemplary manager of its estates, contracts and staff, to be a force for change for a significant proportion of the population. • Ensure that NHS Estates Policy addresses access to services that also promote walking and cycling including building planning as well as outdoor space planning. • Building on learning from experience in food provision in schools, introduction of standards for food in the NHS supported by specifications for food purchased and procured in the public sector. • Development of NHS procurement to allow opportunities for provision of fresh local food. • Development of the NHS as a health promoting workplace and NHS outlets as health promoting environments. • Outside the NHS, we will continue to co-ordinate and lead work across Government and delivery sectors to improve food and health, and opportunities for people to be physically active as part of normal daily life. Led by Cross-Government Ministerial Councils for Food and Health and Physical Activity. Environment and Transport Departments are involved to ensure health benefits are integrated into transport and environment policy and vice versa • Continue productive joint working between the health and education sectors to support the further development of health promoting schools through action to further develop whole school approaches to food and physical activity and to promote emotional well-being and good mental health. • Continue to work with NHS Scotland and other partners to drive forward the tobacco control agenda including through implementation of smoke-free legislation. • NHSScotland's annual expenditure on waste disposal is currently in excess of £8m - the cost of 400 full time equivalent nurses. NHSScotland disposes of over 45,000 tonnes of waste each year of which 15,000 tonnes is categorised as clinical waste. Low/ medium clinical waste disposal costs are approximately six times more than domestic waste on a weight by weight basis. The introduction of landfill tax reinforces the need to minimise the amount of waste sent to landfill sites by better segregation and recycling policy. NHSScotland Boards have in place plans to achieve reductions in the amount of waste. • It is our policy to ensure that all NHSScotland bodies as an integral part of the commitment to the health and well being of the community do the utmost to ensure that all activities are sustainable. To deliver on this commitment all NHSScotland Bodies must have in place effective environmental management systems through which the environmental performance of property assets can be monitored and improved. NHSScotland's Property and Environment forum has developed an ISO14001 compliant system, known as Greencode. ISO 14001 is the international environmental management system standard. Greencode and the recently developed Corporate Greencode system which enables waste, fuel, energy and water use to be monitored at NHS Board level demonstrates our commitment to supporting NHSScotland in achieving a healthier environment and a healthier population. Efficient Government
Health continues to make significant contributions to the 3 Year Efficient Government Efficiency Programme. Over the life of this programme Health and Community Care will release over £1.1billion of efficiency savings. All savings will continue to be retained within individual board areas and will be ploughed back into the NHS to supplement announced spending. The table below provides a breakdown of savings initiatives identified to date and their respective cumulative savings targets year on year.
Ref 2005-06 2006-07 2007-08 Total Aggregate Title No £'m £'m £'m Savings £'m H/C1 NHS Procurement 33 50 63.75 146.75 NHS Support Services H/C2 0 0 10 10 Reform H/C3 NHS Logistics 0 2.5 9.65 12.15 H/C4 Improved Prescribing 5 10 20 35 H/C7 NHS Efficiency Savings 88 134 208 430 Facilities Management H/C8 0.1 0.4 0.8 1.3 Systems H/C9 Drug Purchasing 42 42 42 126 Care Commission H/C10 1 1.6 1.6 4.2 Efficiency Savings H/T1 Reduction in Absence 16.3 34.5 54.8 105.6 Increasing Consultant H/T2 21.1 45.6 73 139.7 Productivity Scottish Primary Care H/T3 6.5 6.5 6.5 19.5 Collaborative Specialty Redesign H/T4 0.9 0.9 0.9 2.7 Projects H/T5 Patient Focussed Booking 2.6 2.6 2.6 7.8 Electronic Transmission H/T6 4 8 12 24 of Lab Results to GPs H/T9 Digital X-rays/ PACS 3.3 13.4 23.5 40.2 TBC Countering NHS Fraud 0 0 2 2 Total Health and Community Care 223.8 352.0 531.1 1,106.9 Savings
National Health Service
In their report on Stage 2 of the 2006-07 budget process, the Finance Committee made a recommendation that the spending assumptions for differing forms of care on which the block allocations to NHS Boards is made should be published in the Health Chapter. The Special Adviser and the SEHD Department Director of Finance met and agreed that this information should be provided and that SEHD will aim to include it in the 2008-08 Draft Budget.
Spending plans 2002-08
Table 8.03 More detailed categories of spending (Level 3)
2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £000s Budget Budget Budget Budget Budget Plans NHS Board Unified Budgets 1 Argyll & Clyde 394,180 430,901 489,309 514,833 - - NHS Board 2 Ayrshire & Arran NHS 345,407 381,031 433,747 462,840 496,914 - Board Borders NHS 97,853 107,909 124,188 132,754 143,455 - Board Dumfries & Galloway NHS 143,593 158,289 181,040 192,270 207,375 - Board Fife NHS Board 296,302 327,187 376,032 399,619 430,918 - Forth Valley 236,627 260,798 298,669 314,943 338,619 - NHS Board Grampian NHS 431,776 469,159 513,841 547,910 583,490 - Board Greater Glasgow NHS 898,543 974,225 1,079,286 1,137,979 1,634,850 - Board Highland NHS 199,643 220,407 255,182 272,460 419,558 - Board Lanarkshire 480,614 528,622 602,127 637,338 686,476 - NHS Board Lothian NHS 646,472 702,539 772,948 812,864 868,621 - Board Orkney NHS 19,720 21,578 23,861 25,740 26,852 - Board Shetland NHS 24,074 26,184 28,522 30,876 31,812 - Board Tayside NHS 382,951 414,943 450,643 483,539 516,958 - Board Western Isles 37,890 40,898 44,980 48,411 50,307 - NHS Board Special Health Board Unified Budgets 1 National Waiting Times 11,831 16,000 29,820 34,256 36,568 - Centre Scottish Ambulance 106,733 117,166 128,100 143,056 162,942 - Service Common Services 150,206 161,723 175,000 194,480 220,552 - Agency NHS Quality Improvement 9,392 10,232 10,900 11,744 15,197 - Scotland State Hospital 20,899 22,734 25,710 28,783 30,846 - NHS 24 22,156 31,561 46,540 45,731 51,484 - NHS Education 182,538 198,836 215,670 289,157 325,263 - for Scotland NHS Health 8,130 9,512 11,140 12,017 13,058 - Scotland Total available for NHS and 5,147,530 5,632,434 6,317,255 6,773,600 7,292,115 7,805,938 Special Health Boards National priorities Cancer 25,000 25,000 25,000 - - - Services 3 Coronary Heart - 10,000 20,000 15,000 15,000 15,000 Disease/Stroke Delayed 20,000 30,000 30,000 29,890 29,100 29,100 Discharge Joint Improvement - - - - 900 900 Team 4 Drug Misuse expenditure by 19,677 19,677 19,677 25,752 - - NHS Boards 5 Audiology - - 4,000 6,000 6,000 6,000 services modernisation Diabetes - - - 550 1,000 1,000 Autism - - - - 1,000 1,000 Clean hospitals - - - - 5,000 5,000 Centre for Change and 4,925 12,798 14,693 21,060 21,325 23,640 Innovation Education and training Education & 97,505 114,423 127,474 140,262 146,694 155,675 Training Primary care services General Medical 452,712 500,827 545,408 649,792 662373 