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

My Action Plan to Fix the National Health Service in Scotland – Alex Neil

The National Health Service is under the greatest pressure it has ever been since it was created in 1948. Stories abound daily about the NHS in crisis, not just in Scotland but throughout the UK. Patients are facing much longer waiting times for essential operations or, especially in the case of cancer patients, for a proper diagnosis and treatment. Accident and emergency departments are nowhere near meeting their (medically driven) target of dealing with patients within a four-hour waiting time. The ambulance service cannot meet its target for reaching the most urgent patients within eight minutes because of the delays in admission to A and E departments. Between 10% and 16% of hospital beds are occupied by people who are medically fit to be discharged but are stuck in hospital because of the lack of available social care services and care home beds. Mental health services are facing unprecedented levels of demand without having the necessary resources to deal with it. Many rural health services are at risk. Chronic staff shortages are common in both the acute and primary healthcare sectors, including mental health, as well as in social care. Staff turnover levels are far too high, and morale is low, made worse by the long-term reduction in real wages since 2010. As well as the exhaustion of dealing with the Covid pandemic when it was at its height, the NHS is now having to deal with its long-term impacts, thus adding to all the other pressures on the system.

During the two years I was the Cabinet Secretary for Health, having taken over from my predecessor Nicola Sturgeon in September 2012, many of these problems had already been longstanding. It quickly became clear to me that wide-ranging reform of the NHS was needed to meet the challenges facing it. The societal changes which have taken place since its creation in 1948 have placed far greater demands on the NHS than had ever been envisaged by its founders. It has now become a large and complex organisation whose modus operandi, including its management and decision-making structures, has become too bureaucratic and out-dated – an issue addressed in greater detail later in this paper.   

Within a few months of becoming Health Secretary, I drew up a list of action items needed to improve the NHS’s performance and outcomes as well as overhaul various aspects of its organisation, giving top priority to dealing with the growing crisis in Accident and Emergency departments throughout Scotland.  

It was of great regret to me when I was moved to another Cabinet portfolio before I could implement my action plan. I would have much preferred to serve long enough as Health Secretary to make the changes which were needed then and are much more urgent now.

Founding Principles of the NHS

The core principle on which the NHS was founded is being eroded in some areas. NHS patients in both Scotland and the rest of the UK are being forced to pay for private healthcare because they cannot access the treatment they need within the NHS. This defies the principle that care is provided free at the point of use and based on clinical need, not the ability to pay.

Some patients are in so much pain they are using up their entire life savings to pay privately for operations they cannot get on the NHS. Not because they want to but because they can no longer tolerate the consequences of having to wait an inordinate amount of time to be treated on the NHS. A report published by the King’s Fund in June 2023 found that “there is growing concern that people in the UK may be forced to choose between funding their own care or enduring longer waits for treatment”.

This situation highlights how urgent it is to address the various crises which currently beset our National Health Service as well as the longer-term challenges which have been ignored or remained unresolved for far too long.

If we are to deal successfully with the critical issues facing the NHS, it is essential to build a national consensus on the way forward. That includes agreement amongst our politicians as well as with the public. The Health Service has enough on its plate without constantly being used as a political football. The Scottish Government should lead the way in building cross-party support for its health and social care policies.

There is already tacit agreement on the way the NHS should be run and funded, as well as the future direction of travel.

The core principle referred to above that access to NHS care be based on clinical need and not the ability to pay is not open to serious challenge, at least in Scotland.

There is no support for imposing charges for NHS services such as visiting a doctor or for a stay in hospital, or for substituting our current system of paying for the NHS through general taxation with a system of “co-payment” or “social insurance”. As the highly respected King’s Fund, a leading authority on health policy, has pointed out, there is no evidence that introducing either health service charges or a system of co-payments or social insurance would be of any material advantage and would not of itself lead to either better outcomes or greater efficiencies in the National Health Service.

The Link between Poverty and Ill-Health

There is also general agreement in Scotland that by far the single biggest cause of avoidable ill-health in our country is poverty and deprivation. This is supported by a large amount of research evidence from health professionals and others. The link between poor health and poverty is now irrefutable.

