Introduction
In August I wrote an article about the difficulties the Scottish government has had in developing strategies capable of guiding the much-needed transformation of health and social care in Scotland. Instead, my argument was that the various strategies the Scottish Government has produced over the years have not provided the kind of robust plans which set out in appropriate detail what has to change and how these changes could be brought about.
What follows are five proposed steps to improve the way the development of health strategy is pursued in Scotland, followed by consideration of what at heart is fundamental to major strategic change for health and social care.
Strategic Capacity And Expertise
The first step is to recognise that those individuals with a leading role in developing strategy really need the strategic skills and mindset to make it happen. It is perhaps not a sufficiently recognised specialist role. The role particularly requires the abilities to: vision/imagine the future, think long-term and identify what the critical factors are that help and/or impede major change, adopt a systems analysis perspective, employ data analysis, and have strong advocacy skills to address the differing views of stakeholders. Despite the significant number of people employed in the NHS in Scotland, the recruitment to key leadership positions appears to value an operational rather than a strategic outlook. Likewise, civil servants are principally concerned with political management and oversight of the NHS, including the important role of mediation among the various stakeholders, and the promotion of government policy to the media and public.
The result is an important under-representation of strategic skills and thinking in the government and NHS. Even where those developing strategy actually have such capabilities, the intense pressures on operational management and extensive scrutiny of performance are not an environment which creates the space for serious strategic development to happen or even be given priority. To change this position requires a radical change by recruiting or identifying a cadre of people who bring the right skills to strategy development, and equally importantly are free of operational demands to employ these skills. How this departure can best be achieved will require further consideration, especially around where such skills can be found.
Stakeholder Engagement And Strategy
A second step needed is to recognise that the dynamics of a strategy development process, which prioritises significant engagement of stakeholders, including different NHS Boards, professional groupings and public/patient interests, can lead to sub-optimal strategic outcomes. Stakeholder engagement is of course crucial to any serious attempt at fundamental change. However, the compromises involved in this process can lead to emphasising the position of particular interests at the expense of the wider collective benefit. One feature of this historically has been the tendency to provide ‘too many’ services in ‘too many’ locations. This not only presents additional financial costs but can also adversely affect service quality. An objective assessment should be undertaken by the strategy consultants proposed above to provide for each major strategy to incorporate a collective Scotland-wide perspective. This would highlight where there are significant benefits foregone by the system as a whole in responding to the requirements of achieving the agreement of stakeholders. Scotland has a longstanding health policy community, pre-dating devolution, upon which Scottish governments have shown considerable reliance historically. The policy community can work against bringing into the strategy process more independent or critical considerations which, given the severe pressures on the system, should become a more explicit part of strategy development.
Finance-Led Strategy
A third step in changing the approach to strategy development is to avoid being overly driven by short term financial constraints. Over the years I have observed that major strategic developments – as well as many smaller initiatives – often from the outset start with the question of ‘what can we afford?’ This confuses economy with efficiency. In simple terms, reducing a strategic programme’s cost by 20% may disproportionately affect its ability to get even near 80% of its original aims. There is a critical mass for any service to operate effectively. Shaving away at that often results in false economies and reduces the total impact of strategic change. To make sure that any strategic development produces high impact results, a review of the cost-benefit ratios against different investment levels should be undertaken to highlight where an optimum investment lies. This of course may restrict the number of initiatives that can be funded at any time, but again the argument is to look at the overall impact on the system and to recognise that different strategic changes will provide different levels of benefit that points to the need to prioritise.
Making Strategic Objectives Tighter
A fourth step-change is tackling the increasingly well recognised feature of many Scottish government policies, including health, of multiple objectives. The 2023 Scottish Government Mental Health and Wellbeing Strategy for example contained by my calculation 14 separate provisions on objectives and principles. This included a vision with nine outcomes, ten priorities along with related outcomes and associated challenges and opportunities, ten core principles, 20 policy priorities resulting from other strategies and a non-exhaustive list of 71 key policy drivers with which the Strategy has to connect. The strategy is just excessively complex and obscures what are the critical, top-level changes needed to give the whole endeavour a focus. Similarly, the Scottish Government-COSLAHealth & Social Care Service Renewal Framework 2025-2035 (June 2025) contains 71 objectives, commitments and changes of varying degrees of precision that overall is difficult to comprehend in terms of what is most important going forward – and that is without even attempting to address the interconnections and overlaps among the various objectives.
