SCOTTISH POLICY FORUMHealth and Prevention

1. Overview

In recent years, the NHS has consistently been placed as one of the top three policy priorities in virtually all public opinion polls. This has been reflected in all political campaigns over the last five years – be it the Scottish independence referendum, EU referendum, or all Scottish and General elections – where claims or pledges in relation to the NHS played a central part.

Last year marked 70 years since the NHS was established. Today it remains one of the most important parts of the public sector. It continues to provide a range of vital services to thousands of people every day across Scotland. It employs almost 140,000 staff across 14 mainland and island NHS territorial boards and eight national boards. Every year, it conducts an estimated 17 million GP consultations, carries out 4 million outpatient appointments, and responds to over 750,000 emergencies.

This level of service means that the health service accounts for a significant portion of the Scottish budget. In fact, the £13.1 billion spent on healthcare is over 40% of the entire resource budget. Despite this, financial pressures continue and are likely to get worse in the coming years.

The Scottish Conservatives have been very active in the health portfolio since the 2016 Scottish election. We have published a range of policy papers on issues like mental health, prevention, and primary care. We have also established a Health Advisory Board, which includes practitioners and policy experts who provide us with ongoing policy advice.

Given its importance, it is likely that the NHS will again be a key part of the 2021 election campaign. Your opinions, be it feedback on existing policy or broader issues, are therefore crucial to our policy development. As ever, the nature of this consultation exercise means we could not cover all topics (for example, specialist tertiary care), but if you do have expertise and opinions that go beyond the scope of this paper, please do share it with us.

We look forward to reading your submissions.

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The final deadline for submissions is Friday 30 August 2019.

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2. The NHS in Scotland

Before we move on to more specific policy issues, we wanted to cover to broader points that are often at the centre of policy debates – the structure of the NHS and its funding.

NHS Scotland Structure

The responsibility for delivering health services in Scotland is mainly devolved to health boards. This is in contrast with England, where Conservative reforms significantly changed the structure of health service delivery.

In Scotland, there are 14 territorial health boards, which arrange services for their local population, and there are seven special health boards which provide a specific service for the whole of Scotland. In addition, an eighth board, National Services Scotland, provides support functions to both territorial and special health boards.

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Health boards are accountable to Scottish Ministers and ultimately to the Scottish Parliament. They are held to account through a number of measures such as Local Delivery Plan standards and annual accountability reviews.

The territorial health boards are therefore essentially responsible for the provision of health services for their area as well as, more generally, the public health of their population – something we come to in the last part of this paper. Collectively, the 14 boards are responsible for approximately £9bn of the total £13bn health, wellbeing and sport budget.

Since April 2016, territorial health boards and local authorities have been required to “integrate” certain health and social care services. This has resulted in the creation of 31 “integration authorities”, referred to as Integrated Joint Boards (IJBs). Only one local authority and health board opted for a different model of integration (NHS Highland). The reforms were passed with cross-party support, with the hope that greater integration would bring about improved quality and efficiency in services.

The perceived benefits of integrating health and social care include: preventing problems like delayed discharge; and ensuring care is provided in the most clinically and cost effective way. Attempts to integrate care are not new and there have been attempts to achieve greater integration over many decades. However, there have been persistent concerns that joint working between partners has not been as effective as it could be. Unfortunately, the evidence we have seen so far suggests that the IJB model is suffering from the same problems.

Funding our Health Service

As mentioned in the introduction, health remains the single largest area of Scottish Government spending, accounting for 42 per cent of the total budget in 2017/18 - £13.1 billion (with around £6.6 billion of this funding spent on staff costs). Despite this, Audit Scotland found that the NHS struggles to break even. Three boards required a loan from the Scottish Government and the majority relied on short-term measures to balance their books. NHS boards achieved unprecedented savings of £449.1 million in 2017/18 by relying heavily on one-off savings. Audit Scotland concludes, very clearly, that this is not sustainable.1

Increased demand, primarily due to projected demographic changes, and increasing medicine and staff costs, are projected to continue put increased pressure on NHS

1 https://www.audit-scotland.gov.uk/uploads/docs/report/2018/nr_181025_nhs_overview.pdf4

budgets. Indeed, the Institute for Fiscal Studies and Health Foundation2 estimate that UK spending on healthcare will have to rise by an average of 3.3% a year in real terms over the next 15 years just to maintain NHS provision at current levels, and that social care funding will need to increase by 3.9% a year in real terms in order to maintain current provision.