703,325 Services 6 Pharmaceutical 108,304 113,366 118,628 125,372 141056 149,240 Services General Dental 203,222 213,299 225,176 253,565 312515 354,515 Services General Ophthalmic 43,762 45,494 47,313 50,788 53319 55,451 Services Resources still to be allocated ------for primary care services 7 Miscellaneous services Research 31,940 33,599 35,348 37,504 43,104 47,604 Support Information Technology - 16,512 19,679 36,821 35,301 45,301 100,301 revenue NHS Central 1,200 950 950 950 950 950 Register Waiting Times Co-ordinating - 5,000 5,000 46,750 49,500 70,000 Unit Glasgow - 2,000 5,000 5,000 5,000 5,000 Hostel Distinction 14,529 17,716 18,425 19,162 19,928 20,726 awards Impairments 25,000 25,000 25,000 22,000 10,000 25,000 Clinical workforce - - - - 5,250 5,475 redesign Efficiency - - - - 13,000 13,000 measures Unmet need - - - - 10,000 10,000 Miscellaneous Hospital & Community 6,119 46,628 36,657 16,621 21,815 25,868 Health Services National Health Service -94,691 -103,662 -104,178 -105,668 -105,668 -105,668 receipts Capital investment Capital 271,578 322,120 362,340 469,600 459,600 528,100 Capital -12,100 -12,100 -12,100 -12,100 -12,100 -12,100 receipts Unallocated resources Departmental Unallocated - 27,576 - 2,321 76,852 32,334 Provision TOTAL NHS 6,382,724 7,101,824 7,903,887 8,629,072 9,329,929 10,072,374
Notes:
1.Indicative allocations for 2007-08 are not yet available because the Arbuthnott formula will require to be updated for in-year changes.
2. NHS Argyll and Clyde was dissolved on 1 April 2006 and its functions were split between NHS Greater Glasgow and NHS Highland.
3.From 2005-06 expenditure on cancer services has been included within NHS Board Unified Budgets.
4.The Joint improvement Team was formerly part of the delayed discharge programme line.
5.Policy and financial responsibility for drugs transferred to the Justice Department during 2005-06.
6.From 2006-07 General Medical Services has been included within NHS Board Unified Budgets
7.Individual allocations for demand led services have still to be decided. The resources available include the financial commitment made by the Executive in relation to the Action Plan for Improving Oral Health and Modernising NHS Dental Services.
What the budget does
Delivering for Health, our action plan for NHS Scotland, builds on the analysis in the National Framework for Service Change of the changing nature of demand for health services in the longer term. Despite the general age for age improvement in the health of the population of Scotland a number of issues must be addressed, including the combination of an aging population and the growth in long term conditions; the trend of rising emergency admissions among older people; and the growing divergence in life expectancy.
NHS Scotland must respond to these factors by changing the balance of services it provides, not by providing simply "more of the same". By providing clearly defined commitments, clear responsibilities and effective mechanisms to hold the service to account, Delivering for Health is driving that change of direction. NHS Scotland will shift towards preventive medicine; towards more continuous care in the community, with targeting of resources and anticipatory care towards those at greatest risk; strengthening local services; providing more support for self care; intensive case management for those vulnerable to emergency hospitalisation; and with more local diagnosis and treatment.
The key actions can be summarised as:
Delivering for Health
Key actions
WHAT? HOW? We will… By… • developing and delivering anticipatory care for those 'at risk' reduce the health gap wherever they live (the inequality in life expectancy • increasing health care services across Scotland) delivered in disadvantaged communities
• increasing support for self care • anticipating the needs of vulnerable people • identifying those people at greatest enable people with long-term risk of hospital admission and conditions to live healthy lives providing them with earlier care to prevent deterioration of health and reduce emergency admissions establish new health and social • prioritising investment in local care services in communities services, including Community Health Centres that deliver diagnostic and day case treatment • developing practitioners with extended roles • fully utilising the skills of all professionals through stronger teamwork in Community Health Partnerships
• identifying priorities for investment in a delivery plan that builds on our accelerate improvements in Framework for Mental Health in mental health services Scotland
• delivering our waiting time build on recent progress on commitments waiting times
• implementing a national information ensure that wherever people and communication technology need care, their medical history system, including an Electronic is available to the service Health Record provider
• delivering services locally in Community Casualty Units when it streamline unscheduled is safe to do so, and in well- (emergency) hospital care resourced Emergency Centres when it is necessary to do so separate planned from • making day case surgery the norm unscheduled care • delivering on our diagnostic waiting time commitments for 2008 remove bottlenecks in • increasing the range of locally diagnostic services available diagnostic services apply a systematic approach to • basing our decisions on National decisions regarding the Framework recommendations concentration of specialist services • establishing the Scottish Centre for Telehealth strengthen health care in • identifying what services can be remote and rural areas safely delivered in Rural General Hospitals • educating and training health care professionals with specialist skills for practice in those hospitals decide where national • aiming to make the best use of specialist services such as valuable specialist skills, and neurosurgery and neuroscience delivering services of the highest and tertiary paediatric services quality should be provided
We will harness the nursing and midwifery contribution to Delivering for Health by implementing Delivering Care, Delivering Health Action Plan:
• Ensuring caring is the essence of nursing and midwifery practice with patients, families and carers the central focus • Developing the Capability of staff, equipping them with the skills and knowledge and to deliver services in a different way • Growing the workforce that will enable sustainability of services
We will support the implementation of the Action Plan flowing from the review of the AHP Strategy including the implementation of the AHP Workload measurement/management publication.
We will support the implementation of the Rehabilitation Framework and the Action Plan for Healthcare Scientists.
Research Support
Research represents an important investment in the future delivery of health and healthcare. Research must be underpinned by an environment in which research can flourish - this means ongoing investment to:
• support the existing disproportionately successful Scottish science base; • encourage the translation of more basic science to address healthcare needs; • support innovative treatments in the NHS for patient benefit; and • generate income by providing the infrastructure which attracts commercial trials.
We will continue to invest in these areas in 2007-2008 through the following.
