Picture of health: Can reform help restore Scotland's NHS?

S,Ps had just returned from their generous summer break when John Swinney announced what he called the most “radical reshaping” of public services since the establishment of the Scottish Parliament. Just over three months on from a Holyrood election where the idea was not floated once – at least not by his party – Swinney took a scalpel to Scotland’s NHS, cutting the number of health boards from 14 to two. 

The first minister spoke of the need to improve public services, the necessity for “simpler and more coherent decision-making structures”. His overhaul would improve access to care, he said, and reduce inequality for patients, ending what is often referred to as a “postcode lottery” of healthcare provision.

That such regional inequalities exist – even in a country as small as Scotland – can be in no doubt. On one of the most serious challenges facing the health service, cancer care, the length of time a patient waits before beginning treatment will depend, in part, on which area of the country they live in. While not a single health board is currently meeting the government’s 62-day target, 92 per cent of patients begin their treatment within that period in NHS Lanarkshire compared to just 61 per cent in NHS Tayside. 

But if health board reorganisation was the panacea to all that ails Scotland’s health service, then surely it would have been tried before now. When Scottish Labour suggested consolidating the number of boards, reducing their number to three, the idea was dismissed by the SNP, with then health secretary Neil Gray saying the process would be “torturous” and “too lengthy”.

“I agree with what Neil said,” says one former SNP health secretary who didn’t want to be named. “I don’t know why they’re doing it – you’re now going to get several years of internal wrangling and delayed decision making by boards because they don’t know what their future’s going to be.” 

In truth, the real imperative driving public service reform is financial rather than clinical. The Scottish Government faces a £5bn black hole in its £70bn annual budget by the end of the decade unless it cuts costs, a detail not mentioned in Swinney’s Programme for Government speech. Instead, the first minister set out the need to move to a preventive model of health care – something politicians have been talking about for decades – focusing on public health interventions, tackling child poverty and using initiatives such as Hospital at Home to reduce delayed discharge.

While the detail set out so far has been limited, the first minister said the current 14 health boards would be replaced by two “strategic health boards” for mainland Scotland, with separate plans being considered for the three island groups – Shetland, Orkney and the Western Isles. 
The job of delivering the new preventive model along with the board reorganisation falls to Angela Constance, the new health secretary who swapped jobs with Gray in the recent reshuffle. Earlier this month, she told parliament of the need to “embed prevention” across government and public services by using vaccination, screening, and working with charities to deliver heart and lung ‘MOTs’. 

There’s no real blueprint for the scale of reform that’s currently envisaged in Scotland’s NHS. The 14 territorial boards date back to 2001 when the last major reorganisation took place, the then Lib-Lab Scottish Executive scrapping the collection of 43 boards and trusts which existed previously. More recently, major public sector reform has included the reorganisation of Scotland’s colleges between 2012-2014 and the creation of Police Scotland and the Scottish Fire and Rescue Service through the merger of the previous regional services in 2013. 

Forced through by then education secretary Mike Russell, the college reorganisation – which saw their number cut from 41 in 2011 to 24 currently – was controversial and led to criticism the institutions had been repurposed incorrectly to focus purely on young learners and not those looking to upskill later in the careers. The overhaul has not put the sector on a more stable footing. A recent report from the auditor general found 19 incorporated colleges reported a combined deficit of £5.6m in 2024-25 – up from £1.3m in 2023-24 – and five institutions needed a cash advance from the Scottish Funding Council (SFC) that year. Meanwhile, student numbers have dropped by almost 16 per cent since 2022-23.

Police Scotland, formed through the merger of the previous regional forces, also endured a troublesome birth amid accusations the then chief constable Stephen House was attempting to foist a Strathclyde model of policing – a one-size-fits-all approach – on other areas of the country. Early high-profile controversies included the death of Lamara Bell in 2015 who was trapped in a crashed car alongside her dead partner, John Yuill, for three days at the side of the M9 due to errors in the nascent force’s call handling procedures. 

“I’ve certainly thought about the Police Scotland scenario as someone who lives and works in the Highlands,” says Dr Al Miles, deputy chair of BMA Scotland’s GP Committee. “It wasn’t helpful to Highland as far as we the community can see – we had good community policing before and then everything was standardised along a Strathclyde model… It doesn’t help crime detection and it doesn’t help crime prevention.

