It has been a confusing week for health and social care.
On Tuesday, the sector bore the brunt of the £500 million in public spending cuts as Finance Secretary Shona Robison announced that £115.8m would be shaved off the in-year budget for health and social care.
Yet 24 hours later, John Swinney's inaugural Programme for Government as First Minister promised to ensure that the NHS "has the resources it needs, today and in the years to come".
To be fair, the scale of the cuts seem much less drastic if you consider that they represent roughly 0.6% of the £19.5 billion allocated to health and social care in 2024/25.
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On the other hand, given how badly health boards were already struggling to balance their books and that integrated joint boards (IJBs) have been slashing local care services on a tragic scale long before MSPs returned from recess, the outlook is pretty grim.
Back in July, Audit Scotland warned that community health and social care was grappling with "unprecedented pressures and financial uncertainty".
A decade on from the creation of the IJBs, the watchdog said it could not find "significant evidence of the shift in the balance of care from hospitals to the community" and that real-terms funding for the IJBs - which are jointly resourced by their respective local councils and NHS health boards - had fallen year-on-year by £1.1 billion (9%) in 2022/23.
The projected funding gap between the cost of services and money available was forecast to triple from £124m in 2022/23 to £357m in 2023/24. The position for 2024/25 may be even worse.
Audit Scotland warned that IJBs were "increasingly having to make unsustainable savings through, for example, not filling staff vacancies and using their financial reserves" and that care and support services had been forced into "tightening eligibility" in a bid to cut costs, contributing to increased levels of unmet need in the community.
As well as the human cost, this tends to have knock on effects for the NHS in the form of avoidable hospital admissions.
Audit Scotland doesn't pretend there is any easy solution to this, although - somewhat ironically - health and social integration was supposed to be the solution.
The whole point of the IJB model was to ease pressure on hospitals by helping an ageing population stay well for longer in the community instead.
Now both sides of the equation seem to be sinking.
The Programme for Government is optimistic in tone but vague on details about exactly how it is going to "strengthen the performance of our National Health Service".
It promises to deliver "around 20,000 extra orthopaedic, ophthalmology and general surgery procedures annually in our new National Treatment Centres".
Annually, when, isn't exactly clear.
In the 12 months to July 2024, Scotland's two operational NTCs - in Fife and Highland - carried out a combined total of 8,193 planned operations.
The Forth Valley NTC is expected to open this year, but reaching 20,000 procedures in the 2024/25 financial year would require a considerable increase in elective activity.
It is also true that the goalposts have shifted considerably.
When the plan for a network of nine regional NTCs was unveiled as part of the NHS Recovery in August 2021, it was envisioned that they would be performing 25,000 elective procedures by 2024/25, and 40,000 next year.
Now most are paused until public finances improve.
The Programme for Government also promises to "[drive] improvements in productivity" by extending nationwide a Theatre Scheduling System initially piloted in three health board areas.
The initiative uses a software tool called Infix to cut down on the administration associated with creating and approving theatre lists, enabling more operations to be carried out.
This is welcome, but given that overall elective inpatient and day case activity in NHS Scotland still lags 12.5% below pre-pandemic levels there is plenty of catching up to do.
In England, the NHS has 108 surgical hubs with a further 26 due to go live in 2025. Around 90 have opened since Covid.
These include a mix of standalone elective units completely separate from acute sites - similar to the NTC model - as well as integrated hubs based within existing hospitals but physically segregated from acute areas, and ring-fenced hubs which have theatre space and beds set aside for their use.
In all cases, these hubs exclusively perform planned surgery, have their own pool of staff, and operate six days a week - or are working towards it.
A report published on Thursday by think tank, the Health Foundation, found that the newly opened hubs were associated with a 22% increase in the number of "high volume low complexity" surgeries (hip replacements, cataract removals and so on) that trusts were able to carry out.
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This isn't the only reason NHS England is now exceeding pre-pandemic levels of elective activity (it also sends more patients to the private sector), but given the delays facing NTCs the Scottish Government might want to consider whether it could do more to adopt a hub model here.
The Programme for Government also refers - again - to "shifting the balance of care to preventative and community‑based support".
The same noble ambition that Audit Scotland observed has floundered for a decade.
Arguably one of the major reasons we have failed to see this shift is because investment has flowed towards hospitals instead of into the community, and specifically not into general practice.
One of the clearest indicators for this is that while the consultant workforce has grown by 28.5% over the past 10 years, the GP workforce has shrunk by 5.4%.
The share of the health budget going into general practice has been gradually eroded, by some estimates to as little as 6%, compared to 11% 20 years ago. The same is happening across the UK.
This is the opposite of what we should be doing if we are serious about prevention.
Likewise with social care. Initiatives such as Hospital at Home - which prevented an estimated 10,000 admissions to hospital for elderly people in April to December last year - are fantastic, but if we allow social care to unravel, it will be little more than a sticking plaster.
Health and social care needs real change - not the same tired mantras.
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