The formula-based Support for Science budget meets the additional clinical costs incurred in the NHS while undertaking non-commercial research funded by external partner organisations, general R&D management and other costs relating to undertaking and sustaining research in the National Health Service in Scotland. The Chief Scientist Office ( CSO) will continue to allocate these resources to NHS Boards in 2007-08 (~ £29m) in direct proportion to the volume of research undertaken. This ensures that funds are flexibly and appropriately allocated according to outputs. Research in the NHS which does not have an external funder is supported by CSO through the NHS Priorities and Needs budget. In order to give this work an appropriate degree of focus and management, this work has been arranged into Programmes of research in clinical priority areas of NHS need with funding totalling in excess of £10m. Following evaluation, agreed Programmes of research will continue to be monitored in 2007-08.
CSO will also continue to progress Scotland's involvement in the United Kingdom Clinical Research Collaboration ( UKCRC), a partnership of organisations working to create a clinical research environment that will benefit patients and the public by improving national health and increasing national wealth.
The main focus of the new investment awarded for this initiative in Scotland to date has been the establishment of Scottish clinical research networks in the areas of medicines for children, diabetes, stroke and mental health, and additional investment in infrastructure in the NHS to support the clinical research flowing from these networks and in other areas. Key outputs for these new activities, which will be closely monitored in 2007-2008, will be an increase in participation in clinical studies, an increase in patient recruitment, and the attraction of both commercial and non-commercial external funding.
Involving the public
The NHS Reform (Scotland) Act 2004 placed two new statutory duties on NHS Boards to promote equal opportunities in all their functions and to involve the public and patients in the planning and delivery of NHS services. Boards are expected to demonstrate year-on-year improvements in the delivery of these new duties as demonstrated in the annual reports of the Scottish Health Council. This year the Minister used the Council's independent assessment as a basis for discussion with a representative group of patients prior to each Board's annual review.
Waiting times
Reducing the maximum waiting times continues to be one of our key priorities for NHSScotland for two reasons: quality of life and clinical outcomes will be improved overall through shorter waits; and patients consistently say that this is what they want from the NHS.
The Service has already delivered on the Executive's targets of no-one with a guarantee waiting for more than six months for a first outpatient appointment or for in-patient and day-case treatment by the end of 2005. It is also on course to deliver the shorter maximum wait targets of eighteen weeks for a first outpatient appointment and for in-patient and day-case treatment by the end of 2007. For the first time, waiting times targets have been set for key diagnostic tests. From the end of 2007, the maximum waiting time for CT, MRI, Ultrasound and Barium Scans, Upper Endoscopy, Cystoscopy, Sigmoidoscopy and Colonoscopy will be nine weeks. From that date, no patient will wait more than 18 weeks for a first outpatient appointment or for inpatient/day case treatment. The nine-week standards for diagnostic tests will be included within these maximum waiting times - they are not additional.
NHSScotland is consistently delivering the Executive's targets of a maximum wait of 8 weeks for Coronary Angiography and a maximum wait of 18 weeks for Angioplasty and heart bypass surgery. From the end of 2007, no patient will wait more than 16 weeks from GP referral, through a rapid access chest pain clinic or equivalent, to cardiac intervention thereafter. For those patients not presenting with chest pain, from the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment.
Additional condition-specific waiting times targets have also been set for delivery by the end of 2007. From that date, no patient will wait more than 18 weeks from GP or Optometrist referral to cataract surgery and all orthopaedic departments handling trauma cases must ensure that any patient entering a Specialist Orthopaedic Unit for surgery following hip fracture should be operated on within 24 hours of admission.
We have also set a target for patients seen in accident and emergency units. From the end of 2007, patients will wait no longer than 4 hours between arrival at a unit and admission, discharge or transfer. This target will apply to all other unscheduled care in Community Casualty or Minor Injuries Units or areas of assessment units where trolleys are used.
National Waiting Times Centre
The Golden Jubilee National Hospital in Clydebank has played a very important role in providing additional facilities for planned surgery and other patient procedures, and contributing to reductions in waiting times, since it was purchased for the benefit of NHS patients in summer 2002. At that time, it was undertaking 2,500 procedures a year. In 2005-06, the Hospital performed over 28,600 procedures, exceeding its target of 25,000 procedures by 14.5%. This was a 54.7% increase in activity on the previous year. The Hospital has delivered the commitment in fair to all, personal to each to perform 28,000 procedures a year by 2007-08 two years ahead of schedule, and is now working to build on this performance by undertaking over 30,000 procedures in 2006-07.
Delayed discharge
We also reaffirm our commitment to reduce the numbers of people who remain in hospital when ready for discharge because of a lack of community or home based health or social services. The number of patients inappropriately delayed in hospital for more than six weeks has reduced by 73% since the launch of the Delayed Discharge Action Plan in March 2002. This is a significant improvement and continuing investment in joint NHS/Local authority partnerships is expected to produce further reductions in delayed discharges. The challenge is to plan community care capacity for the future of our ageing population. Partnerships are developing a whole systems approach to tackling the problem to prevent avoidable admissions, facilitate appropriate rehabilitation and improve patient management processes.
Healthcare Associated Infection and Clean Hospitals
Tackling healthcare associated infection ( HAI) in hospitals is a key priority, most importantly in relation to improving patient safety, but also in terms of improving NHS efficiency by freeing up the resources currently spent on avoidable infections (a broad brush estimate of the cost of HAI in Scotland is up to £180,000,000 per annum, or 380,000 bed days lost). Over the last three years, the Healthcare Associated Infection Task Force has developed a range of national policy, guidance and best practice. This includes a groundbreaking Code of Practice; a National Cleaning Services Specification that clearly sets out cleaning requirements and a tool to monitor compliance; and guidance on antibiotic prescribing. This coherent national approach has provided a strong foundation for tackling HAI across Scotland.
The Task Force's new phase of work seeks to achieve a reduction in avoidable HAI by focusing on continuous improvement in infection control practice at a local level. This will involve driving full implementation of the procedures developed in the first phase of work, and ensuring that non- compliance within NHS Boards is highlighted and addressed. The Task Force has already rolled out the National Cleaning Services Specification monitoring tool to NHS Boards and the first report on compliance is due to be published in August 2006. The number of NHS staff completing the Cleanliness Champions Training Programme has increased threefold since August 2005 from 550 to well over 2,000. The Task Force is also developing a national hand hygiene campaign - a key issue in tackling infections at the front line - and a National MRSA Control Strategy. This work is supported by £15 million of funding over three years.
Community based services
Delivering for Health reinforces the overall policy direction that more care should be delivered locally. It underlines that patients should be at the centre of the delivery of responsive care and treatment, with more convenient services delivered more quickly at each stage of the patient's care, with services being as local as possible. As well as shorter waits and greater convenience for patients, the public wants reassurance that services are being delivered safely and sustainably; and communities want to know that services will be available locally wherever possible. Investment is already in place and will continue to support these policies and to boost capacity including infrastructure developments, to improve access and to increase the range of services which can be provided closer to where people live and work.
