Why prevention, power-sharing and relentless implementation must shape Scotland’s next chapter
Scotland’s public services are at a defining moment. For people waiting too long for support, families navigating systems that were not designed around them, and communities living with widening inequalities, reform cannot be abstract. It must begin with people’s lives, not structures.
Structures, finance and governance matter, but they are not the point. The real test is whether people can live well, recover well, stay connected, contribute, and get support at the right time. If reform cannot answer that test, it risks becoming another exercise people experience from the outside.
When it comes to money, let’s focus on making the most of what we have—not assume that more automatically means better. We need to tackle inefficiency, use funds wisely, and ensure any cuts are clearly justified and transparent.
Form should follow function
Scotland’s public bodies and arrangements may need review, but there is a difference between reform that changes how things work and restructuring that simply moves lines on a chart. If governance changes but activity does not, outcomes are unlikely to shift.
Any restructuring should be clear about the problem it is solving, the outcome it will deliver, and how impact will be measured. Fiscal sustainability matters, but if reform is only about money, rather than better health, stronger communities and improved outcomes, it becomes a distraction rather than part of the solution.
Less “world class”, more clarity of action
Government documents often speak of “world class” services and outcomes. The instinct is understandable, but the phrase is too easy to repeat and too hard to measure. Scotland needs a clear-eyed account of where we are, the gap we need to close, the action we will take, who will take it, how it will be funded and what we will measure.
That is not a lack of ambition. It is ambition with a route map. Scotland has an implementation problem, and aspiration alone will not solve it.
Reform must be preventative
Too often, public services respond late. When someone is already in crisis, when an admission might have been avoided, or when confidence, mobility and connection have already been lost. Reform must shift power, attention and investment upstream to prevention, early intervention, rehabilitation, supported self-management and community-based support.
This is not a soft option. It is the practical route to better outcomes and more sustainable services. People living with long-term conditions often need trusted, consistent support close to home more than another process, referral or wait. When support is designed around what matters to people, it eases pressure on acute services and helps people regain confidence, independence and quality of life.
The work of Sir Michael Marmot and the Collaboration for Health Equity Scotland places, the principle of proportionate universalism, and the inverse care law all matter here. Need is not evenly distributed. Universal support must be delivered at a scale and intensity proportionate to inequality, and services are still too often least available to those who need them most. These should be criteria for prioritisation, not academic footnotes.
Relentless implementation
At Chest Heart & Stroke Scotland, our ambition is No Life Half Lived. In our first strategy in 2018, we quoted Jack Welch: “In real life, strategy is actually very straightforward. You pick a general direction and implement like hell.” It still resonates because the hard part of reform is rarely agreeing that prevention matters or that services should be joined up. The hard part is implementation.
What is the action? Who is taking it? How will it be funded? What will stop so something better can start? What measures will show whether lives are improving? Reform requires fierce competence: the disciplined ability to make choices, follow through, learn quickly and stay focused on the lives people are trying to lead.
Partnership must be real
The third sector cannot be invited in only after decisions have been made. Organisations like CHSS bring reach, trust, evidence and lived experience into the rooms where decisions are made. If reform is to work, those strengths must shape service design from the beginning.
The handling of third sector voting rights on Integration Joint Boards raised a deeper question about whether voluntary organisations are seen as part of the system or merely useful delivery capacity at its edge. If voluntary organisations are expected to help deliver reform, they must also help shape decisions, set priorities and share accountability.
Partnership means shared purpose, shared accountability and a willingness to share power. It means NHS, social care, local government, communities and voluntary organisations working around the person, rather than expecting the person to navigate between us. It also means treating lived experience as evidence that should influence decisions.
Leadership, workforce and engagement
Reform needs a broader understanding of leadership. Leaders are not defined only by title or sector. Leadership is present wherever people take responsibility for change, build trust, make sense of uncertainty and help others act. When leadership is in play, it should be supported, not suppressed.
