Governance for Scotland’s health system needs to be strengthened amid concerns the current arrangements do not provide sufficient scrutiny or oversight, according to the auditor general.
Stephen Boyle said changes to need to be made to accountability regimes in order for a national reform programme to be delivered ‘at scale’.
“The delivery of NHS services must be reformed for Scotland’s health service to remain affordable and sustainable,” Boyle said today in a new report looking into how governance works for the country’s 22 health boards, including 14 territorial boards.
“NHS Scotland’s governance arrangements are key to delivering that reform, but they need to be strengthened. The planning of healthcare in Scotland is becoming more complex and the Scottish Government needs to ensure lines of accountability and decision-making are clear.”
A range of governance groups are in place across NHS Scotland but there are ‘weaknesses’ within the scrutiny and assurance processes at the Scottish Government level. This risk could be reduced by making greater use of non-executive directors to provide more challenge, Boyle, pictured below, recommended.
The planning and governance of healthcare in Scotland is becoming more complex, and this limits NHS boards’ ability to drive reform. The mix of local, regional, and national partners makes decision making and accountability difficult. The report also highlighted the inconsistency of governance across health boards: some were flagged for having put effective regimes in place, such as NHS Lanarkshire and the Scottish Ambulance Service, whereas governance, leadership and culture issues were raised in 2022 at NHS Forth Valley.
The board was de-escalated in October 2024 with the Scottish Government reporting that there was a ‘stronger sense of team working across health and social care, supporting the reduction in unfunded beds and improved performance in a number of areas’.
The report also highlighted a ‘high turnover’ rate of NHS board chief executives during 2023/24 and 2024/25. Twelve new chief executives have been appointed, including ten new chief executives for territorial boards.
A new planning framework has been introduced by the Scottish Government and new national strategies for reform are due in 2025. Dealing with this change will be challenging for boards, but it should give them more clarity and help them to work more collaboratively to deliver reform, added Boyle.
NHS boards use a blueprint for good governance that was produced in partnership with the Scottish Government. The blueprint has been well received but there is scope for it to be strengthened to more clearly set out how board governance should be adapted to deliver reform.
Neil Gray, health secretary, said: “I acknowledge the Auditor General’s spotlight report on governance in the NHS in Scotland.
“This supports the approach we have already set out for protecting, strengthening and renewing our National Health Service. The recently published operational improvement plan that focuses on the four key areas of improving access to treatment; shifting the balance of care; digital and technological innovation; and prevention, along with the forthcoming publication of a population health framework and a health and social care service renewal framework in June, establishes a clear path.
“In order to ensure this modernisation and renewal of our services is supported, good governance will be key and the Scottish Government will work closely with NHS Boards to ensure we deliver on our ambitions.”
Earlier this year, the Scottish Labour Party said it would cut the number of the health boards in Scotland to three, as it signalled its intent to put NHS reform on the agenda ahead of the Holyrood elections next year.
Jackie Baillie, the party’s health spokesperson, said: “Scotland’s NHS is at breaking point and patients and staff across Scotland are suffering the consequences of the SNP’s failure.
“The status quo won’t cut it, but the SNP’s overcrowded and bureaucratic structures are standing in the way of modernisation and hindering accountability. A Scottish Labour government will cut the number of health boards, reduce bureaucracy and red tape, improve accountability, put patients and frontline services first, and build an NHS that is truly fit for the future.”