There is an urgent need for a national comprehensive, effective, and ambitious anti-poverty strategy in Scotland. Although developing such a strategy is not part of its remit, the NHS should nevertheless play its part in targeting advice, assistance, support, and substantially more resources at people living in poverty on helping them to live healthily. It should also do much more to directly help people from deprived areas by, for example, offering job and training opportunities in the NHS.

The Critical Role of Social Care in Improving Healthcare

A third policy area where there is already a broad consensus in Scotland is the recognition of the critical role that social care must play in delivering an effective and humane health service.

However, there is no consensus on how best to organise social care services in Scotland to do this.

The creation of 31 “health and social care integrated joint boards” has not had the desired impact on improving social care provision or on health outcomes. There is an urgent need to fundamentally review these arrangements as part of a wider radical reform of the management and decision-making structures within the NHS. The last thing we need, however, is another costly and unnecessary national bureaucracy through the creation of a new National Care Service. This proposal should not just be deferred. It should be withdrawn with immediate effect.

The Centre for Children’s Care and Protection at Strathclyde University conducted a research study on behalf of the Scottish Government in 2023, looking at social care programmes in Finland, the Netherlands, New Zealand, Northern Ireland, and Ireland. The study found that none of the countries researched had successfully attempted to create a national adult and children’s social care agency. Any attempts to centralise these services had all failed. 

The Scottish Government has failed to produce any evidence that transferring responsibility for delivering children and adult social care services to a new national agency would succeed in improving outcomes. The millions of pounds already spent on this ill-advised project should instead have funded enhanced pay and conditions for frontline social care workers.

The Need for Investment and Reform

The fourth area of health policy where there appears to be general agreement is the urgent need for NHS “investment and reform.” The problem is the lack of definition of what “investment and reform” means in practice.

The purpose of this article is to fill that void by mapping out a plan of action to make the NHS in Scotland fit for the future.

The starting point must be to deal with the legacy of gross under-investment in the NHS dating back to 2010.

The Truth about Funding

The Nuffield Trust has shown that there was virtually no growth in UK healthcare spending in the decade leading up to 2020 “after adjusting for changes in the population size and demographics”. The spending per head on health was basically stagnant in real terms for 10 years, even though the demand for services continued to grow significantly due principally to the increase in the UK’s population and the increase in the number of older people within our population.

The gross under-funding of the NHS during this period has had a disastrous and long-lasting impact on today’s NHS.

To put the scale of the under-funding in perspective, the NHS needs a 4% real-terms annual increase in funding to maintain its commitments and achieve its targets. The average annual increase in funding in the period after 2010 was only around 1%. The annual 3% shortfall in necessary funding accumulated over the decade from 2010 resulted in a real term cut of well over 30% in the NHS’s budget. A catastrophic amount by any standard.

During the decade from 2010, total healthcare spending in the UK as a share of GDP averaged 9.9% per year. This compares to 12% in France and 13% in Germany. Measured as investment per head of population, the UK spent £40 billion less than France and £73 billion less than Germany on healthcare during this period. Research undertaken by the House of Commons Library in August 2023 showed that the annual UK health outlay per person of £5,884 is now about a third less than Germany and Norway at £9,104 and £8,817, respectively.

Put simply, the chronic under-funding of the NHS has left it without the capacity to cater for the current and projected levels of demand for its services. We do not have enough doctors, nurses, and other medics. We do not have enough of the modern equipment needed to help with accurate and speedy diagnosis. We do not have enough beds in our hospitals and care homes.

The King’s Fund’s comparative study of the UK’s NHS against 18 other wealthy, developed nations has shown that we now have the lowest number of CT and MRI scanners per million people; 2.5 beds per 1,000 people compared to an average of 3.2 per 1,000; and, along with Greece, the second highest avoidable mortality rate. Only the US was worse.

As well as finding that the UK lags other countries in its capital investment it also states that “the UK has strikingly low levels of key clinical staff, including doctors and nurses, and is heavily reliant on foreign-trained staff. Remuneration for some clinical staff groups also appears to be less competitive in the UK than in peer countries.”

On a more positive note, this report also found that “the UK health system performs well on some measures of efficiency, such as the rate at which cheaper generic medicines are prescribed. The UK also spends a low share of its health budget on administration”.

