The Cabinet Secretary for Health and Social Care sets out why the Scottish Government is pursuing NHS reform
It takes hard work to make something simple.
In a system as complex as NHS Scotland, treating millions of people with thousands of different needs, it is tempting to think that complexity is the price of scale. I disagree. The harder we work at simplifying how care is delivered, the better that care becomes. That is the principle behind the reforms I am pursuing.
Since taking on the role of Health Secretary, I have heard every week from clinicians and patients about the same problem. A health and care system tangled in bureaucracy, preventing good people from doing their jobs properly. I hear it from a brain cancer specialist trying to get a patient onto a clinical trial. I hear it from a discharge team trying to move a patient ten minutes down the road.
This needs to change. That is why the government has set out our intention to move from 14 territorial health boards to two strategic boards, with a geographical spread right across our mainland, highlands and islands.
I want an NHS where it doesn't matter which side of a health board boundary you live on. I want front-line staff spending their time and skills on patients, not on navigating multiple different versions of the same process.
Scotland currently has 14 territorial health boards, 32 local authorities, 31 health and social care partnerships and 84 accountable officers across our health and care system.
There are too many layers, too much duplication and too much variation for patients based on where they live.
For example, the Queen Elizabeth University Hospital in Glasgow must work with six different health and social care partnerships just to discharge patients from hospital. Tayside and Fife sit next door to one another, yet moving a patient between them can mean multiple layers of approval.
That is not a system designed around people. It is a system designed around structures, and it is costing us dearly. Delayed discharge alone is estimated to cost at least £440 million a year - money that should be going into care, not into managing complexity.
I know there are legitimate questions.
Will this mean centralisation? No. It is the opposite. This is about reducing the variation in how services are delivered across Scotland, investing in our communities and care closer to home, through models like Hospital at Home, so that people are treated on their own doorstep wherever possible, not funnelled toward the centre.
Will the unique needs of rural and island communities be lost in a bigger structure? No. We know our rural and island communities need bespoke arrangements, and we will take that into account as we develop these proposals. Reform will not mean rural communities are forgotten.
Is this a cover for job losses? No. Simplifying our NHS is not a numbers exercise, and I will not begin this work from a spreadsheet. We have commitments to no compulsory redundancies and to fair work principles, and they will hold.
This is not just about an organisational chart. Fundamentally, this is about improving services for people. It is about making sure that a patient calling NHS 24 does not have to repeat their story because their local board's data cannot be seen by anyone else. It is about giving people one continuous journey through health and care, instead of passing them from pillar to post.
This work has already started. Over the past year, our health boards have already been working together across two sub-national structures, east and west, and it is working. Long waits for outpatient appointments have come down substantially in the last year. Activity across the NHS is up.
As well as improving productivity, closer collaboration between boards can genuinely improve care. But voluntary collaboration can only take us so far. Without structural change, progress will always be fragile, dependent on goodwill rather than design.
We cannot, of course, reform the NHS in isolation. We must also reform how social care is delivered. We will require partners from local government, the third sector and, most importantly, the people who use and deliver social care and social work services to agree the next phase of reform.
Nothing about the detail is fixed. We have very deliberately not come forward with a fully formed programme, to allow local communities and staff to properly shape these plans. But the direction is clear.
Change needs to happen. Under this Government, NHS staffing is up by nearly 30 per cent over the past two decades and health and social care budgets now stand at a record £22.5 billion - yet demand on our NHS continue to rise along with pressure across the system.
We owe it to patients and to the extraordinary people who work in health and social care to build something more sustainable that we can pass on to the next generation with confidence.
Our NHS was a hard-won gain of the post-war era. It is precious, to me and to this country. But if we do not change, we run the risk of losing everything we have worked so hard to build. Simply put, the status quo is not an option. The NHS was created for the people, and it is time to put people first.
Angela Constance, Cabinet Secretary for Health and Care, Scottish Government