A fundamental principle for us is that where healthcare services can be provided locally in a safe and effective way, they should be - while accepting that specialised services will often need to be provided in centres of excellence. NHS Scotland's approach can be summarised "as local as possible, as specialised as necessary". Primary care services play a central part in the provision of NHS services to people in their local communities, close to home and close to where they work. For many people, their only experience of the NHS is in primary care, and indeed over 90% of NHS care is provided a primary care setting. Many people rely on their GP practice, their pharmacist, dentist and optometrist to help them stay healthy, to provide treatment when they are ill, and to provide links to other services in the NHS either in the community or in hospitals, the voluntary sector or social care. The scope of professional practice is expanding across the professions which mean that a greater range of care and treatment is available in local settings. For example, nurses and community pharmacists are supporting the development of chronic disease management; and faster access to services is possible through NHS24 which provides telephone access to a health professional 24 hours a day for advice and support.
The Partnership Agreement and the White Paper "Partnership for Care" set out the context for partnership working in Scotland and for the development of Community Health Partnerships ( CHPs). Building better health and social care services around the strengths and needs of Scottish communities underpins the reforms included in the NHS Reform (Scotland) Act 2004 and provides the impetus for a strong Community Health Partnerships agenda.
CHPs are a central plank of the vision set out in Delivering for Health. They are local service delivery mechanisms through which health improvement, and shifts in the balance of care, will be delivered by the NHS, local authorities and the voluntary sector, with greater involvement of service users, carers, staff and independent contractors. They have two key aims:
• Shifting the balance of care to local communities; and • improving the health of local people and reducing inequalities.
CHPs are fully involved in local NHS strategic planning, priority setting, decision making and resource allocation and play a lead role in wider community planning processes led by local authorities. They have delegated responsibility for all primary and community based services including joint health and social care services and community hospitals and resource centres. CHPs will need to maintain an effective and formal dialogue with their local communities through the development of a local Public Partnership for each CHP.
As well as changes in the organisation of NHS services with the development of 'single systems', including the development of CHPs, there are other significant developments underway as a result of the duty on NHS Boards to provide or secure 'primary medical services' for their population. NHS Boards have increased flexibility to use a range of contractual and delivery mechanisms to ensure primary medical services are developed and delivered in ways which reflect local circumstances and priorities.
The changes described above are complemented by modernised contracting arrangements in other areas of primary care; as well as strategic development of the infrastructure which supports an expanded range of services provided more locally. Examples of key areas of activity are given below. In all of these arrangements there is a greater focus on quality and the appropriate deployment of professional skills through teamwork.
The Right Medicine: A Strategy for Pharmaceutical Care in Scotland (Scottish Executive, 2002) provides a strategic framework for the development of community pharmacy including new contractual arrangements underpinned by an e-pharmacy programme. The drugs bill continues to be an area of significant activity in order to manage expenditure.
Oral Health and Dentistry
The Executive will continue to implement the measures outlined in An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland. The measures contained in the Action Plan aim to address Scotland's poor oral health record, provide better access for patients and provide an attractive package for the professional staff that the Executive wish to recruit to, and retain within, the NHS. Implementing these changes involves increased investment in NHS services and new and additional funding of £150m over the three years 2005 - 2008 has been provided for this purposes. Since 1 April 2006 the Executive had been delivering the Partnership Agreement commitment to provide free dental checks for all by 2007. From that date the dental examination which was previously chargeable has been provided free.
SEHD is addressing the shortfall in the number of dentists in some areas of Scotland. The number of dental students in Scotland has been increased and a range of recruitment and retention measures has been put in place to increase the dental workforce in NSSScotland, including golden hello payments. These payments range from an allowance of up to £6,000 to each newly qualified taking up their vocational training year in Scotland to an allowance of up to £20,000 over two years to dentists entering substantive general dental service in Scotland within three months of completion of training.. The increase in dental training capacity will be supported by more outreach training throughout Scotland, for example, the establishment of new outreach training centres in Aberdeen and Dumfries & Galloway. Through the dental action plan substantial new financial support of £150m over 3 years has been made available to improve oral health and modernise NHS dental services.
Eyecare Services
The final report of the Review of Eyecare Services in Scotland will be published in 2006-07. The aim of the Review is to encourage the development of integrated eyecare services to ensure patients receive a good quality and effective service, in a convenient setting without undue wait.
Since 1 April 2006 the Executive had been delivering the Partnership Agreement commitment to provide free eye checks for all by 2007. The free NHS eye examination which has been introduced extends the scope of the previous sight test to an examination which is tailored to the needs and symptoms of patients and allows them to receive, free of charge, an appropriate health assessment of their whole visual system. The eye examination will include a sight test where required.
Community Hospitals
A Review of Community Hospitals is currently underway. The purpose of the review is to address the Partnership Agreement commitment to develop the important role of community hospitals, and to develop a strategy for sustaining small, rural and community hospitals where they are safe and effective, including the provision of minor surgery, rehabilitation services and a resource for practitioners with special interests. The Review of Community Hospitals will thus support the implementation of significant elements of Delivering for Health.
E-Health
Significant additional resource is planned to support the introduction of a comprehensive health information system built around an Electronic Health Records outlined in Delivering for Health. This will require investment in an infrastructure to support the Electronic Health Record including improved broadband network services, access to flexible workstation facilities such as wireless notepads, patient and staff authentication facilities and resilient all day, every day systems delivery. We will build on and exploit systems already in place and take national procurement action to fill gaps in systems supporting the sharing of information, with unified databases, effective communications links and standardised protocols, All of this is needed to support resource allocation in support of patient care and best care practice by multi disciplinary teams.
Information management and technology ( IM&T)T
The provision of more services in the community means that the infrastructure has to be safe and clinically appropriate, provided in accordance with legislative requirements and good practice guidance, accessible for patients, their carers and the public. In addition to local investment, which is delivering an increasing number of new purpose built primary care facilities continued investment will further support joint working projects, 'community health service centre' projects, new 'dental centres' and premises extensions/improvements to support GP training. Work also continues in relation to IM&T to enhance patient care and support staff. For example, a functionality upgrade programme for GPIT is well underway, and the burden on GPs to provide and maintain infrastructure has been taken on by Health Boards. Almost all (99.8%) practices are computerised with supporting systems and the infrastructure to support and exploit electronic patient records in primary care is continually being enhanced, for instance by investment in scanners to help practices go paper light, phasing in of a generally available emergency care summary, ongoing work to improve the process for transferring patient records, and investment in the e-pharmacy programme. This is all designed to pave the way towards the introduction of an electronic health record accessible to all clinicians, not just those in primary care.