NHS Priorities

In Scotland NHS spending per head is about 3% higher than England. In 1999-2000, the spending on health per person in Scotland was 22% higher than in England. It dropped to 10% higher in 2009/10. Had successive Scottish Governments maintained these differentials then spending per person on health in Scotland would today be comparable to our European counterparts.

The key conclusion from the King’s Fund analysis is the need for both Scotland and the UK to significantly increase spending on the NHS. These additional resources should focus on expanding capacity by recruiting, training, and improving the terms and conditions of medical staff and in physical resources such as advanced diagnostic equipment, more hospital beds along with a major expansion in primary, community/social, and mental health services. The recent (welcome) announcement by the Scottish Government of an additional £500 million for the NHS in 2024/25 should be targeted at these priorities.

Future investment plans must cater for the changing nature of healthcare demands, especially the rising tide of chronic diseases such as arthritis, diabetes, dementia, etc.

Today’s NHS is not well enough placed to deal with these chronic conditions. The failure to deal with them in the community is leading to too many people being hospitalised even although it is both safer for patients and more cost-effective for the taxpayer to have these patients treated in the community.

A central theme of planning future healthcare must be to provide the primary and community care sectors of the NHS with the resources needed to keep people healthy and out of hospital. Thus, the bulk of future NHS spending increases must be directed towards the primary and community care sectors.

Experience tells us that we cannot rely on the existing territorial health boards in Scotland to do this so the Scottish Government will have to devise a method of ensuring the necessary funds reach our GP surgeries and other primary and community care agencies.


In Scotland, the most urgent issue is to deal with the dire shortages of medical staff, including nurses and allied professionals, in both GP surgeries and the acute sector. Failure to do so quickly and effectively will result in the NHS being unable to improve health outcomes for patients or meet its key performance targets or recover from the pandemic. Solving the staffing problems are what should keep the Cabinet Secretary for NHS Recovery, Health, and Social Care up at night.

In its Workforce Strategy for the NHS and Social Care published in March 2023, the Scottish Government committed to grow the NHS workforce by 1% over the next five years.

This target is totally inadequate and needs to be urgently revised.

Given the number of existing staff shortages, the wholly inadequate rates of recruitment and retention currently being experienced by the Scottish NHS, the number of staff who are due to retire within the next five years, the numbers taking early retirement from the NHS, staff turnover levels involving the loss of existing staff to various destinations, the projected increase in population, the increasingly older age structure of the Scottish population plus the additional demands which the NHS will face in the next five years it is very difficult to see how a 1% increase in the total workforce will come anywhere near meeting the workforce numbers needed by the Scottish NHS to meet its targets.

In December 2017, the Scottish Government pledged to increase the number of GPs in Scotland by at least eight hundred over the next 10 years (2018 to 2028). Six years on, only 11% of that target has been reached.

Meantime in real terms (after adjusting for part-time work) the size of the GP workforce in Scotland has shrunk by 5.4% over the past decade while the number of patients registered has increased by 7%.

Without urgent action to rectify this situation there is no chance of the Scottish Government coming anywhere near achieving its target of 800 more GPs by 2028.  

In any case the target is too low, for the same reasons cited above as to why the overall 1% workforce target is too low.

It is also not the right target to set. A more realistic target would be the number of WTE (whole-time equivalent) GPs needed to meet the projected increase in demand for their services.

Given the trend for an increasing number of GPs choosing to work part-time at various stages of their career, simply targeting an increase in the crude number of GPs is likely to lead to a significant under-estimate of what is required.

For all these reasons the target therefore needs to be revisited, as does the Scottish Government’s plan for achieving it.

More generally, the Scottish Government must waken up to some new realities. There is now a global market for medical staff, including nurses and allied professionals such as dentists. Obamacare in America alone has created a demand for many thousands more medical personnel. India now has a middle-class population who rightly are demanding high-quality healthcare. The NHS can no longer rely on huge influxes of Indian medics. Meantime increasing numbers of young medics from Scotland and the rest of the UK are flocking to countries like Australia who are offering much higher pay and much better terms and conditions than are currently available in the UK.