To address this funding gap, the UK Government made a significant funding pledge to coincide with the 70th anniversary of the founding of the NHS. The Prime Minister announced that the government would invest an additional £20 billion per year in health services in England. This will result in an estimated £2 billion of funding for Scottish health services in ‘Barnett consequentials’. This funding is not ringfenced, but there is cross-party consensus that all health consequentials should be passed on (although the Scottish Government’s commitment only extends to resource, and not capital, funding).

As a result of this United Kingdom Government commitment, the Scottish Government will be able to increase NHS funding in Scotland well above inflation. A report by the Fraser of Allander Institute suggests that could be 2.7% per year until 2021-22. This would push health spending to 50% of Holyrood's budget, from 41% at the start of this decade.3

Graph: Health Share of Resource Budget (FoA)

2 https://www.ifs.org.uk/publications/129943 https://www.sbs.strath.ac.uk/economics/fraser/20181108/Scotlands-Budget-2018.pdf

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It is clear that NHS funding will play a key role in the 2021 Scottish election campaign. In 2016, the Scottish Conservatives went into the election promising a “triple-lock” on NHS funding, where we promised the health budget would rise annually by whatever is highest out of inflation, 2%, or Barnett consequentials.

Given the projected pressures on its budget, the sustainability of the NHS in Scotland will depend on a combination of savings and additional funding. We would appreciate any views from you on how we should approach this topic in our next manifesto. Understandably, this is a topic that is impossible to answer in a few paragraphs, but we are looking for any suggestions on where you think savings or indeed additional funding could be found.

Discussion Questions

Q1. Would you advocate any structural changes to NHS Scotland?Q2. What should our approach to NHS funding be in the 2021 election?

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3. Primary and Secondary Care

There is cross-party consensus in the Scottish Parliament about the need to shift the balance of care from secondary settings (e.g. hospitals and A&E departments) towards more primary and community settings (e.g. GP surgeries). People should only be in hospital when they cannot be treated in the community and should not stay in hospital any longer than necessary for their care. This means reducing inappropriate referrals, attendance, and admission to hospital, as well as providing the right treatment in a timely fashion and reducing unnecessary delay in individuals leaving hospital. The integration of health and social care is an example of a policy that was meant to help deliver these objectives, but there are a range of issues where further progress is needed.

Very broadly, primary care refers to services provided by health professionals in either clinics and practices, or in a patient’s home. It is normally the first point of contact with the NHS and primary care professionals are considered the “gatekeepers” to secondary and tertiary services. The majority of patient contacts occur at this level.

Within primary care there are four practitioner services:

GPs Dental Pharmaceutical Optical

These practitioners are mainly independent of the NHS and are contracted by health boards. Their contracts are usually negotiated on a national basis (either at a Scottish or UK level) but health boards still have some scope to negotiate local contracts or to employ practitioners directly as salaried NHS employees. Services offered in medical general practice are free of charge but some services provided by other primary care practitioners are chargeable (e.g. dentists and opticians).

The Scottish Government has recently made several workforce pledges in the primary care sphere to strengthen the workforce, including increasing the number of GPs by at least 800 by 2027, training an additional 500 advanced nurse practitioners, and training an additional 1,000 paramedics.

Secondary care, on the other hand, is mainly hospital-based health care provision. Services range from emergency care (Accident & Emergency) to non-emergency treatment (usually through outpatient departments or elective treatment).

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General Practice

GPs are doctors who specialise in primary care and are registered in the General Practitioner Register of the General Medical Council. Most GPs are independent contractors, meaning that they are responsible for running the business affairs of the practice and employing and training practice staff. GPs and practice-employed nurses combined have an estimated 24.2 million face-to-face consultations with patients.

As mentioned above, primary care – just like other areas of health and social care - is facing an increase in demand for services placing increasing pressures on existing resources. Projected demographic changes will see the number of older people increase in relation to the number of younger people, as well as an overall rise in the number of older people. The number of people aged 75 and over is projected to increase by 27% over by 2026 and by 79% by 2041.

While the estimated headcount of GPs working in Scottish general practice has changed very little over time, the estimated Whole Time Equivalent (WTE) of GPs has been declining since 2013 (from 3,735 in 2013 to 3,575 in 2017 - a decrease of over 4%).