In addition to the matter of multiple objectives, there is also a tendency to have objectives that contain ambitions that are not supported by any proper consideration of feasibility. The Scottish Government’s NHS Recovery Plan 2021-2026 contained several such objectives. For example, there was a commitment to ‘design a new sustainable system, focused on reducing inequality and improving health and wellbeing outcomes, and sustainable communities’, one to support the needs of people with dementia to live well, including post diagnostic support, and another to reduce attendances at Emergency Departments by 15% to 20% – all without any detail on how these objectives could be made to happen.
The complexity and over ambition of objectives risk making it difficult to build programmes of change which are clear about the major strategic shifts required to secure transformation and how they will be delivered. There is a pressing need to streamline and better organise the way objectives are presented in strategies with fewer – certainly top line – objectives. Objectives also need to be presented in a measurable form, supported by an evidence-based plan of what is needed to achieve the objectives, backed by realistic timescales – all necessary to determine the feasibility of the objectives
Supporting Service Strategies With Resource Planning
The fifth and final step relates to strategic resource planning. While there is widespread recognition of the importance of strategic resource planning, this is not matched by the intensity with which it is undertaken. As an example, the already mentioned Financial Framework for the Mental Health and Wellbeing Strategy in looking forward did not contain any spending figures but only had a list of five ‘early priorities for investment’ presented without comment. The subsequent Mental Health and Wellbeing Strategy Delivery Plan and Workforce Action Plan – Update on Progress and Next Steps only included six statementson specific examples of additional spending. Some of these were ambiguous because they did not separate new funding from what was already being spent. Most importantly, there was no overall financial plan setting out past and future total spending on mental health analysed by relevant categories. It therefore proved difficult to understand the financial consequences for mental health of pursuing the whole strategy beyond the very short list of funding provisions included.
There are also causes for concern on workforce planning. The Mental Health and Wellbeing Strategy announced that a Mental Health and Wellbeing Workforce Action Plan would be published. That plan was subsequently included in the Update on Progress and Next Steps document. A list of activities around education and training and initiatives to attract staff to particular roles, all undoubtedly of benefit, was produced. However, the only additional staffing resources identified were some new psychology posts. The complete mental health workforce plan was not set out. This made it difficult to understand how the strategy’s aims, for instance the reduction in mental health inequalities, would be supported by any changes to the make-up of staffing or not. Similarly, in the Health & Social Care Service Renewal Framework 2025-2035, there is no workforce plan of any sort. Even the National Workforce Strategy for Health and Social Care in Scotland of March 2022 provides no overview of the planned changes to the numbers and make-up of the entire health and care workforce, and there is no way to link it to the Health & Social Care Service Renewal Framework. There is an urgent need to incorporate into strategies detailed and audited resource plans (finance, workforce, technology and estates). This will create a framework upon which to guide strategy as it is implemented without gaps and delays resulting from underdeveloped resource plans. It will also avoid missed opportunities for better services caused by the absence of the full resource base. At the same time, more attention needs to be given to making sure that service strategies are produced with the clarity necessary to calculate accurately future resource requirements.
Developing Strategic Planning
Audit Scotland in its NHS in Scotland 2024 report made a series of recommendations including that the Scottish Government publish a series of national strategies setting out a medium-term approach to health and social care reform ‘to provide greater certainty for boards as they prepare their plans.’ Current government strategies do not provide such certainty. In fact, when there is an increasing call for transformative change and major reform, strategies have shifted towards a more evidently incremental and gradualist approach. In essence, strategies have less strategic content. This reflects in large measure that health strategy essentially operates on an ‘existing service plus development’ basis. Change is delivered through add-ons. The tighter financial and other resource constraints have become, the more limited the opportunities to construct a strategy on an ‘existing service plus development’ basis becomes.