We also need to name power honestly. Some senior leaders appear to hold influence, yet often feel they do not have the agency to create change. Whether that is real or perceived, it matters. If those at the top do not believe they can make decisions and act, how can the wider system be expected to?
The voluntary sector also brings a diverse leadership cohort that can contribute to reform. Charities are mission-led and often close to communities; public bodies are rightly scrutinised and accountable in specific ways. We should not need every sector to look the same to learn from one another. CHSS has existed for more than 125 years, longer than the NHS and many of Scotland’s public bodies. There is insight to share if we are willing to break bread, trust and listen.
Workforce planning will be one of the hardest tests. People are our most valuable and expensive resource, and good work strengthens wellbeing and shared economic effort. But planning cannot be based only on the options leaders are told they do not have. Taking compulsory redundancy off the table so quickly after the Programme for Government was published may offer reassurance, but it also risks limiting the ability to reshape services honestly and effectively. The Scottish Government approach to workforce planning rightly came under scrutiny from both Stephen Boyd [IPPR] and Stephen Boyle [Auditor General] at their evidence session at the Public Service Reform committee. If we start with an ineffective and inefficient approach, we will hardly meet the objectives we so desperately want to see achieved.
That challenge is not confined to the public sector. Voluntary organisations often face cost pressures that are not matched by funding arrangements. If public sector protections are maintained while voluntary sector partners absorb reductions, charities close and services disappear. Outsourcing headcount and budget reduction through the voluntary sector is not sustainable, fair or credible.
Engagement takes time, but not engaging costs more. At CHSS, listening to people with lived experience has not always been comfortable, but it has made our work stronger. Public services need the same discipline: not consultation as theatre, but engagement that changes decisions, resource flows and delivery.
Values are delivery tools
Values are sometimes treated as decoration, as words on a poster or a corporate powerpoint slide. At CHSS, our values push us to be agile, accountable and led by people with lived experience. They require us to listen carefully, act with pace, focus on impact and be honest about what is and is not working.
If Scotland is serious about reform, it must create the conditions for public services and community partners to work in that way. That means trusting frontline teams, valuing community capacity and holding the whole system accountable for outcomes that matter to people: dignity, confidence, connection, recovery and the ability to live well.
The CHSS whole systems model
For long-term conditions, reform must connect every stage of the journey: prevention, early diagnosis, treatment, rehabilitation, supported self-management and living well in the community. The CHSS Community Healthcare Support Service is a whole systems model built around that principle. It contributes community reach, trusted relationships, evidence, lived experience and practical support.
We have spent several years developing, testing and delivering this approach, including shifting investment into more preventative and people-centred support. We have been through many of the changes and challenges our public sector colleagues now face. Reform may feel less daunting if we work more closely together.
Who better to contribute to reform than voluntary sector organisations and leaders already working in whole-systems ways every day? If Scotland wants population health reform to move from document to real-life application, it must include those already connecting prevention, rehabilitation, self-management and community support.
Conclusion: from ambition to action
Leadership in this moment requires more than support for the idea of reform. It requires courage to move resources upstream, humility to share power, persistence to keep people’s experience at the centre, and the willingness to reject false choices between prevention and treatment, community support and clinical care, efficiency and compassion.
Public service reform should be judged by whether it helps people live the life they want to lead. For the one in five people in Scotland living with chest, heart and stroke conditions or Long Covid, reform cannot be abstract. It must mean timely rehabilitation, trusted advice, supported self-management, connection to community and services that see the whole person.
The promise of reform is a Scotland where services are more human, preventative and joined up. The risk is that reform becomes another programme people experience from the outside. We should choose the harder, better path: reform co-designed with people, delivered through genuine partnership and measured by whether lives are improved.
That is the spirit of No Life Half Lived. It is also the leadership Scotland’s public services need now: practical hope, rooted in people’s lives, matched by urgency and delivered with the competence to make change real.
Jane-Claire Judson is CEO of Chest Heart & Stroke Scotland