Aided and abetted by the crisis in the NHS, many profit-making private healthcare companies throughout the UK are thriving. The higher salaries and better working conditions in this sector act as a magnet for attracting staff away from the NHS. Meantime the “traditional” private sector which operates as part of the “NHS family”, including the GPs and dentists who are contracted to work for the NHS, are struggling to cope with rising demand and too few resources.

As the recent strikes by medics have shown, the NHS must waken up to the new reality. We must significantly enhance the pay and conditions of our entire NHS workforce.

Key aims should include restoring the real-term levels of pay to what they were prior to 2010; to ensure that NHS pay rates are internationally competitive; and to close the gap between remuneration levels (and terms and conditions regarding hours, travelling expenses, flexible working arrangements, etc) for permanent staff and those for temporary staff such as locum doctors, bank nurses and agency nursing.

This last measure is needed to end the vicious cycle of staff shortages resulting in much greater use of locums and bank/agency nursing, whose superior pay and conditions cause more permanent staff to leave the NHS to become locums and bank/agency nurses, thus causing further shortages!

The vacancy rates for medical staff demonstrate the need to make a medical career in Scotland much more attractive, both financially and through enhanced terms and conditions.

According to the Royal College of Nursing about 500 (10 %) consultant positions are currently vacant, with many being so for a considerable period. Vacancies for oncologists/radiologists are running at over 20%. Over 6,000 (10%) nursing and midwifery jobs are unfilled. The number of GPs in Scotland has also fallen in recent years.

Equally concerning is the recent drop-off in the number of applicants to study nursing in Scotland, resulting in over 500 university places not being filled. These figures are ominous for the future of the NHS in Scotland.

Until we can solve the projected longer-term crisis in medical staffing (which will take five to 10 years, given the time it takes to train doctors and nurses) an ambitious and comprehensive recruitment drive is urgently required to deal with more immediate staffing shortages, to fill existing vacancies and reduce the pressures on existing staff. As a matter of priority, we should be incentivising doctors, nurses and allied health professionals who have previously worked for the NHS and who retain their licence to practise to return to work on either a part-time or full-time basis in the NHS.

In the last eight years or so, over 2,000 doctors have taken early retirement from the NHS in Scotland. If we can persuade even a quarter of these people to return to work for the NHS, even on a part-time basis, it could significantly improve performance; especially if a similar return rate of return for nurses and other healthcare professionals can be achieved.

There was an attempt by some local NHS organisations during the pandemic to undertake such a recruitment exercise. Unfortunately, it was not done very satisfactorily. For example, the Royal College of Surgeons in Scotland reported that only 15% of its retired members have been contacted to ask them to return to work, hardly an ambitious effort. I also know of many nurses who responded to the call for help during the pandemic but didn’t even receive an acknowledgement, let alone a reply, to their offer to help from the NHS. The NHS must try again but do so properly and professionally this time.

While such a recruitment drive is designed to meet the immediate needs of the NHS, there is also an urgent need to address longer-term staff requirements.

Across the UK, only 16% of medical school applicants were successful last year.  The other 84% were rejected for admission to medical schools.

These figures are a disgrace and represent a massive failure by our political class north and south of the border. Surely it makes sense both financially and for securing the future of the NHS, that a much higher percentage of these applicants be accepted into medical school. If we do not do so, then the scale of future staff shortages in the NHS will become astronomic, possibly to the point where it becomes unviable in its present form.

In Scotland there are about 5,000 medical undergraduates going through training in Scottish universities, 55% of whom are domiciled in Scotland. When they graduate only about 70% of the Scottish graduates take a medical job in Scotland. Less than half of all the medics we train in Scotland stay in Scotland.

These statistics demonstrate the need for action.

The Scottish Government needs to significantly raise the cap on the number of Scottish-domiciled students admitted to Scottish medical schools; the SNHS needs to work closely with the medical schools to increase the percentage of Scottish-domiciled students who remain in Scotland to work for the NHS here; it also needs to recruit many more of those students from the 55% who are non-domiciled in Scotland to stay and work in the Scottish NHS, ideally on a permanent basis; incentives should be offered to undergraduates and trainees to encourage them to work in the SNHS for a given period of, say, five years on completion of their course by, for example, offering to write off all or part of their student loan; the SNHS should also make much more use of apprenticeship and graduate apprenticeship programmes to help solve staffing shortages. Consideration should also be given to offering maintenance grants to medical undergraduates in return for signing up to a commitment to work in the Scottish NHS for a given period upon graduation. Failure to keep to the terms of the contract would require repayment of the maintenance grant.

