Scotland risks tolerating the “managed decline” of all public services unless a clear plan is launched to reform the NHS, social care and the benefits system, the spending watchdog has concluded.
Stephen Boyle, auditor general for Scotland, said the quality of schools, policing, justice, waste disposal and other systems vital to society are all under threat without major changes to these three big areas which account for more than 50 per cent of spending.
In a stark warning, he said it was “unfortunate” that Scotland was “not yet further forward in setting out the clear vision for how health and social care [and other] public services will be delivered in the future”.
“Where do we spend public money? When you take out health and social care and now social security spending? There’s not that much left,” he added. “And if we’re not progressing at pace with change and reform for those first two, it has significant ramifications for other public services.”
His cautionary message followed revelations that Caroline Lamb, Scottish NHS chief executive, has ordered all health boards to cut down on free prescriptions and procedures of limited clinical value due to a £500 million hole in NHS finances this year. In a letter to NHS managers last month, Lamb warned that the overspend in health and social care threatened to drag the entire Scottish government budget into the red.
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The NHS Scotland budget for 2024-25 is £19.5 billion and accounts for about 40 per cent of outgoings. Combined with social security spending, the total outlay reaches £26.2 billion. Spending on social care has previously been estimated by Audit Scotland to reach £5 billion.
In an interview with The Sunday Times, Boyle said the public does not need auditors to tell them the NHS is struggling and he feels patients’ relationship with the NHS — previously a “national religion” — is “fraying”.
The last Audit Scotland report on the health service found only three of the SNP’s eight waiting times targets had been met in the past five years. Performance against the goal to treat cancer patients urgently referred to hospital was described as “poor”. Hopes of cutting the number of patients stuck in hospital when they are ready to be discharged to 1,550 were also dashed.
“I think a lot of it screams that this is a system that’s not working,” he said. His investigations have found an absence of coherent strategic planning for the future of health and care, he said.
“I don’t wish to oversimplify what is an enormously complex system of how we deliver health and social care,” said Boyle. “But what is clear to us when we do our work is that the current model we have is not sustainable. And it’s not just about the sustainability of health and social care. Before long, I think we’re already seeing it, it’s the sustainability of other public services. But the key lies in the reform of health and social care. Getting that bit right first unlocks how we’ll deliver a sustainable range of public services across the piece.”
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While he did not endorse other healthcare funding models such as charging the most affluent for aspects of treatment, Boyle said: “What we’re clear about is the current set-up is not one that’s going to deliver high-quality outcomes and sustainable public finances.”
In 2022, the BBC revealed how NHS leaders in Scotland had discussed abandoning the founding principles of the service by having the wealthy pay for treatment. The discussion of a “two-tier” health service is mentioned in draft minutes of a meeting of Scotland’s NHS leaders in September. They also raised the possibility of curtailing some free prescriptions.
Nicola Sturgeon, the former first minister, said the principles of the NHS were “not up for debate”. Referencing the story, Boyle said debates about affordable, sustainable models that deliver better outcomes “are exactly the type of conversations that leaders need to be having”.