Within the next few years, experts believe that there will be a shortage of more than 800 GPs across Scotland. Currently, a third of Scottish GP training places go unfilled and as many as 3,000 Scottish trained doctors are now estimated to work abroad. The Scottish Government has sought to boost GP recruitment but a major drive to find an extra 100 GPs resulted in only 37 coming on board.

Scottish Conservatives have led the way through our Save Our Surgeries campaign in calling for the Scottish Government to commit 11% of all health funding for general practice – a call that was made by the RCGP. The Scottish Government has since committed to 11%, but only for broader primary care, rather than just general practice.

Other commitments we have made in the past include making it easier to book GP appointments through a simple online booking system being made available to all practices, as well as a greater use of text and email reminders. Missed appointments cost the NHS millions of pounds every year as well, and we have called for the government to consider introducing fines for missed appointments for those who miss three or more of them. This would bring GPs in line with dentists who are allowed to levy fines.

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GP Contract

To practise as a GP, it is necessary to complete a recognised medical degree, which is normally a 5 year course. Following this, graduates must complete two years of foundation training before undertaking three years of specialist GP training and only then being entered on the GP Register. The cost of training primary care staff varies by profession, but the estimated cost of training a GP in Scotland in 2018 was £450,172.

GPs, as independent contractors, enter into a centrally-negotiated contract with the Scottish Government. The latest contract – agreed in 2018 - sees GPs as fulfilling roles to support a wide range of clinical professionals, working as an expert medical generalist and senior clinical decision maker within multi-disciplinary community teams.

The GP contract sets the structure for pay and expenses, the workload formula, the wider primary care team as well as infrastructure. It also sets out the role of the multidisciplinary team and the practice team, including general practice nurses, practice managers and practice receptionists.

Rural GPs

The provision of healthcare in remote and rural areas faces a number of specific issues, including the recruitment and retention of staff as well as the large distances that some people have to travel to access services.

A number of rural GPs have voiced their concerns over the Scottish Government's new contract. In a letter to the Cabinet Secretary for Health and Sport, the Rural GP Association of Scotland (RGPAS) highlighted concerns that the workforce allocation formula “seems heavily weighted against rural communities”. We would like to explore whether a separate rural GP contract would be desirable.

Attempting to address some of the unique challenges of staff recruitment and retention in rural areas, the Scottish Government introduced a Rural and Remote Incentive Scheme in 2017, which aims to make positions in rural locations more appealing to GPs. Under this scheme support is provided to rural and remote practices, including “golden hello” payments of £10,000 to GPs taking up their first post in a rural practice and relocation packages of up to £5,000. The take up of the scheme has been very low.

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Pharmacy

The second most used primary care service is pharmaceutical. The main role of community pharmacists contracted by health boards is the dispensing of NHS medication. However, the range of NHS services provided by community pharmacists has grown over the years and their role now also includes the provision of the minor ailments service, the chronic medication service, the acute medication service and public health services such as smoking cessation and the provision of emergency contraception.

Community pharmacists are all independent contractors providing NHS services on behalf of the NHS Board, but the NHS also directly employs pharmacists who work across hospitals. In addition, pharmacists and pharmacy technicians also work in GP practices and can either be directly employed by the GP practice or be a community pharmacist providing sessional work.

One of the policy papers we have released over the last 3 years was a pharmacy plan. With the projected pressure on GPs due to increase further, we believe we need to look at ways to alleviate this. Pharmacies are in an ideal position to help, which is why we want to see them become a key partner in primary health care.

By increasing their capabilities and allowing them to become trained prescribers we can allow pharmacies to treat common ailments more speedily. By exploring the introduction of extended hours for pharmacies, including in 24-hour supermarkets, we can help provide immediate help around the clock. This would not only take pressure off our GPs, but also provide better patient care – something that is key to the plan.

The five points we have outlined in our plan were as follows:

Community pharmacists given access to appropriate patient records Community pharmacists given the opportunity to become trained prescribers

and allow more common ailments to be treated in pharmacies Pharmacists to lead medicine reviews for patients Produce a workforce plan for pharmacy to allow for increased clinical roles in

pharmacy clinics, GP surgeries, care homes and hospitals Exploring the introduction of 24-hour pharmacy services.