Such incentives could also be used to encourage graduates to work in those parts of the NHS where the shortage of skills is greatest, such as in rural areas.

Increasing the availability of free accommodation for junior nurses and doctors should also be considered to help recruit and retain staff.

More Beds

As well as too few staff, the NHS in Scotland and the UK has one of the lowest ratios of beds to population in Europe. According to the Royal College of Emergency Medicine (RCEM) between 2011 to 2019, Scotland experienced a loss of 1,500 beds, although on a more positive note “the NHS in Scotland has consistently maintained the highest level of beds per 1,000 people of any UK nation”.

At a UK level, the RCEM states that “compared to OECD EU nations, the UK is the second least bedded per 1,000 population”.

The recommended safe occupancy rate for NHS beds is 85%. This figure allows for extra capacity to manage sudden increases in demand, as well as reducing the chances of patients contacting hospital-acquired infections. The RCEM has estimated the average hospital bed occupancy rates to be 95.5% in Wales, 94% in England and 89% in Scotland as of September 2022.

The RCEM estimates that an additional 448 beds are required in the Scottish NHS “to achieve optimum occupancy levels”, an increase of 3.3%.

Waiting Lists

The shortage of staff and beds as well as the pandemic are the main reasons why waiting lists for elective procedures have grown to record levels over the past three years. A range of initiatives are required to get these waiting lists reduced more rapidly, including making more extensive use of robotic surgery techniques, for example to remove prostate cancers; using already available AI technology to undertake a range of activities including the enhancement and speeding up of diagnosis and improving bed management; making greater use of theatre facilities in the evenings and at weekends when and where the necessary staffing is available; and learning other tried and tested ways for safely increasing the volume of procedures.

Patients spending a long time on a waiting list for a vital operation can often develop other symptoms of ill-health, including mental health problems. It is therefore vital that getting the waiting times and lists down to reasonable levels must be a top priority.

Accident and Emergency four-hour and Ambulance Service Targets

The lack of enough beds is also one of the main reasons why the NHS continues to miss its four-hour target for treating patients within our Accident and Emergency departments. Too many patients who are being admitted to hospital by their A and E consultant cannot be discharged to a hospital ward because there is no bed available for them. There is also a knock-on impact on the ambulance service, as it cannot discharge its patients from the ambulance as there is no available room for these patients in A and E departments.

As reported in the Herald newspaper on 16th December 2023, 10% of all ambulances arriving at Accident and Emergency Departments in Scottish hospitals on 4th December 2023 had to queue for two hours to offload their patients. That meant around 750 patients in need of emergency medical care spent two hours waiting in the back of an ambulance before being admitted to A and E. It also meant that many other patients had to wait much longer than should be the case for their ambulance to arrive to transport them to A and E.

These were the average figures across Scotland. In some parts of the country, patients had to wait up to five hours to be offloaded from the ambulance and admitted to A and E.

Once in the A and E departments, less than 65% of patients are being seen by a doctor within the four hours’ target time. That is 30 percentage points fewer than the 95% target for being seen within four hours.

Delayed Discharges and Social Care Services

The problem of bed shortages is further exacerbated by the number of “delayed discharges”, accounting for up to 16% of all hospital patients at any one time. These are patients who are medically fit to be discharged from hospital but do not have the necessary social care support in place to return home, be it to their own house or a care home.

The only way to solve this problem is to invest more in the social care sector, starting with urgent action to solve the severe staffing shortages.

In Scotland there is general acceptance that the problems of the health service cannot be solved without greater funding for social care and that a prerequisite to successfully addressing the problems in social care is an increase in the minimum wage for frontline staff from its current level of about £12 to at least £15 an hour, coupled with measures to enhance social care as a career. Without doing so, high staff turnover rates currently running at over 40% a year and equally high staff shortages will persist.