Public Protection
Developing a more flexible workforce has implications for public protection, necessitating clarity around roles and responsibilities of staff, employers and regulators. See Workforce Regulation
Pay modernisation
The implementation of pay modernisation through the new Consultant and GMS contracts and Agenda for Change represents a major investment in our NHS workforce. These three strands share a common goal - to reward, motivate, and free up staff to deliver re-designed and improved services to patients. We expect delivery of these contracts to link closely with the Department's overall policy objectives for NHS Scotland with a particular focus on improved productivity, enhanced services to the public, service re- design around the needs of patients and carers, improved recruitment and retention and improved management and development of staff.
Pay modernisation is a toolkit which helps and supports systems to deliver on a wide range of key NHS priorities in securing sustainable, safe, and effective changes to service provision. It is also a driver for positive culture change in the NHS in behaviours, attitudes, and ways of working which will be of long term benefit to both staff and patients. Health Boards are required to provide Pay Modernisation Benefits Realisation Plans which will demonstrate how they are using the new contractual arrangements to support both the delivery of key targets and "Delivery for Health". This planning process which requires updates every 6 months, is now well established.
Agenda for Change commenced implementation in December 2004. The current focus is on matching and evaluating and assimilating over 140,000 NHS Scotland staff to the new system. The size and complexity of this task is acknowledged, as is the level of commitment demonstrated by those in NHS Scotland, both staff and management, who have been working together in partnership to bring in the new arrangements. The Scottish Pay Reference and Implementation Group is tracking progress on a monthly basis and providing support and assistance to Boards as they introduce the new system.
A clear timetable for completing the introduction of Agenda for Change across NHS Scotland by December 2006 has now been established, and progress towards delivery is actively monitored.
The new Consultant Contract was introduced from 1 April 2004 and over 95% of consultants now have agreed job plans. There is now emerging evidence through the Pay Modernisation Process of positive change flowing from the job planning processes associated with the contract, including more efficient use of consultant resource for the benefit of patient care. There are no significant additional cost pressures, beyond the identified pay inflation and pay scale progression from the Consultants contract anticipated for 2007-08.
The nGMS Contract was also fully introduced from 1 April 2004. The new contract encourages recruitment and retention in the GP workforce through better management of GP workload, investment in primary care infrastructure, and by transferring responsibility for out-of-hours services to Health Boards.
This contract also links GP payments to the quality of care that they provide for patients, through the Quality and Outcomes Framework (QoF). This Framework is realising significant benefits for patient care and clinical outcomes in the primary care sector. General Practitioners in Scotland have showed a high level of achievement in the provision of quality care to patients across Scotland, a reflection of considerable improvements made by practices over the previous year.
The Contract was reviewed on a UK-wide basis, and a revised set of arrangements were put in place from April 2006; some further changes are anticipated in 2007-08.
Workforce general
The NHS is here to deliver healthcare services that meet patients needs, however in order to do any of that, it needs people to deliver those services. People with the right training, skills, competence in the right place at the right time. Scotland's diverse and ageing population mean that there will be more work to do and more work that will require to be carried out differently. A changing workforce demographic provides us with an opportunity to reach out to non traditional recruits and take steps to ensure our employment and learning opportunities support the development of a workforce that is reflective of the population at all levels, there by improving our decision making processes and ultimately the services that we provide.
Workforce Development
Workforce planning is complex and challenging especially in a changing environment but that makes it all the more important. The budget supports capacity for workforce planning in NHS Boards, and in the 3 workforce planning regions that have been established, to build on the progress achieved to date and improve the robustness and amplitude of the workforce planning function in NHS Scotland. At national level, the information from NHS Board and regional workforce plans will be used to populate the national workforce plan, inform future supply needs, and as a basis for setting training numbers.
Workforce Regulation
Scotland is working with the other UK countries to regulate healthcare professionals across the UK, with the primary objective to improve patient safety. Scotland's continuing aim will be to ensure that any regulatory legislation supports the development of new roles and expansion of practice of existing professional groups to meet the specific needs of the devolved health service.
Scotland is leading a project on regulating Healthcare Support Workers through an employer-led regulatory model and a centrally held list. This will be piloted in three NHS Board areas from January 2007 and complemented by a concurrent action research project.
Future regulation will be influenced by the outcome of the DHUK-wide consultation on its reviews of medical and non-medical regulation. The implications will be fully considered with stakeholders for a Scottish Executive response. There is likely to be a stronger future role for NHS employers.
Medical Education Issues
The Modernising Medical Careers ( MMC) reforms of postgraduate medical education seek to provide better and more focussed training for doctors in future, meaning that less time is wasted during training so that doctors achieve their Certificate of Completion of Training in the fastest possible time. NHS Boards have been tasked to assess the local service delivery and financial impact of MMC, to determine the solutions required to maintain service continuity during the implementation phase and secure the long term sustainability of medical services.
Education Learning and Careers
The education and learning policy framework will be implementation and we will work with NHS Education for Scotland to ensure commissioned learning and education is fit for purpose and cost effective. We will launch the Career Framework which aims to provide staff with a coherent career pathway and the NHS with a flexible workforce. The career framework, in conjunction with the drive towards modernising healthcare careers, promotes the transferability of roles; skills competences and educational qualifications across the NHS. Opportunities for learning and development will be linked to the implementation of Personal Development Plans and the introduction of the Knowledge and Skills Framework. There are practical tools available that enable KSF outlines to be built into Personal Development Plans through health sector workforce competences.
Reputation and Attraction
The reputation of NHSScotland is to a large extent dependent on the experiences of staff and customers and therefore it is important that NHS staff understand the impact of their behaviours and the need to ensure policies promote equality and inclusion. We will continue to promote working in the NHS as a desirable career and develop NHS Scotland as an exemplar employer to best position Health Boards in the global labour market and enhance capacity to recruit staff. Consultant 600 budget
We will continue to work with health boards to increase, where appropriate, the number of medical consultants working in the NHS, in the context of the wider impacts of delivering for health, the impact of modernising medical careers and service.
UK Medical Bodies
The Scottish Executive Health Department contributes a pro rata share of financial support to the Postgraduate Medical Education and Training Board, which is the statutory UK body responsible for setting and ensuring appropriate standards of post-graduate medical education and training and approving changes to the curriculum.
Children and young people
We will continue to support the outcomes from the Cabinet Delivery Group for Children and Young People and support the development of Integrated Children's Services Plans. Key initiatives at a national level include Getting it Right for Every Child and the child protection reform agenda and the implementation of joint inspection arrangements for children services by 2008.
To support this we will deliver an Action Framework for Children and Young People's Health in Scotland which will include health improvement, community based care, tertiary services, secondary care, Health for all Children (Hall4), children and adolescent mental health services, emergency care, workforce, public involvement, performance management and the interface with he integrated children's services agenda.