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Linked to the issue of pharmacies and primary care, is the issue of prescription charges. The scrapping of these was hailed as one of the flagship policies of the Scottish Parliament, with only Scottish Conservatives opposing this. In the 2016 election we argued for the reintroduction of charges on those who could afford it, which was projected to raise around £60 million. However, there is no doubt at all that people in Scotland value the idea of free prescriptions. We have listened to them and changed our policy to reflect this. However, we continue to argue there are other ways the system could be amended. For example, we know that the NHS is currently spending £10m on paracetamol, £2.9m on aspirin, £1.6m on sun cream and £1.8m on shampoo – all of which are available in supermarkets for very little.

Waiting Times

The performance of the NHS is measured in a range of ways, but the most widely covered measure is waiting times. The three most pertinent ones are:

95% 4 hour A&E target 18 week Referral to Treatment Target 12 week Treatment Time Guarantee

We will look at each of them in turn.

A&E Target

This target stipulates that 95% of all A&E patients should be admitted, discharged or transferred within four hours of arrival at an A&E department across NHS Scotland. It is important to emphasise that this is only an interim target and a stepping stone towards returning to the 98% standard.

Although the standard is measured in the Accident & Emergency Department, Health Boards are required to ensure best practice is installed throughout the whole system, including health and social care, to address wider issues of patient flow through each hospital in order to safeguard the timely access to services across the patient’s ‘journey’ and ensure the whole NHS system works together effectively.4

The statistics are not very positive, especially considering that the primary target is meant to be 98% of patients treated or discharged within 4 hours. The latest figures from April 2019 show that only 89.9% of patients waited less than 4 hours.

4 https://www2.gov.scot/About/Performance/scotPerforms/NHSScotlandperformance/AE-LDP 11

The graph below shows national performance on the 4 hour A&E standard since January 2017.

There are a range of reasons for this performance, including delayed discharge blocking transfers to hospital wards, but the primary issue is one of demand. The dip in performance in the graph above over the winter is due to an increase in accidents and illnesses, for example. Reducing demand has therefore been a key aim for policymakers.

One of the ways to reduce demand is to ensure that people whose injuries or ailments are not serious enough for A&E are diverted elsewhere. This can be through the above-mentioned minor ailments service in pharmacies, or dedicated minor injuries units. We also know, however, that over 20,000 people enter emergency departments drunk and incapable every year, at a cost running to millions of pounds. We have therefore supported the creation of a network of Recovery Centres, which would take referrals from ambulances and the police to alleviate A&E pressures. Combining such a service with alcohol dependency support would unlock additional long-term benefits.

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Referral to Treatment Target

Shorter waits can lead to earlier diagnosis and better outcomes for many patients as well as reducing unnecessary worry and uncertainty for patients and their relatives. Shorter waiting times will have a positive impact on the health of the patient, but in the long-term may result in some positive impact on businesses, as key workers who are absent from work due to illness may be treated earlier and will therefore be able to return to the workplace earlier.5

The standard for this target is for 90% of patients to wait no longer than 18 weeks from referral to treatment. The performance here is, again, not very positive. In March 2019, 77.3 per cent of patient journeys, for which an 18 weeks Referral to Treatment waiting time could be measured (ca. 90% of all,) were reported as being seen within the stated time.

The graph below shows the percentage of patient journeys completed within 18 weeks since March 2017.

5 https://www2.gov.scot/About/Performance/scotPerforms/NHSScotlandperformance/12WeekFOA-LDP13

Treatment Time Guarantee

The treatment time guarantee is a slightly narrower measure than the 18 week target above, but it is a legal requirement. It has been set out in legislation in the Patient Right’s (Scotland) Act 2011. The TTG places a legal requirement on health boards that once planned inpatient and day case treatment has been agreed with the patient the patient must receive that treatment within 12 weeks.

In consequence, the standard is for 100% of patients to be seen within 12 weeks of agreeing inpatient/day case treatment. The performance against this is very poor. During the quarter ending March 2019, 68.4 per cent of patients were reported as commencing inpatient/day case treatment within 12 weeks.

The graph below shows the percentage of patients who have started inpatient/day case treatment within 12 weeks since quarter ending March 2017. In numerical terms, it has been breached over 190,000 times since its introduction in 2012 – it has never been met.