Such an increase would require very substantial funding, amounting to hundreds of millions of pounds and will take time to implement given the current state of the Scottish Government’s finances. Frankly, the recent Scottish Government Budget should have earmarked the £150 million it used for a council tax freeze to invest in tackling the crisis in social care instead. Also, instead of allocating over £200 million for next year to “active travel” it should re-direct this money to the social care budget; a much higher policy priority by any measurement. Such a move would be much more in line with the First Minister’s stated priority of tackling poverty.

Another critical issue is the lack of enough care home places in Scotland, the availability of which has gone down by over 2,000 places in the last decade. This shortage must also be tackled, ideally as part of a wider strategy for improving both the availability and quality of care provision.

Meantime the NHS should establish a network of “convalescence units,” sometimes referred to as “step-up, step-down” or “intermediate” facilities, to accommodate and support those patients who have been medically discharged but are unable to go home immediately.

Such a policy was agreed to 10 years ago when I was the Health Secretary but was never properly implemented.

Primary Care and Community Services

These improvements to social care and the others set out above must be delivered within the context of the need for systemic change within the NHS.

Increased budgets and capital resources for the NHS will not on their own be enough to solve its underlying problems. There needs to be a comprehensive, long-term business plan for health and social care which addresses the strategic challenges arising from the ageing of the population, the rapidly changing demands from patients and the increased costs of new medicines and innovative technologies.

As the King’s Fund has stated, “priority must be given to investing in primary care and community services in order to anticipate people’s needs, promote independence and offer alternatives to hospital”.

In Scotland, the primary care sector’s share of the NHS’s budget has fallen to 9%, down from 11%, making it the “poor cousin” of the service. Given that GP surgeries deal with about 90% of visits to a doctor in Scotland and given the current crisis in this sector, it is essential that the primary care sector’s budget share be restored to at least 11% of the total budget.

We should learn from the Netherlands. There, primary and social/community care services are available locally on a 24/7 basis. One of the results is that attendances at their A and E departments are one quarter of those in the UK in relation to population size. We should aim to replicate the Netherlands to help realise the King’s Fund vision for the primary health sector.

Prevention of Ill-Health

Prevention of avoidable sickness and ill-health is essential for the success of the NHS. A report published in December 2023 by Tony Blair’s Institute for Global Change highlights the need for an “NHS illness prevention service”. Its purpose would be to “scour medical records to identify and seek out those who need pre-emptive treatment, health advice and weight-loss drugs.”

It argues that “the NHS app must be revamped to alert people to treatments and tests they should be having” and that by doing so the NHS “could save billions of pounds a year and boost the economy by reducing record levels of illness absence”. Given that about 40% of the NHS budget is spent on treating preventable conditions this proposal should be pursued with urgency subject to adherence to patient authorisation protocols and a guarantee regarding the privacy of the data being accessed with artificial intelligence.

The report’s author, Ryan Wain, said that the proposed prevention programme “would build on the infrastructure created during the pandemic and be delivered in communities, pharmacies, primary care and other settings”.

Our strategic objective should be to maximise the opportunities throughout the healthcare system so that, as far as possible, prevention replaces the need for treatment. 

In my view, in Scotland the obvious organisation to lead such a transformation would be Public Health Scotland.

The Critical Role of Medical Science and New Technologies

The proposal mentioned above regarding the prevention of avoidable illnesses is an example of the revolution which the use of new technologies can have on the NHS and patients. As well as AI, other key technologies which can help bring about dramatic improvements in healthcare include the greater use of data analytics, genomics, robotics, digitisation, and the much greater use of tele-medicine. Every patient should have access via an app or other devices to their own medical records, to help them better manage their own health as well as provide the necessary data to those who are treating them.

We should also be aiming to substantially reduce the time-gap between the development of new medicines, new technologies and new techniques and their implementation.

The Covid crisis demanded new vaccines be developed and delivered for patients within months, whereas traditionally that process would have taken many years. This was revolutionary for the world of medicine. We need to do much more of it. Fortunately, with new technologies like AI increasingly available it should be possible in future to develop new cures and have them safely available for patients much more rapidly. 

Health and Social Care Management and Decision-making Structures

Reference is made above to the need for radical reform of the management and decision-making structures for health and social care services.

The current structures are not fit for purpose. There are too many separate organisations. In a country the size of Scotland we do not need 14 territorial health boards, 8 specialist health boards, 3 regional structures, 31 health and social care partnership boards, plus a plethora of other non-statutory bodies plus the Scottish Government’s Health Directorate. This structure needs to be streamlined.