We have also established a National Steering Group for Specialist Children's Services which is expected to review current provision and produce a National Delivery Plan by the autumn of 2007. This will include proposals for a national and regional network for the delivery of specialist services in Scotland.
Maternal health
We are establishing a Ministerial Action Group on Maternity Services which will take forward work focusing particularly on neonatal services, models of maternity care and integrated working, transport issues, workforce and regional planning of maternity services.
We will issue an Infant Feeding Strategy for Scotland that will reflect outcomes of the 2005 public consultation on the draft strategy. We will also be proceeding with work originating from the recent review of infertility services in Scotland.
Delivery
The Department places high priority on working effectively with NHS Boards and others to secure delivery of Ministers' priorities and objectives. A number of actions have been taken to increase the effectiveness of NHS Boards and to ensure that they are responsive not only to policy priorities but also to the needs and circumstances of their local residents. For example:
• single system working is now bedded in across all NHS Boards, helping to streamline management and accountability arrangements and improve integration between phases of care; • Community Health Partnerships have been established, connecting primary and community care planning and delivery more closely to the communities they serve; • Boards have been supported to strengthen regional planning arrangements so that better integrated approaches can be taken to planning and delivering more specialised services such as cancer, CHD and some mental health services.
In addition, the Department has introduced a number of changes designed to support delivery-focused planning and performance in Boards. In 2005, Boards were asked to complete the first Local Delivery Plans looking forward to 2006-07 and the 2 subsequent years. The plans focus on a clearly-defined set of key measures and targets, including financial targets, and Boards are required to provide planned profiles for each measure, demonstrating how Ministers' key targets will be met and against which actual performance is tracked through the year. The plans are made public by Boards. All plans were reviewed and accepted by the Department by May 2006.
Within the Department, a new Directorate of Delivery has been established, drawing together performance management, improvement and support, analysis, planning and access support functions. The new Directorate is able to take a more integrated view of performance of individual Boards and of the NHS across Scotland as a whole. It can offer resources and other support to Boards if performance departs materially from planned levels or other risks to the delivery of Ministers' objectives emerge. The Directorate also has a role within the Department in assisting HD business areas to develop effective strategies for delivering new and existing policies.
The Directorate of Delivery, through the Improvement and Support function, is playing a key role in helping Boards redesign and improve services to enable them to meet Ministers' new, tougher access targets for the benefit of all patients. For example, collaborative work streams are helping to improve performance to meet the 4-hour maximum wait target for Accident and Emergency services, and the 9-week maximum wait target for diagnostic tests. Boards must meet both targets by the end of 2007.
Our approach continues to be about enabling and encouraging continuous improvement and good performance. The Annual Review process, which sees the Health Minister meet the chair of each Board and his senior colleagues, in public, for a discussion about past performance and future challenges, enables Ministers to highlight to individual NHS Boards areas where performance must be improved. Resources can be allocated to particular issues and conditions attached to the use of resources. Where there is poor performance that threatens service quality to patients or significantly increases the risk of a Board failing to achieve Ministers' targets, a range of interventions are sanctions is available. For example, Ministers may choose to send in a task force or a support team to help rectify issues in particular problem areas. Minister can also of course, replace the Chair or non- Executive directors of NHS Boards.
Clinical standards
Improving the quality of healthcare is a key element in the Department's approach. This involves improving the quality of health care by raising the standards of all to those of the best. NHS Quality Improvement Scotland is leading this agenda. This involves giving advice and support to the NHS, and the development of national standards and inspections against those standards. The work of NHS Quality Improvement Scotland relates both to specific clinical conditions and to standards for key performance areas such as clinical governance and risk management, nutrition and hospital acquired infection. NHS Quality Improvement Scotland has developed a quality assurance framework to ensure that managed clinical networks - which have a vital role to play in delivering improved services and care - are effective. NHS Quality Improvement Scotland also has a major focus on ensuring patient safety, and ensuring that robust systems are in place to achieve this.
Other Health Services
Spending plans 2002-08
Table 8.04 More detailed categories of spending (Level 3)
2007- 2002-03 2003-04 2004-05 2005-06 2006-07 £000s 08 Budget Budget Budget Budget Budget Plans Training for Prosthetists & 2,971 3,120 3,200 3,230 3,322 3,365 Orthotists Grants to 2,246 2,296 2,296 2,645 2,273 2,273 Voluntary Bodies Miscellaneous Other Health 13,978 13,912 11,417 5,119 2,122 2,737 Services Research 12,696 13,443 14,624 15,364 14,964 15,164 Mental Health Act 1,504 4,543 9,703 17,553 19,523 21,053 Implementation Scottish Low Income Scheme 902 952 990 1,030 1,030 1,030 Administration Other Health -807 -899 -261 -161 -161 -161 Service receipts Total 31,986 37,367 41,969 44,780 43,073 45,461
Notes:
1. Welfare foods has been transferred from Other Health Services to Health Improvement. 2. Genetic Services is now included within the Public Health and Workplace Health line within Health Improvement.
What the budget does
Research
The Chief Scientist Office ( CSO) Research Budget promotes high quality research with the aim of improving health and health services for the people of Scotland. Typically, at any one time, CSO is directly supporting over 200 research projects in areas of NHS need, with an emphasis on, but not exclusive to, health priority areas. Projects examine questions about service delivery, prevention of disease and the effectiveness of both diagnosis and treatments. In addition, 7 research Units each pursue larger programmes of research in areas such as public health, health services research and health economics. These are regarded as an essential component of CSO's provision for conducting and developing capacity to conduct research. They are subject to quinquennial strategic and scientific reviews. CSO also helps to develop research capacity by providing funds for talented individuals through a range of research training fellowship and postgraduate studentship awards.
In 2007-08, research resources will be focused on:
• funding research projects and programmes of research with direct relevance to the Health Service with particular emphasis on research priority areas and on new science based approaches to the prevention, diagnosis and treatment of disease; • advancing population research, in particular by co-funding the Genetics & Healthcare Initiative, now known as 'Generation Scotland', which focuses on the genetic base of common diseases which have a major impact on public health in Scotland. Participation into this family based study will continue in 2007-2008 with the aim of recruiting 50,000 individuals (aged 35-55 years) over 5 years with a cohort of 15,000 in the initial 2 year feasibility study; • supporting the development of a highly skilled research workforce in Scotland by: • funding a new scheme for approximately 6 pre-doctoral level fellowships per year leading to the attainment of a PhD (or MD) as part of a package of measures in Scotland to support the UKCRC Modernising Medical Careers Initiative, • co-funding an £8m partnership initiative between SHEFC, NES and the Health Department for research capacity building amongst nursing, midwifery and allied health professionals.