“I don’t think the population in the Highlands feel positive about Police Scotland in terms of what it’s meant for local communities and that’s one of the key risks of moving to two health boards managed from Edinburgh and Glasgow. How can they possibly understand the local needs in these far-flung parts of Scotland?” 

If Swinney has only just begun sketching out the ‘why’ of health board reorganisation, he’s not even touched the ‘how’ yet beyond reducing their overall number. Both he and his finance secretary Jenny Gilruth rule out compulsory redundancies but have repeatedly refused to put a figure on the number of posts they expect to see go. Given the lack of detail and the fact that none of this was in the SNP manifesto, it’s hard to avoid the suspicion this was a rushed job, a point made by Tory public service reform spokesman Murdo Fraser who said the proposals appear to have been “written on the back of a fag packet”.

“I completely agree with government that the NHS in Scotland needs restructuring and overhauling – there are inherent inefficiencies in the current setup – but it is really unclear to us how a proposal of two health boards was arrived at,” says Miles of the BMA. 

“It’s really unfortunate for staff working in the NHS because it has caused a huge amount of uncertainty amongst colleagues who work for health boards because they don’t know if they’re going to have a job or not. John Swinney has said there will be no compulsory redundancies but how you go about achieving economies without staff redundancies is really unclear.” 

As has happened in previous public service overhauls, there is an anticipation that jobs duplicated across health boards will be among those to be cut – non-clinical roles in management, HR, IT are among those cited. But there are those who believe this analysis – where so-called ‘back office’ functions are culled – doesn’t really stand up to scrutiny. Appearing before Holyrood’s new public service reform committee earlier this month, Stephen Boyd, director of the Institute for Public Policy Research (IPPR) Scotland, a think tank, said it was wrong to believe the public service is “bloated” and that significant numbers of people could be lost without it having an “impact on delivery”.

“I’m sceptical the target can be achieved,” he told MSPs. “If it is achieved, I worry about what that would mean for the quality of delivery.” He added that for many working in the public sector, the distinction between so-called ‘front office’ and ‘back office’ roles was a meaningless distinction they didn’t recognise.  

Reorganisation of how health is delivered is, however, just one part of public service reform. Ivan McKee, the minister with PSR in his job title, has called it the “defining task of this parliament” and has promised something radical, far beyond just “marginal changes”.  What that will look like remains to be seen but it’s likely that every area of government will be affected. 

In the same speech where he set out his plan for Scotland’s health boards, the first minister also began the conversation on the reorganisation of the country’s 32 councils – another idea which did not appear in the SNP manifesto. Indeed, the only mention of ‘local government’ in that document came in relation to helping councils mend potholes, although the SNP did commit to public sector reform and pledged to reduce the number of Scotland’s public bodies. 

“In Scotland today, we are faced with the reality that some of our councils are too small to be strategic, and some are too big to be local,” Swinney said in his Programme for Government speech. “The government believes that should change.”

The first minister has embarked on what he called a “three-month period of intense engagement” to listen to ideas about the restructuring of local government. Promising to keep an “open mind” and not be “overly prescriptive”, it is nevertheless clear the government’s preferred end point is one where there are considerably fewer local authorities. 

And you only need look at the SNP’s big election idea on health – walk-in clinics – to see what that listening mode might look like. Figures published over the summer show that despite claims the facilities would reduce pressure on GP surgeries and help end ‘the 8am rush’, attendance at walk-in clinics has been low, with just over 2,000 patients seen in a month across six centres. 

According to the statistics from Public Health Scotland, the Edinburgh clinic in Wester Hailes was the busiest, seeing the equivalent of around 28 patients a day – not far off the number seen by one GP in a busy surgery. Despite three professional bodies – the Royal College of General Practitioners Scotland (RCGP Scotland), the Royal College of Pharmacy (Scotland), and the Chartered Society of Physiotherapy Scotland – calling for a pause to the roll out of walk-in clinics, the government has vowed to press on with the creation of around 40 units across the country. 

Just like the walk-in clinics, the health board restructuring risks turning into a “big distraction”, according to the former SNP health
secretary. 

“I suspect this is something [the government] has come to quite late,” they said. “The danger is that organisations hit the pause button, they become internally focused and we won’t actually get a lot of benefit out of it by and large. I’m not entirely sure why we’ve decided to go down this particular route at this moment in time, given the performance issues we still have within NHS Scotland.”