The quality of management is variable. In my view the NHS would benefit from having more managers who are medically qualified and experienced.

There are far too many layers of management within many of the boards listed above. Decision-making at every level is too centralised.

Overhead costs are too often inflated. For example, many of these boards have their own separate IT systems which cannot communicate easily with others in the health and social care network, too many properties are lying empty or are under-used because they are no longer fit for purpose and should be sold off to help fund essential capital equipment.

The effectiveness of the boards of directors appointed to run these organisations is variable. They are also not accountable enough to the communities they are there to serve.

It’s not just the number of management boards which is important. Remits also need to be changed to ensure the maximum decentralisation of decision-making.

In my view there should be about three or four strategic regional healthcare authorities in Scotland whose responsibilities would be to set targets and budgets, monitor performance and outcomes, etc.

Within the strategic confines set by the regional authorities each local delivery unit, be it an acute hospital or provider of primary care services, should operate autonomously.

The specific issue of the relationship between healthcare and social care services must also be re-visited. My own view is that there is a convincing case for retaining social care services within the remit of local councils, especially given the important links with other essential services such as Housing and Benefits Support. But there also needs to be a clear plan for ensuring that health and social care services are properly co-ordinated and where apposite integrated.

The Scottish Government should set up an independent task force to review these issues and to make detailed recommendations to the Scottish Government and Parliament within twelve months.   


Finally, the Scottish Government’s recently announced massive cuts to other essential services will be detrimental to improving the health of the nation. The £200 million cut to the housing budget will put even more pressure on the NHS, as the people affected suffer avoidable physical and mental health problems.

The Scottish Government’s Budget for 2024/25 should have adopted a much more progressive approach. It should have used its powers to introduce a land levy on the largest estates in Scotland to raise at least £1 billion in revenue for additional investment instead of cuts to the NHS and other core public services. It should now use the time still available for it to amend its budget to legislate for a land levy and reverse the cuts.

It should also prepare a detailed 10-year Plan for the Future of Health and Social Care in Scotland and do so with the active participation of those who will be expected to deliver it as well as the wider community.   

The proposals outlined above are by no means an exhaustive list of what the NHS needs to do to prepare for the future. But implementing these recommendations would certainly make a massive difference to the NHS, its staff and, most importantly, the patients. The question is whether our rulers have the necessary wherewithal to implement these changes, or whether they will just continue tinkering at the edges. Time will tell.

My message to the Scottish Government is that if it is serious about addressing the crisis in the NHS in Scotland it needs to do much more than it is currently doing and it needs to do so now.

Alex Neil was the Cabinet Secretary for Health from 2012 until 2014 in the Scottish Government

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

1 comment

  • David Belfall

    This provides a very impressive analysis and a comprehensive blueprint for fixing the NHS. Whether it is doable within the current financial model is another question….

    Of particular note is the link which Alex makes between health and social care – a very important topic but not one which looms large in the public debate about the future of the NHS. He says that “The creation of 31 health and social care integrated joint boards has not had the desired impact on improving social care provision or on health outcomes”. On this we will shortly have a report from Audit Scotland on the performance of these boards. Alex goes on to refer to the need for “a comprehensive, long-term business plan for health and social care”, greater funding for social care “amounting to hundreds of millions of pounds” (instead of the cuts currently being seen as a result of recent budget decisions) and the example set by the Netherlands where “primary and social/community care services are available on a 24/7 basis” and “One of the results is that attendances at their A&E departments is that attendances are one quarter of those in the UK in relation to population size”.

    This last point is specially important because the queues of ambulances outside our A&E departments, and the long waits for attention, constitute one of the most evident failures of the NHS today. This is basically a problem of supply and demand. There is no prospect of improving supply until more doctors and nurses become available in the fullness of time. Thus, meanwhile the focus should be on diverting demand elsewhere – which is why the comparison with the Netherlands is so relevant.

Got something to say about this? Leave your comment below. Comments may be moderated before displaying. By posting you agree to abide by our Terms and conditions. This site uses Akismet to reduce spam. Learn how your comment data is processed