Mental Health Act Implementation
The Mental Health Act implementation funding, which includes expenditure by the Mental Welfare Commission, continues to support various aspects of the implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003. This includes publication of the Code of Practice and topic guides on the Act; the Mental Health Tribunal for Scotland (which hears applications for and appeals against compulsion) and research into the operation of the new Act. These resources help ensure that partner agencies combine to deliver the benefits for service users and carers set out in the Act.
The Mental Welfare Commission for Scotland protects the interests of people with mental disorders by conducting inquiries, hospital visits, and meeting with patients, relatives and carers, and people subject to Community Care and Guardianship Orders.
We will continue to support further development and improvement of mental health services with a focus on promotion, prevention, protection, quality, care and recovery from settings that span a spectrum from specialist hospital care to care in people's own homes and communities.
Health Improvement
Spending plans 2002-08
Table 8.05 More detailed categories of spending (Level 3)
2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £000s Budget Budget Budget Budget Budget Plans Health improvement 26,000 26,000 26,000 26,888 27,229 29,179 strategy 1 Tobacco control 2 - - - 9,800 11,800 13,800 Alcohol misuse 2 - - - 11,726 12,078 12,450 Public health and workplace health 7,360 19,045 28,044 35,525 40,136 33,763 3
Mental wellbeing 4 - 5,000 4,773 5,847 5,850 6,283
Welfare Foods 5 13,981 13,981 13,981 10,981 10,981 14,981 Drugs misuse 3,658 5,161 7,084 6,222 - - Total 50,999 69,187 79,882 106,989 108,074 110,456
Notes:
1. In addition to the above directly funded expenditure, significant spending on health improvement is carried out by NHS Boards through their unified budgets.
2. Prior to 2005-06 expenditure on smoking and alcohol misuse was not separately identified.
3. This line has gradually been expanded to include a number of other budgets including Genetic service which was previously shown separately under Other Health Services.
4. The "Mental wellbeing" figures for 2003-06 do not include funding allocations to Local Authorities, which were held on behalf of Community Planning Partners for local actions in support of the 'Choose Life' Suicide Prevention Strategy. This funding was transferred to Local Government Finance Division as part of General Allocated Expenditure. Budget figures for 2006-08, however, include the £3.198m of 'Choose Life' funds which will be held by Mental Health Division.
5. Welfare food expenditure was previously shown under Other Health Services
What the budget does
The overall strategy for health improvement was set out in Improving Health in Scotland: The Challenge. The strategy includes:
• a programme of co-ordinated action aimed at improving life expectancy by addressing life circumstances, lifestyle risk factors and priority health topics; • better communication, higher profile and more focused delivery; and • sustained action across four key settings: the early years, the teenage transition, health of working age people and community based health improvement.
The Challenge also has an overarching aim of tackling the health inequalities that persist in Scotland.
Successful improvement in health requires complex, multi-stranded actions to: promote safer, healthier lifestyles; improve diet and levels of physical activity; tackle the problem of alcohol abuse; address the health of homeless people; improve mental health and well-being, and co-ordinate initiatives to promote good physical and mental health in the workplace. The Prevention 2010 programme, also discussed in the "Closing the Opportunity Gap" section, takes forward Delivering for Health recommendation that the health service actively targets those at high risk of ill health and provide early interventions designed to prevent a deterioration in their condition. The programme's pilots (receiving up to £25 million between 2005-08) will seek to demonstrate that it is possible to engage with people in deprived communities with the long-term aim of reducing deaths and hospital admissions from conditions such as stroke and CHD
Along with the Scottish Executive, the NHS including NHS Health Scotland, COSLA, local government, the voluntary sector, the private sector and Community Planning Partnerships have key responsibilities to lead this programme and deliver services both alone and in partnership to improve health.
We will continue to support community planning as the key framework for developing a joint plan for health improvement in a local authority area. Working in partnership with NHS, local authorities will lead the development of Joint Health Improvement Plans and will include input from all Community Planning Partners. NHS boards' local health plans may incorporate one or several joint health improvement plans. NHS Local Health Plans will also reflect regeneration outcome agreement priorities.
Similarly, the views of health professionals and a range of stakeholders are helping to shape the scope and structure of a reorganisation of health protection arrangements in Scotland. This reorganisation has been caused primarily by the need to ensure a cohesive, integrated response to the major health problems caused by exposure to biological, chemical, radiological and physical hazards and the challenges of new and re-emerging infections.
Healthy Start
Towards the end of 2006, the current Welfare Food Scheme will be replaced throughout the UK by a new scheme called Healthy Start. Under this new scheme, pregnant women and families from low-income groups and all pregnant women under 18 years old will receive vouchers which can be redeemed for milk, fresh fruit and vegetables and infant formula from their local shops. Vouchers can be used in a wide range of participating shops and pharmacies. The Welfare Food Scheme tokens could only be exchanged for milk and infant formula but the new scheme offers much more flexibility and choice. Breastfeeding and non-breastfeeding mothers are set to benefit equally from the scheme. Community Care
Spending plans 2002-08
Table 8.06 More detailed categories of spending (Level 3)
2007- 2002-03 2003-04 2004-05 2005-06 2006-07 £000s 08 Budget Budget Budget Budget Budget Plans Grants to the 2,097 2,327 2,327 2,537 2,595 2,655 voluntary sector Scottish Commission for 6,500 15,862 19,615 16,515 15,285 16,285 the Regulation of Care Minor 165 160 - - - - expenditure Total 8,762 18,349 21,942 19,052 17,880 18,940 Mental Health 13,300 14,000 14,000 14,000 14,000 14,000 Specific Grant
What the budget does
We are committed to delivering a wider variety of flexible person-centred care services to help more people live independently for longer within the community, and so improve social inclusion. We have set out four national outcomes for which local partnerships are developing local improvement targets. We continue to support local authorities and the NHS in driving forward the Joint Future agenda and to reduce delayed discharges.
Local Authorities spend around £1.7 billion a year on these services, of which around £1 billion a year is on older people (65 or over), and employ 35,400 staff in adult Community Care services. Additional provision is being made available for local authorities through the GAE baseline for health and community care. This will provide significant extra resources for services for older people, whose numbers are expected to increase quite quickly in the years ahead.
With the pressures of an ageing population, we will continue to invest in social care services, through local authorities and the voluntary sector, with the aim of delivering a wider variety of flexible person-centred services to help more people live independently for longer in their own homes or in sheltered housing, to support family carers and to reduce inappropriate admissions and inappropriate length of stay in hospitals. At any one point in time, local authorities maintain 58,000 older people (65 or over) every day in their own homes with home care services, and support another 33,000 older people (often those over 80) in 970 care homes. They also give services to 22,500 adults with learning disabilities, and support wholly or mainly 1,000 adults with mental health problems in care homes, and give home care services to 3,000 such adults.
