Angela Constance: NHS reform isn't optional

It’s the end of a busy parliamentary day and the lights in the ministerial tower are going dark as the offices empty. But Angela Constance is still here explaining why the “simplification” of Scotland’s health system makes sense.

Subject to consultation, the process will see the country’s 11 mainland health boards cut to just two, with separate plans potentially bringing Shetland, Orkney and the Western Isles together. It’s a radical change from an administration which has put reform at the centre of its Programme for Government. Public services will become “more modern, more flexible, more person-centred”, First Minister John Swinney said, and NHS care will undergo the biggest and boldest transformation of the devolution era. 

There are to be no voluntary redundancies, there is to be an emphasis on frontline services, and greater use of technology is to help drive efficiencies, the government has said. But much of the five-year plan is still be filled in.

MSPs have been talking about the Swinney government’s reform agenda all day, not only in the chamber and at committees but in the garden lobby and over lunch. Time and again the question of detail arises – why isn’t more known about what the change will look like in practice? Has enough work really been done? 

“This is the design stage, and very deliberately have we not come forward with a fully formed programme,” Constance tells Holyrood. “I have been around long enough to know that if I did people would rightly be saying, either the workforce or patients, ‘where’s the collaboration and building consensus?’

“It’s important that government leads – that we have put a flag in the ground saying we need to do public service reform,” she goes on. “And actually, people know that change isn’t optional. People know that we need to find better ways for patients to access treatment and better ways of working, given that demand on our health and care system continues to increase.”

This is not, Constance points out, her “first rodeo”. An MSP since 2007, she has held four previous cabinet roles and another four ministerial briefs covering everything from drugs policy to skills and social security to home affairs. She is also the fourth health secretary we’ve had in the past five years. “It’s bigger and broader than any other portfolio that I have had the privilege of being responsible for,” she says. “I’m enjoying it very much.”

Similar to her last brief, justice, there’s a sense of “coming full circle”, she says, given the time she spent as a social worker in hospital and care environments, and she feels “very fortunate” to be able to draw on that professional experience now. 

She’s “cognisant of the scale of the challenge”, but “not daunted by it”, she says. “I do have experience; I do have resilience.”

Constance will need those attributes in what is certain to be a tough session. After all, there’s no chance this scale of change can be achieved without difficulty. “It better be full-on and hard work,” Constance says of the term ahead. “You don’t achieve anything by sitting on the sidelines, but you do have to take folk with you.” And anyway, she says that at this stage in her career she is “too old to be fooling around”. 

It’s just as well the cabinet secretary is prepared for tough conversations. Health unions are amongst the country’s most powerful, patient bodies are organised, and political rivals vocal. While the government is determined that change is necessary, it cannot force this through without consensus, and recent history shows us just how necessary that agreement is: the much-vaunted National Care Service fell when stakeholders baulked at the plan as it advanced.

“I can do the hands-across-the-wall,” says Constance. “I’m also quite direct. If I see something I don’t like or don’t agree with, I wouldn’t go around the houses with it, I’ll say it. 

“But we do need to work together,” she goes on. “We work better when we work together. I’ll work very hard with the workforce but also other parliamentarians.”

The east-west split now imagined for mainland Scotland follows “subnational” work which was accelerated last winter under Constance’s predecessor, Neil Gray. Territorial health boards were directed to take on a joint planning approach to “key priorities” including digital care, business systems, emergency access standards and orthopaedic elective services, sharing resources and capacity across local boundaries.

In late 2024, John Burns, then chief operating officer of NHS Scotland, told health boards that a “disjointed approach with little transparency or governance” existed and had created “the opportunity for duplication with unclear prioritisation and strategic direction, potentially leading to misspent public monies”.

The directive was given as the government tried to tackle sprawling waiting lists and control costs, and the work that followed has created “strong foundations” for what’s to come, Constance says. “It’s a collaborative arrangement that relies on choice and the nature of willingness that exists within area boards. That has begun to work well and we want to take that a stage further. 

I know, hand on heart, if we went forward with a fait accompli that would not have landed well

“Around 40 per cent of the Scottish Government budget is invested in health,” she continues. “The aspiration – and I think it’s more an aspiration across the political parties – is about how do we move from reacting and treating poor health to actually preventing it? My sense when I speak to other parliamentarians is that that’s a shared aim; that’s what we want to move towards. The more resource and spend on treating ill-health, the less there is for other services and around prevention.”

The shift is “not optional, it needs to be done”, she emphasises. “We need to make a start, we need to be serious about this endeavour,” Constance says of the government, “but we also need to take people with us. I’m a realist. I’m pragmatic.

“Of course there’s a lot of detail to work through,” she continues, “but it’s important we do that together. I know, hand on heart, if we went forward with a fait accompli that would not have landed well.”

Constance has already had to deal with news that did not land well. The planned replacement for Monklands Hospital in Airdrie was rejected in June, with Constance ordering its “comprehensive redesign” and stating that, at a cost of around £5m per bed, the £2bn NHS Lanarkshire scheme would have been an “unprecedented concentration of capital investment in a single health project”. There was outcry from Labour, the Conservatives and Reform UK, whose MSP Graham Simpson accused the SNP of having “hoodwinked” locals for votes.

Addressing parliament, Constance said the business case for the project had been sent to the health and social care management board the day before the election period began and vowed to “bust a gut” to make sure the new blueprint would be before her “by next year”, with a view to the start of building work in 2028.

There was better news early this month, in contrast, when she confirmed that NHS Forth Valley has now fully exited the special measures imposed under then-health secretary Humza Yousaf in late 2022 amid concerns over leadership and performance.

