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

The Future of the NHS in Scotland: A Vision for 2048 – Peter Cawston

As we approach the centenary of the National Health Service (NHS) in Scotland in 2048, it is crucial to envision its transformation into a system that champions equity, environmental sustainability, and community well-being. The challenges of health inequality and climate change present Scotland with a unique opportunity to lead by example, creating an NHS that is a global model for fairness, resilience, and sustainability.

In 2048, Scotland’s NHS has become a cornerstone of a fair and sustainable society. The gap in life expectancy between rich and poor has dramatically narrowed, and communities across the nation enjoy equitable access to healthcare. This transformation is powered by Scotland’s renewable energy revolution and a commitment to reducing carbon emissions across all sectors, including healthcare.

The NHS is no longer just a provider of health services but a key player in addressing the social determinants of health. From supporting local economies to empowering communities, the service has embraced its role as a catalyst for positive change.

Reimagining NHS Spaces and Practices

Sustainable and Accessible Facilities
By 2048, NHS Scotland’s premises have become models of environmental sustainability and community integration. GP practices and primary care hubs feature energy-efficient designs, including natural ventilation, solar power, and living roofs. These buildings are set within vibrant green spaces—community gardens, wildflower meadows, and outdoor gyms—that double as spaces for health promotion and biodiversity.

Car-free access routes have become the norm, encouraging walking and cycling for both staff and patients. Inside, technology is seamlessly integrated to improve efficiency and reduce waste, ensuring that digital health services are accessible to everyone.

Community-Driven Care
Healthcare delivery is rooted in collaboration with local communities. GP teams are embedded in their neighbourhoods, attending community events, supporting local businesses, and fostering trust through personal engagement. This localised approach has strengthened the relationship between healthcare providers and the communities they serve, resulting in better outcomes and higher satisfaction. Communities are enabled in numerous ways to co-create the shape of services delivered in their locality.

Frontline healthcare is delivered through small teams, which have become the backbone of the NHS.  Every patient in Scotland has a named GP and receives relational care and continuity with a trusted individual provider, who is supported by a small and known administrative and clinical team. This has radically reduced demand on health care, improved patient self-management and reduced reliance on pharmaceuticals, technological interventions and specialists. Instead, patients and professionals are partners in developing tailored, personalised health care plans that are suited to their unique needs.

Empowering NHS Scotland’s Workforce

Scotland’s NHS workforce in 2048 is thriving, diverse, and well-supported. Roles across all levels—from clinical to administrative—are highly valued, with comprehensive training pathways ensuring inclusivity and career progression. This approach has addressed recruitment challenges and created opportunities for individuals from disadvantaged communities to join the healthcare sector.

Sustainability at the Core of NHS Scotland

Carbon-Neutral Healthcare

NHS Scotland has achieved its ambitious target of net-zero carbon emissions. Sustainability is now embedded in every aspect of healthcare delivery, from building design to prescribing practices. Measures such as the widespread adoption of low-emission inhalers and robust recycling programmes have significantly reduced the carbon footprint of healthcare services.

Prescriptions now include information about both financial and environmental costs, empowering clinicians and patients to make informed, sustainable choices. Social prescribing has become a cornerstone of care, offering alternatives to pharmaceuticals that address the root causes of health conditions.

Minimising Pharmaceutical Reliance

A holistic approach to healthcare has reduced over-reliance on pharmaceuticals. Community-led initiatives, such as peer support networks and physical activity programmes, play a significant role in addressing chronic conditions like obesity, mental health disorders, and diabetes.

Addressing Health Inequalities in Scotland

In 2048, NHS Scotland actively combats the root causes of health inequality. Localised action has been central to addressing social determinants of health, with healthcare services working in tandem with housing, welfare, and employment support organisations.

GP practices now offer integrated advice on energy-saving measures, mitigating fuel poverty, and supporting communities to adapt to climate challenges. Free public transport to all healthcare appointments, alongside active travel plans, ensures equitable access to services while promoting sustainability.