The new Social Work Inspection Agency will inspect community care services across Scotland. The Chief Inspector's annual report will inform Ministers of local authorities' progress towards objectives and standards of delivery.
The Executive is continuing to invest in community care services, making provision through Grant Aided Expenditure for an additional £182m of local authority funding in 2007-08, to expand services in response to increasing demand and to support improvements in quality of care.
• £57.5m to meet pressures on care home fees and bring stability to the care home sector. • £42.0m to provide care for the increasing numbers of older people. • £27.0m for staff training to improve quality of care and meet new requirements for workforce registration. • £15.0m to provide faster access to homecare, contributing to the Executive's target of increasing the proportion of older people receiving intensive home care to 30% of all those receiving long term care, by 2008. • £13.6m to improve the quality of care provided through the voluntary sector, meeting requirements for care standards, and for staff training and development. • £5.0m to deliver additional services and support for people with learning disabilities in the community, following the resettlement programme set out in The same as you? learning disability review. • £2.0m to alleviate waiting lists for self directed care through direct payments and increase uptake. • In relation to the Executive's direct expenditure on community care, as set out in Table 5.06 above: • The Executive awards grants under Section 10 of the Social Work (Scotland) Act 1968 to support a range of national voluntary sector organisations working in the Community Care field; and • The Executive supports, through Grant-in-Aid, the Care Commission, which was established on 1 April 2002. The aim of the Commission is to further improve the quality of all care services in Scotland and to put people at the heart of regulation. It registers and regulates services against the provisions of the Regulation of Care (Scotland) Act 2001 taking account of the National Care Standards published by Scottish Ministers. The Commission is also partly financed through fees charged to registered services.
We continue the Mental Health Specific Grant at £20m per year overall (£14m from SEHD and £6m from local authorities) which supports 375 small scale but valued community based mental health projects. These projects and initiatives are mainly provided by the Voluntary Sector and among other provisions include drop-in centres, counselling services, and education and employment schemes. Other Health and Community Care Related Local Authority Funding
Spending Plans 2002-08
Table 8.07 Local Authority Grant Aided Expenditure ( GAE) Provision for Core Services
2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 £000s Budget Budget Budget Budget Budget Plans Home Based 314,383 420,865 442,604 467,247 495,170 518,244 Elderly Residential Accommodation 294,946 310,902 326,577 342,691 357,529 373,029 Elderly Services for the 260,772 278,927 290,684 302,769 320,577 328,956 Disabled Care Home Fees - 24,000 62,646 62,646 99,768 120,099 Environmental 62,405 65,567 68,049 70,611 70,616 70,649 Health Other Health and Community 271,077 356,206 383,302 424,322 433,737 441,567 Care Total 1,203,583 1,456,467 1,573,862 1,670,286 1,777,397 1,852,544
What the budget does
The Health and Community Care Grant Aided Expenditure ( GAE) figures relate to the level of local authority net revenue expenditure on these services that the Executive is supporting through grant. GAEs are not budgets, but rather a basis for the distribution of grant through AEF. Local authorities are, however, free to allocate their available resources to each service, including Health and Community Care, on the basis of local needs and priorities. The figures in this table are included in the GAE summary table (table 7.04) contained within the Finance and Public Service Reform chapter of this document.
Annex A: Health Department Delivery Plan Objectives and Targets
The 2006-2007 Health Department Delivery Plan will focus on the following areas:
The 4 key objectives of the delivery plan are: • Health Improvement for the people of Scotland - improving life expectancy and healthy life expectancy; • Efficiency and Government Improvements - continually improve the efficiency and effectiveness of the NHS; • Access to Services - recognising patients' need for quicker and easier use of NHS services; and • Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs.
Within these objectives we will be focussing on the following priorities:
Health Improvement for the People of Scotland
• Reduce health inequalities by increasing the rate of improvement for the most deprived communities by 15% across a range of indicators including: CHD, cancer, adult smoking, smoking during pregnancy, teenage pregnancy and suicides in young people: target date 2008. • To reduce adult (16+) smoking rates from 26.5% (2004) to 22% (2010). • Reduce incidence of exceeding the weekly alcohol limit of 21 units to 29% for men, and of 14 units to 11% of women: target date 2010. • 50% of adults (aged 16+) accumulating a minimum of 30 minutes per day of physical activity on 5 or more days per week. • 95% uptake target for all childhood vaccinations (ongoing). • Reduce suicide rate between 2002 and 2013 by 20%. • Reduce by 20% the pregnancy rate (per 1,000 population) in 13-15 year olds from 8.5 in 1995 to 6.8 by 2010.
Efficiency and Governance Improvements
• NHS Boards to operate within their revenue resource limit; operate within their capital resource limit; meet their cash requirement. • Sickness Absence Rate: 4% by 31 March 2008. • Productivity: increase in consultant productivity by 1% pa over the next 3 years.
Access to Services
• Ensure that anyone contacting their GP surgery has guaranteed access to a GP, nurse or other health care professional within 48 hours from April 2004. • 60% of 5 year old children (primary 1) will have no signs of dental disease by 2010. • No patient with a guarantee should wait longer than 6 months for in- patient or day case treatment from 31 December 2005, reducing to 18 weeks from 31 December 2007. • By the end of 2005 no patient will wait longer than 6 months from GP referral to an out-patient appointment, reducing to 18 weeks from 31 December 2007. • By end 2007 no patient will wait more than 4 hours from arrival to discharge or transfer for accident and emergency treatment. • By end of 2007 the maximum wait for cataract surgery will be 18 weeks from referral to completion of treatment. • By end of 2007 the maximum wait for admission to a specialist unit for hip surgery following fracture will be 24 hours. • Women who have breast cancer and need urgent treatment will get it within one month where appropriate. • By 31 December 2005 no patient urgently referred for cancer treatment should wait more than 2 months. • From 30 June 2004 the maximum wait from angiography to surgery or angioplasty will be 18 weeks. • By end 2007 the maximum wait for cardiac intervention will be 16 weeks from GP referral through rapid access chest pain clinic or equivalent. • By the end of 2007 patients will wait no more than 9 weeks for any MRI or CT scans and other key diagnostic tests. • From the end of 2007 no patient will wait more than 16 weeks for treatment after they have been seen as an out-patient by a heart specialist and the specialist has recommended treatment. • By end 2007, 75% of 999 emergency calls responded to within 8 minutes.
Treatment Appropriate to Individuals
• For 2006/07 reduce all delays over 6 weeks by 50% and all delays in short-stay specialties by 50%. • By April 2008 no one should be delayed for over 6 weeks and no patient should be delayed in short-stay specialties. • By 2008/09 we will reduce the proportion of older people (aged 65+) who are admitted as an emergency in-patient 2 or more times in a single year by 20% compared with 2004/05. • Cervical screening target 80% ongoing. • QIS clinical governance and risk management standards improving.