Strategy development now has to bring about a major drive to re-balance, re-structure and (in some cases) reinvent the health and social case system. This requires radical rethinking. There has to be a major reworking of the make-up of the type and range of services made available to citizens. The good news is that there is already a broad understanding and, to some degree, local experience of the types of services that are needed increasingly to help the process of change. Some of these will be long-standing and established, especially in primary care. Others will be more recently developed, less familiar services that will prove more challenging to roll out.
At its most fundamental, high-level form strategy should be built around a series of strategic imperatives. Each of these should capture a fundamental priority shift to the make-up of services required for the future. For the health and care system as a whole there might be only around half a dozen of them. Individual clinical and social services will have their own, more specific strategies which will obviously need to align appropriately with the necessity of meeting the top-level strategic imperatives.
One such potential strategic imperative which has been much discussed over many years is reducing the reliance upon inpatient care. It is essential to emphasise that this is not first and foremost about resources and funding but is about improved benefits that should drive and validate the strategic changes. In the case of reducing reliance on inpatient care there are many benefits for service users including: reduced risk of infection; less exposure to over-investigation and intensive treatments; less disconnection from home life; less disorientation and disablement; the opportunity to assess and manage people in the environment in which they normally live; quicker recovery; and better integration with other health and support services around a person’s home and community.
Therefore, the strategic change is about providing better experiences and outcomes for service users. Critically, there will also be a system benefit. Reducing reliance upon inpatient care shifts service provision on to alternatives whose costs are overall lower than those of existing inpatient care. At the same time different types of services can reduce health and social care needs through, for example, crisis and rapid response capability in the community, greater support for self-management to mitigate the incidence and severity of crises, health promotion to make people fitter, and highly integrated health and social care home support to reduce gaps and delays in care. The system becomes more cost-effective, increasing funds for meeting other needs that are not presently so well-placed.
Conclusion
To conclude the argument, there has to be a major improvement in the process of formulating strategy along the lines of the five steps set out above. However, what is required now is not just about improving strategy development against the range of ambitions currently published in strategy documents. There has to be a much more radical approach to what is required to deliver transformation than has ever been seen in the life of the NHS. This will require a highly sophisticated approach that maps out in significant detail how the make-up of services will change over a number of years in a way that overall provides increased benefits at lower cost and delivers long term sustainability. It will be imperative that new services are properly designed and supported by effective evaluation, consideration is given to managing interim double-running costs, and good information systems are in place to provide sound and timely feedback on progress. This will have to happen across a range of fundamental strategic imperatives. And of course, the delivery of services day to day and management of operational challenges will have to continue to be overseen. Most importantly of all, the Scottish Government has to make a very serious commitment to develop its capability to undertake the major strategic change needed. There is a lot to be done to build a strategic infrastructure.
Peter Williamson taught and researched health care policy and management at Aberdeen Medical School, was a strategy director for NHS Boards, and led policy work on health and innovation for the Scottish Government.
References
Gwyn Bevan The impacts of asymmetric devolution on health care in the four countries of the UK (The Health Foundation and Nuffield Trust, September 2014).
Scott Greer ‘Options and the Lack of Options: Healthcare Politics and Policy’, The Political Quarterly 79(1) (2008)
Audit Scotland NHS workforce planning: The clinical workforce in secondary care (July 2017).
Scottish Government NHS Recovery Plan 2021-2026 (June 2021)
Scottish Government-COSLA National Workforce Strategy for Health and Social Care in Scotland (March 2022)
Scottish Government-COSLA Mental Health and Wellbeing Strategy (June 2023)
Scottish Government-COSLA Health & Social Care Service Renewal Framework 2025-2035 (June 2025)
Scottish Government-COSLA Mental Health and Wellbeing Strategy Delivery Plan and Workforce Action Plan – Update on Progress and Next Steps (June 2025)