In response to the worsening performance, the Scottish Government produced several new plans and strategies, mostly focusing on the delivery of new facilities, diagnostic

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equipment and workforce recruitment. It has also set interim targets over the next three years it intends to meet, but there has not been much sign of improvement yet.

Discussion Questions

Q3. How can we further support GP recruitment and retention in Scotland?Q4. Are there any specific steps we should take to support rural GP surgeries?Q5. Would you support non-attendance fines for those who miss their

appointments more than three times?Q6. Should we increase the role of community pharmacists in primary care? If

yes, how?Q7. How do we reduce demand in A&E departments? Do you support Recovery

Centres as suggested by us?Q8. If you do have an insight into the health service, what are the key reasons

for longer treatment waiting times? What can we do to address this?

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4. Mental Health and Addiction

Another area that has seen an increase in cross-party cooperation is mental health, where there are still significant gaps in provision (especially for children and adolescents) as well as significant waiting times. In addition, recent drug death statistics have also forced all parties to rethink how we approach addiction and treatment in Scotland.

Mental Health

There is a growing recognition across Scotland that we need to embark on a step-change in mental health support. A staggering one in four of all Scots experience a mental health problem, sometimes with knock-on effects on physical health, personal relationships as well as work. Waiting times for treatment are still incredibly high, with up to a third of people having to wait for over four and a half months in some health boards.

Our 2016 manifesto included a range of policies in relation to mental health. We argued that the next mental health strategy should be a long-term 10-year delivery plan to achieve this objective, with an additional £300 million to be invested in improving mental health treatment over the 5 years of the Parliament. This should be used to improve capacity and staffing across the health service, with an ambition to provide dedicated mental health support in every GP surgery and every A&E department 24/7. Additional support should be directed towards social prescribing - both in the development of innovative social prescribing networks and in the information available to GPs on services in their local area to which they can then refer patients.

We have expanded on this in a mental health policy paper released in late 2016. Measures in the paper included:

A new £10 million community mental health development fund to help increase the capacity for social prescribing and to fund projects across Scotland

Bringing forward plans for mental health ‘link workers’ in GP practices as part of our aim to have specialist mental health support in every GP practice or hub

Mental health support provided in every A&E department on a 24/7 basis Appointing a mental health champion in schools and businesses Helping more disabled people who also suffer with mental health issues into

work Looking into how social media companies can help tackle online bullying The implementation of a better referral system for young people who self-harm.

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Loneliness

Linked to mental health, but recently treated as a separate issue by policymakers, is the issue of loneliness. Originally seen through the prism of the elderly who can feel isolated in their own homes because of mobility issues, there is a growing recognition of the impact of loneliness on younger people too.

Statistics show that for a growing number of people loneliness is a regular or permanent situation that can have significantly negative effects on their health and wellbeing. According to Age UK:

across the UK, 3.6 million older people in the UK live alone, of whom over 2 million are aged 75+

1.9 million older people often feel ignored or invisible Loneliness can be as harmful for our health as smoking 15 cigarettes a day and it

can also lead to increased risk of dementia, depression and anxiety.

However, there is increased understanding of how loneliness also affects young people. ONS research found that 40% of 16-24 years olds consider themselves lonely and almost 10% of people aged 16 to 24 described themselves "always or often" lonely - the highest proportion of any age group. Loneliness can be linked to a lack of permanence or sense of belonging - such as young renters who felt few connections to their local community. It can also be driven by social media and the "digital world". Scottish Conservatives have suggested that loneliness is an increasing public health problem, which needs significant, targeted action across all age groups. In late 2018, we have published our Loneliness Action Plan:

Increase Focus on Youth Lonelinesso Examine how the curriculum could be amended

Improve Social Prescribingo An online platform for social prescribing and a national audit

Connect Communitieso Roll out Community Link Workerso Organise local conferences for GPs and prescribers to connect

Implement a National Awareness Campaigno Create a Scottish National Loneliness Day

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Support Innovationo Maximising digital platforms for targetingo Support innovative intergenerational projects

Drug Addiction

The latest set of statistics on drug deaths published in the summer of 2018 served as a wake up call to politicians on all sides of the spectrum. Scotland’s drug death rate was revealed to be the highest in Europe. The 934 deaths in 2017 is the highest ever recorded and marks the fourth consecutive year in which the total number of deaths has risen.