Technology in NHS Scotland

Scotland’s NHS has embraced digital innovation to enhance care while maintaining its human touch. Universal electronic prescribing has reduced administrative burdens and improved patient safety. Virtual consultations are standard practice, supported by community-based digital literacy programmes to ensure that no one is left behind in the digital age. Technology is used to augment human connections, allowing healthcare professionals to focus on delivering personalised and compassionate care.

Biodiversity and Greenspace in Healthcare

Scotland’s health facilities now prioritise biodiversity and greenspace, recognising their therapeutic and environmental benefits. Urban orchards, wildflower meadows, and community gardens are commonplace, promoting biodiversity and serving as tranquil spaces for patients and staff alike.

Green prescriptions have become a standard part of care, encouraging patients to engage with nature through gardening, outdoor exercise, and eco-restoration projects. These initiatives not only enhance physical and mental health but also foster a sense of community and purpose.

A Catalyst for Broader Change

The transformation of NHS Scotland has had far-reaching impacts beyond healthcare. By supporting local procurement and renewable energy initiatives, the NHS has strengthened regional economies and contributed to Scotland’s leadership in sustainability. Collaborations with community organisations have created green jobs and bolstered economic resilience, embedding health equity into Scotland’s broader development strategy.

Conclusion: A Vision for Scotland’s Future

If we do not envisage the future we want, then others will shape it for us. The NHS in Scotland remains a valued institution in 2024, but in its current form does not offer the shape of a health service that will be fit for purpose in 2048. The crises of climate change and widening inequalities along with the challenge of creating a sustainable service that can meet the needs of the population mean that we must engage now with the NHS of the future. This will require a far more mature and honest public debate about what purpose the NHS in Scotland serves, and in whose interests, than has hitherto often been the case.

This debate needs to engage with the reforms required to shift the centre of gravity and funding away from centralised, specialised, hospital-based services into community-based services. These will result in difficult trade-offs and balancing competing demands, including those of well entrenched interest groups. For example, care approaches such as realistic medicine, forward care planning and reduced reliance on pharmaceutical prescribing, currently in their infancy, will need to become integrated into all health consultations. This will require greater patient-centredness in medical practice, but also greater public understanding of the limits of medicine and the harms which excessive medicalisation causes.

Long term continuity of relational care with a trusted provider such as a GP is probably the single most cost-effective and evidence-based way in which a health service can maintain trust, reduce inefficiencies such as inappropriate tests and treatments, and improve patient satisfaction and practitioner retention. Restoring the proportion of NHS funding to levels previously invested in general practice would be necessary to enable this to happen. Somewhat ironically, a major step in reform towards the NHS of the future may be to restore a key element from the past, albeit in a modernised form.

The challenges in shaping the NHS of 2048 are not insurmountable, if we can look up beyond the day-to-day demands of perpetual crisis management and dysfunctional short termism. There is a profound democratic deficit in the NHS in Scotland, with communities having little say or influence at all levels, particularly those who are most vulnerable and impacted by the mismatch between care and need. Greater community control of the various levels of health-care service, reconfiguring procurement policies towards local suppliers and sustainable supply chains, investing in modern community premises rather than centralising services in hospitals, and integrating the information revolution and artificial intelligence with person-centred human care, are some of the steps on this journey which we need to be engaging with now.  Above all we need the same belief that the founders of the NHS had in 1948 – that the future is ours to shape and that the NHS in Scotland can and will safeguard the well-being of future generations while contributing to a more just and resilient society.

Peter Cawston is a Deep End GP based in Glasgow who has advisory roles in health inequalities and clinical sustainability

This blog is based on a round table discussion held in 2022 in which a small group of Glasgow-based GPs and NHS Officers met to discuss the question: how can we transition to a just and sustainable General Practice? The workshop was kindly supported by the NHSGGC Community Wealth Building team and the Glasgow HSCP GP engagement fund

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