Despite more staff and money, the NHS in Scotland is still not improving in line with Scottish Government commitments, the financial watchdog has warned.

Audit Scotland said that, although health boards have made unprecedented savings, the NHS in Scotland remains financially unsustainable, with seven health boards needing government loans last year.

Auditor-general Stephen Boyle welcomed Scottish Government plans and frameworks for reforming the NHS but said there was a persistent implementation gap between policy ambitions dating back more than a decade and delivery on the ground.

‘Despite increased spending, the NHS in Scotland remains unsustainable and it will be extremely challenging to eradicate long waits by the spring of 2026,’ he said.

‘This time round, it’s vital that the Scottish Government delivers on its reform plans. That means publicly setting out the detailed, measurable actions that will enable change and help everyone understand how a different health service will work.’

Delivery gap

Nora Murray-Cavanagh, deputy chair of BMA Scotland, said the report exposed the widening gap between ambition and delivery and the chronic mismatch between resource and demand in the NHS.

‘For too long, Scotland has lacked serious long-term planning for health and social care and consideration towards what will make our NHS sustainable and future proof. We now have yet another report making it clear that this warning can no longer be ignored. We cannot once again discuss it briefly and move on, if we do so it will be at our peril. Audit Scotland’s conclusion is stark: the current model of healthcare delivery is not sustainable in the face of rising pressures.’

Murray-Cavanagh, a GP in Edinburgh, said Audit Scotland’s finding that the NHS remains financially unsustainable even after unprecedented savings showed that ‘more of the same’ was not an option.

‘We cannot keep expecting the NHS to meet every demand while hoping problems resolve themselves. Without strategic planning, genuine consultation and critically, meaningful reform, the system will eventually fail. Additional investment is always welcome, but fundamental change – especially the long-promised and essential shift of care into the community – must be delivered. The recent funding deal for general practice is a positive start but is only the first step.

Community services need real resource while ensuring secondary care, already at breaking point, is protected.’

Ambition paused

The report paints a picture of a health service struggling to deliver. Only three of the eight waiting times standards are being met and five have seen a drop in performance.  

Audit Scotland says performance continues to be hit by factors including a backlog in planned care and the availability of staff and beds. It also warns a standard – that patients should wait no longer than 18 weeks from referral to treatment – had been paused since March 2025.

‘While there has been a shift in focus to waits over 52 weeks, the likelihood of meeting waiting times standards in the short term remains low.’

Health secretary Neil Gray said good progress was being made in transforming Scotland’s health services. He pointed to record numbers of hip and knee operations and said that long waits of more than 52 weeks had reduced for five consecutive months. He also highlighted investment in shifting care from acute to community settings, more money for general practice and increased Hospital at Home capacity.

Persistent inequality

Other issues highlighted in the report include health inequalities and the impact on staff of working in a system where demand is consistently high. Dr Murray-Cavanagh said staff must feel valued and supported.

‘It is deeply concerning, but sadly unsurprising, that ongoing pressure is creating patient-safety risks. BMA Scotland’s recent wellbeing survey found one in four consultant and SAS doctors reporting that services in their area are normally unsafe, a finding echoed by Audit Scotland.

'The growing struggle to meet demand is also taking a clear toll on staff, with sickness absence hitting a record high in the year to June 2025. These issues reflect a system trapped in short-term firefighting rather than long-term strategy.’

Turning the NHS around ‘will require honest, brave conversations’ and actually delivering on change, she added. ‘Scotland now needs reform: a decisive shift to a forward-looking, sustainable approach – one that protects patients, supports staff and addresses deep-rooted inequalities.’