Over the last decade the number of deaths has increased by 105%. During this time the average number of deaths per year was 687, around double than in the previous decade from 1997-2007 with an average of 366 deaths. Although men still account for the majority of deaths, a recent report by the Scottish Government highlights an increase in the proportion of deaths among women from 19% in 2002-2006 to 29% in 2012-2016.6

6 https://spice-spotlight.scot/2018/07/20/drug-related-deaths-another-unwelcome-record-for-scotland/18

The human cost of drug use is immense – drugs wreck families, destroy lives and are holding back some of our poorest communities. The financial cost is just as severe. It has been estimated that drug misuse costs Scotland £3.5 billion a year.

The Scottish Government’s efforts to reduce drug misuse have failed and the crisis is getting worse. Any criticism of the government’s approach, however, is met with one primary policy call – to relax Home Office rules and allow “shooting galleries” to be set up, where addicts can inject drugs in a safe and controlled environment. We have rejected this proposal and instead published our own strategy on how to reduce drug addiction and reduce drug related deaths.

Our plan is based on a simple premise: users do not need a drugs plan to help them manage their addiction, they need a life plan to help them end their addiction. We believe virtually every problem drug user can be brought off drugs and supported back to a functioning lifestyle. At the centre of our plan is a call to give every problem drug user in Scotland a personalised Life Plan to support and sustain their transition from addiction back to a functioning life.

We also believe we will have most impact by getting in early. Our strategy sets out relatively radical steps to deal with first time drug offenders – to ensure their first time is also their last time. This would divert first time offenders from the justice system and instead offer help.

Some of the policies included in our paper were:

Local Commissions for individuals caught for the first time in possession of drugs

An independent review of methadone treatment A redesign of alcohol and drug services The redirection of funds into rehabilitation, recovery and abstinence More prison-based interventions followed by transitional and long term support

for addicts Increased peer support, employability and education programmes A third sector led recovery taskforce

Discussion Questions

Q8. What do you think needs done to improve mental health treatment in Scotland?

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Q9. Are we right to treat the issue of loneliness as a public health priority? What steps would you suggest to address loneliness across any age groups?

Q10. Do you support “shooting galleries” as a way to reduce drug deaths?Q11. What are your views on our addiction policy paper? Are there other ideas

that we should consider?

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5. Prevention and Public Health

Apart from being responsible for diagnosis and treatment of individuals, in recent decades the NHS has acquired a broader public health function too. This is the part of the NHS which is generally tasked with improving and protecting the health of populations as opposed to individuals.

Public health measures include, but also go beyond, the provision of traditional health services with public health professionals working to influence all of the so-called determinants of health. These include individual behaviours such as smoking and diet as well as life circumstances like housing, education and the environment. As a result, public health is closely linked with other organisations such as local authorities.

Public Health in Scotland

Scotland’s poor health outcomes have long been a key issue of concern for policy makers. We have high rates of health inequality – for example, men in some parts of Glasgow can expect to have just 56 years of very good or good health, which is 12 years less than in Orkney. Smoking remains a major problem - among the lowest 20% income percentile, there is a 34% smoking rate. On obesity, Scotland is now ranked as the heaviest nation in the UK and one of the heaviest OECD countries.

In order to reduce the pressures on the NHS, some of these inequalities and public health challenges simply need to be addressed. It means that long term practical solutions need to be found and implemented, with the emphasis on preventable health.

Scottish Conservatives have led the way in the Parliament on this agenda. Brian Whittle MSP – a former Olympic athlete – has produced several policy papers with a range of ideas around preventative measures that can be taken. They are built on a simple premise - to be effective in tackling their negative impacts on our society we must be prepared to tackle the root causes. The two key pillars to a healthy lifestyle are physical activity and nutrition. There is an intrinsic link between physical activity and nutritional intake: you cannot discuss one without paying attention to the other. Furthermore, there is a requirement to take note of barriers to opportunity and participation, which are different for different communities.

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Nutrition

The link between good nutrition and physical health is clear. However, there is also a growing body of evidence indicating that nutrition may play an important role in the prevention, development and management of diagnosed mental health problems including depression, anxiety, schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD) and dementia.