But that was not before her former colleague Michael Matheson – another former health secretary – had his say on the planned NHS reforms, telling Scotland Tonight: “If you think that changing the number of health boards from 14 to two is going to improve patients’ outcomes, then my view is that’s fool’s gold and it won’t deliver that for you.”

Constance says his full comments had more “nuance” than is contained in that line alone. But, brushing off its content, she asserts her authority. “I don’t get uptight or agitated about the comments anybody makes, whether they’re former colleagues or not,” she says. 

There are, I believe, compelling arguments to be made for a two-board structure

“The reality is right here, right now, I am the health secretary, I have a situation in front of me and there is a clear case for the simplification of our National Health Service. And if we are all honest and we tried to sit down with a blank piece of paper, would we create a system with 13 territorial health boards, seven special boards and 31 health and social care partnerships, 31 integrated joint boards and a system where we have 84 accountable officers? I suspect we wouldn’t for a country our size. 

“There are, I believe, compelling arguments to be made for a two-board structure that’s built on the work that has already commenced.”

While Constance is speaking, her party is reacting to the latest comments by Prime Minister Andy Burnham on the legal triggers for an independence referendum.

At the day’s PMQs, Burnham compared the situation in Scotland with that of the Good Friday Agreement, which provides grounds for consideration of a border poll “when there is clear consensus in the country”. “I would say that it is exactly the same situation in Scotland,” Burnham said in a reply to the SNP’s Chris Law. “I am not aware that there is majority public support for another referendum, and until that changes there will not be one.”

The comments looked like a shift in position from a man who has previously ruled out any prospect of such a vote, and the Scottish Government seized upon them before Burnham later reiterated by letter to John Swinney that indyref2 is “off limits”.

Constance says that “for a long time Westminster politicians have just run away” from what is a much-debated question in Scottish politics. 

“There’s always been a lot of focus on nationalists, people like me who believe in independence to their core but also who ultimately believe that Scotland has the right to vote on her own future. There’s always been a focus on the Yes movement to have the solution – to have all the answers,” she says. But in her view “it’s on the ones who would continue to deny Scots have a legal right to decide” to provide some answers themselves. 

“If this is meant to be a democracy, there has to be a legal right for the people of Scotland to have their say,” Constance says. “If you ask most people, irrespective of their views on independence, the vast majority of people accept the principle that Scotland has the right to decide.”

I’m not fearful of describing myself as a nationalist because I am a Scottish nationalist

Constance says she is “old enough to remember the Scottish Constitutional Convention” (SCC), the cross-party body which included trade unions, business groups and faith organisations all aligned in support of devolution. More than just a talking shop, the SCC developed proposals for how devolution would work and included everyone from Scottish Labour to the Scottish Greens.

The whole project rested on mutual respect, Constance suggests, and she calls herself an “instinctive nationalist”. It’s not a term that all in her party are easy with, despite the SNP’s name and ideology. “I know,” she says, “it’s just how I describe myself. 

“I’m not fearful of describing myself as a nationalist because I am a Scottish nationalist – I’m a civic nationalist. I want the best of partnerships, the best of relationships with our nearest friends and neighbours in the rest of the UK. We will always be a geographical island and we will always have shared interests, but I’m a Scot who believes in independence. 

“I accept and I hope I’m always respectful to the fact that there are other people who wouldn’t describe themselves as a nationalist. I don’t have any complaint or issue with that. I hope I’ve always been respectful to those who support the status quo and the Union. At the end of the day, I will never demur from my belief. I have believed it since the late 1970s, since a debate in my primary school about the first referendum in 1979.”

Whatever she was like as a schoolgirl, Constance says she is now “roaring through [her] fifties”, and credits ageing with sharpening her focus. “I do think you evolve with age”, she says.
If you ask her if she had any qualms about taking on the health job, she will fix you with a look and tell you she is “delighted to serve” her country. Were there no concerns about accepting John Swinney’s job offer? The answer is in the fact she’s in the post, she says. 

“People speak of a postcode lottery, of the inequity in parts of the country. NHS simplification is the way to address that,” she says of her reform programme. 

She’ll need to work with public service reform secretary Ivan McKee on what goes ahead. Appearing before the dedicated committee, McKee was asked about the “number in mind” for NHS savings. “Ms Constance leads on that,” he told the panel, noting that while there are “no doubt” some “considerable” savings possible, improvements in care are “the bigger driver for the consolidation of health boards”.

Constance agrees that the current system presents barriers to care for some patients. “Every week I look at the performance statistics, health board by health board, specialism by specialism,” she says. “What we see is that some health boards will be doing very well in terms of activity and reducing waiting times in some specialisms and not others.” It’s an argument for pooling resources, she says, and allowing people to go outwith their local area where quicker care is available. 

we need to confront the reality that we can and should be doing things better

“Not every patient will want to travel for treatment,” she says, “but many patients do prefer to travel if it means they can get their hip or knee operation quicker.”

She’s inspired by “pacy” programmes like Discharge Without Delay, the NHS Tayside initiative which aims to reduce bed blocking and sees a release plan made for in-patients at the outset of their hospital stays, subject to revisions. It’s the kind of thinking Constance wants to see applied across the country. 

Scotland, she says, is “the ideal size” for reform of the kind that she’s begun. “We are not too big, and we are not too wee. But we need to confront the reality that we can and should be doing things better.

“Our health and our care system is in my view the most precious public service. We need to protect it for the future.”