Scotland’s independent think tank
Scotland’s independent think tank

Governance of NHS Scotland – Sir Ewan Brown

The three main political parties at Holyrood appear to agree that the £19 billion NHS Scotland is out of control and in need of reform. Recent quotes from senior politicians include:

  •       Labour – “Across Scotland, our NHS is on life support”.
  •       SNP – “Scotland’s NHS is in need of fundamental reform. The health service must be overhauled”.
  •       Conservative – “There is a crisis in our NHS”

If nothing is done to address the over-complex/dysfunctional structure and weak governance of NHS Scotland, the situation is very likely to get worse. 

I have previously written about governance in both the private and public sectors. My concerns about NHS Scotland’s structure and governance stem from Humza Yousaf’s Parliamentary statement in November 2022, “that because of leadership, governance and cultural failures, NHS Forth Valley has been put under Scottish Government control”. 

The NHS Scotland crisis is clearly much more than failures of leadership, governance and culture in regional boards – but weak governance and concerns around culture are frequently warning signs that “all is not well in the state of Denmark”

There are 14 regional health boards which are supported by Public Health Scotland, seven special health boards providing national services, and four Integration Boards (expected to co-ordinate with thirty-two local authorities). The aggregate annual budget of the 14 regional boards is in excess of £12 billion.

The authority and discretion of regional health boards, which have statutory form and governance and financial responsibilities, has been progressively eroded by the increasing emphasis on the entirely theoretical entity called NHS Scotland, which appears to have no statutory existence or legal identity of any kind.

This has resulted in increasingly directive behaviour, without proper accountability for financial and operational consequences, and a vehicle for disrespect for the chairs and other directors of health boards, which at times has extended into a quasi-bullying environment. It takes an enormous commitment to public service for anyone with serious career achievements to their name to want to become a health board chair under those conditions. There is also a risk that potential board members, who might wish to assert the governance authority of a regional board, are not welcome.

That said, Government should be encouraging the best qualified people to join the regional boards (which oversee circa 30% of Scotland’s budget) as chairs and non-executive directors.

In February 2023, Audit Scotland put its finger on the conflicts and ridiculousness within NHS Scotland in reporting “Regional NHS boards are expected to deliver services well beyond their budget’s capacity. The Covid Recovery Plan was promised in 100 days. Achieving this meant that boards were not consulted. Yet they are the ones expected to deliver”.

To improve governance, it is essential to clarify accountability and improve lines of communication.

 Have regional boards merely become rubber-stamping bodies which are regularly second-guessed by Ministers and civil servants? If so, should they be abolished? If not, how can they better demonstrate the value they add; and how can the effectiveness of chairs and non-executives be strengthened once they are in post? The quality of information available to board members needs to be improved, for example by allowing papers to be non-publicly disclosable and preventing dominant chief executives from controlling the agenda (a major problem in the private sector).

Principles of good governance would require that NHS Scotland, which has a chief executive, should be formally constituted with a chair and non-executive directors. This is clearly not the case. An alternative governance structure would be to create a real entity, NHS Scotland, that is accountable to Ministers and at arms’ length, confining Government to policy, monitoring and agreeing strategy and the business of protecting health and preventing disease (which is a cross-governmental function) and holding NHS Scotland to account on behalf of the electorate.

The 2022 Blueprint 2 governance document (which built on Blueprint 1), is fundamentally flawed. Instead of spending time researching best governance practice, the review team should first have mapped NHS Scotland and its complex structure and considered whether it was capable of being conventionally governed. Instead, there are 37 references to the research material examined and no references to the structure and complexity of NHS Scotland. The result is no more than a fig leaf for good governance. The Blueprint addresses “effective governance across NHS Scotland”, with a “primary audience of Board Members and Executive Leadership Teams”. However, it does not seem to apply to NHS Scotland, its chief executive or those who work for her.

Presiding over health and care spend of more than 40% of the Scottish budget, as well as major capital projects, the chief executive of NHS Scotland (who is also Director General Health and Social Care) has routinely been a civil servant. Is a career civil servant, with little or no experience of running a small business (never mind a £19 billion behemoth) necessarily the best person to lead the biggest organisation in Scotland? 

I have no political affiliation. Nor do I have an understanding of how, when or why a Government might be prepared to reach out to other parties to find common ground on a major issue of national importance that affects every citizen of Scotland. 

It is therefore as a political innocent that I would love to see Scotland showing the world what could be achieved by its political leaders laying down their partisan positions and coming together around a cross-party forum charged with redesigning and reforming NHS Scotland for the 21st century – and ensuring that it is capable of embracing a National Care Service in whatever form Government decides it should take. Embedded in this process must be a fresh look at good governance that is effective and fit for purpose. By creating a non-partisan forum, it should be acceptable to deploy the huge body of knowledge and experience of senior civil servants and health professionals to assist the process. 

If, politically, this is seen as a bridge too far, an alternative approach might be to set up a short-life group with a brief to:

  • map all the constituent parts of NHS Scotland and determine who reports to whom
  • map the proposed National Care Service and its relationship to NHS Scotland
  • map all significant collaborators and other key stakeholders
  • consider digitisation opportunities (eg artificial intelligence and robotics) to do more for less
  • plan removal of some health care services (eg diagnostics) from hospitals to the community

and only then determine what structure and governance model might be most appropriate. 

What must not be allowed to happen is to perpetuate a £19 billion organisation that is in urgent need of major overhaul and does not make best use of public money.

Ewan Brown, who has served on the boards of listed and private companies, universities and charities, is the author of Corporate Ego. His book describes the spectacular fall from grace of seven prestigious Scottish companies – Burmah Oil, Ivory & Sime, Lilley, HBOS, RBS, Johnston Press and Standard Life; and he identifies major failings in governance as the common cause. Ewan contends that governance in the public sector, and NHS Scotland in particular, is not fit for purpose. 


If you would like to contribute to Reform Scotland’s NHS 2048 forum, please email [email protected]

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