It is necessary for individuals, practitioners and policy makers to make sense of the relationship between mental health and diet so we can make informed choices, not only about promoting and maintaining good mental health but also increasing awareness of the potential for poor nutrition to be a factor in stimulating or maintaining poor mental health.7

Poor physical health is a risk factor for developing mental health problems. Changes in food production techniques, such as processing, the use of additives, and industrialised farming, have all been directly attributed to serious physical health problems including, coronary heart disease, some cancers, osteoporosis and dental disease.

So when considering how poor mental health is tackled (whether in prevention or in treatment) it is evident that any solution must involve access to an active healthy lifestyle. Moreover, mental and physical health must not be considered separately, rather they are both linked to the same solutions.

Some of the recommendations we made in relation to nutrition are listed below:

Educate and support parents to home cook healthy meals from the time babies move on to solids.

Encourage nurseries to promote a positive relationship with food, for example a vegetable patch where children grow their own and pick the vegetables which are then cooked on-site for them.

Continue the grow-your-own ethos into primary schools coupled with fresh local produce offered at school lunches.

Encourage nutritional literacy at school with practical food skills, including cooking and growing, reintroduced throughout primary and secondary schools.

Encourage school children to be part of the development of a healthy school meal.

7 http://www.scottishconservatives.com/wordpress/wp-content/uploads/2018/09/Scottish-Conservatives-A-Healthier-Future-Final.pdf

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Look at reducing the lunch hour in schools to encourage uptake of school meals. Explore changing the law to have an exclusion zone around schools for mobile

food vans. Explore changing the planning laws to prohibit new fast food restaurants (or

similar) opening up within a certain distance from schools during school hours.

Active Lifestyle

The benefits of an active lifestyle are well-documented and include improvements in both physical and mental health. Recent research by The Scottish Sports Alliance concludes that activity and sports participation can have the following personal health benefits:

Reduced Health Risks o 33% reduction in heart disease o 30-40% reduction in type2 diabetes o 20-40% reduction in breast cancer

Reduced Mental Health Risks o 20-30% reduced incidence of depression and dementia o 38% reduced cognitive decline risks o Reduced anxiety

Quality Later Life o 30% reduced falls o 36-68% reduced hip fractures o 38% reduced cognitive decline risk

The importance of developing good physical literacy from the earliest age is of paramount importance with many of the neurological pathways, cardio vascular pathways, as well as bone density, substantially embedded by the time a child reaches school age. It would therefore follow that the most impactful long term strategy would include early years’ intervention and a policy which ensures easy access to, and readily available, information on the importance of physical activity for the early years.

There should be a link between physical education at school (physical education being defined as teaching pupils why and how they can live an active lifestyle) and their ability to apply this learning and enthusiasm in the community. Within the education framework and in conjunction with local authorities, cognisance should be taken at a local level of what extracurricular activities are offered that link the school physical education programme with the council’s own programme. Adjustments can be made to

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ensure the easiest possible access to a long-term relationship with activities of choice (this could also apply to art, drama, music as well as physical activity and sport). Quite simply, creating an active pathway from nursery through to adulthood should be a priority. Linking physical education to opportunities in extra-curricular and community activity, which allows children to apply what they learn in school, is logical.

Some of the recommendations we made in relation to physical activity are listed below:

Allocate sugar tax income to keep schools open during holidays, weekends and after school for activity clubs and also offer a nutritious lunch as part of the club.

Ensure doctors and primary school teachers are adequately trained in physical activity and that any multi-disciplinary teams include dieticians and exercise physiologists.

Local authorities should be encouraged to develop schemes providing access to community sports facilities for free to those from deprived backgrounds.

Ensure local facilities remain in communities, involving the local community in the development of the activity programmes to encourage participation, ensuring accessibility and affordability.

Provide secure funding to SportScotland and elite sport as the marketing tool to encourage grass roots participation.

Ensure that activity and sports pathways are available from early years to elite. Offer training to those approaching retirement to work in the third sector as

coaches, administrators or officials.

Discussion Questions

Q12. Where do we draw the line between state intervention and positive public health outcomes?

Q13. Do you have any feedback on the policy suggestions in relation to nutrition we outlined in the paper? Do you have any to add?

Q14. Do you have any feedback on the policy suggestions in relation to physical activity we outlined in the paper? Do you have any to add?

Q15. Are there other areas in public health that the NHS and the government should aim to tackle?

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Appendix - Health and Social Care Expenditure 2016/17 (£m)

Source: SPICe - Primary Care in Scotland, SB 19-32, May 2019

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