It painted a picture of a system where the basic funding model no longer reflects demand, and the demographics of an ageing population are shifting the goalposts ever further away.

None of this is a surprise, but some of the figures are worth reflecting on.

Money

Calum Campbell, chief executive at NHS Lothian, noted that the health board had entered 2023/24 with a funding gap of £52 million compared to £28m last year.

The "largest part of that problem", he added, was down to what is known as 'NRAC' – the NHSScotland Resource Allocation Committee formula developed between 2005 and 2007 and implemented in 2009 as a way of calculating each health board's "fair share" of resources.

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It is based on weighing up the number of residents against their age, sex, deprivation, burden of disease and excess costs associated with issues like rurality.

Over time, however, it has slipped. By 2021, eight out of the 11 mainland boards were losing out. Fife, for example, has racked up a cumulative shortfall of around £100m.

Lothian has been hobbled by a double-whammy of the fastest growing population in Scotland (twice the national average) and a rapidly ageing population.

This is resulting in what Mr Campbell dubbed a "care deficit". Lothian's population has grown by 156,000 in the past 15 years, which should equate to 21 extra GP practices; instead the region's GP workforce is shrinking and surgeries are folding at one of the fastest rates in the country.

The A&E department at the Royal Infirmary of Edinburgh (RIE) – built to handle 85,000 people a year – is dealing with 120-130,000.

Given that National Records of Scotland anticipate that 84% of Scotland's population growth will occur in Lothian by 2033, the outlook is daunting.

Mr Campbell added: "When I talk about our sites currently being full and pressure, that's why I'm saying there's been a care deficit, the largest population growth will be in Lothian and the sites are already full."

Professor Caroline Hiscox, the chief executive at NHS Grampian, revealed that bed occupancy in Aberdeen Royal Infirmary was running at 106% in the final week of May – a level that would once have been unheard of even in winter (the optimal threshold for patient safety is 87%). She added that NHS Grampian, which has its own issues with NRAC, would "not be in a position to balance revenue against expenditure over the next five years".

There has been repeated talk of NRAC reviews and reform, but for now there is no sign of any imminent change.

Costs

Various factors are pushing up health board costs. The ageing population is one.

In Fife, the number of people over 65 is projected to increase 30% by 2043. These changing demographics are already feeding into the bill for medicines – the second biggest expense for the NHS after staff.

Carol Potter, chief executive at NHS Fife, noted that it had experienced a "12% increase in the cost and volume" of its spending on drugs as a result of more elderly patients.

On top of this, Public Health Scotland forecasts that the burden of disease will grow by 21% over the next 20 years despite the total size of Scotland's population reducing. There will be fewer of us, but we will be proportionately older and sicker – partly also due to a legacy of obesity. A rise in cardiovascular diseases, cancers, and neurological diseases will account for more two thirds of the increase.

None of this bodes well for a health service which is already cash-strapped and struggling to cope.

In the here and now, some health boards are also saddled with decades-old PFI contracts where, as Ms Potter put it, the "inflationary uplift tied into those contractual agreements [is] running much higher than the funding increases from Government".

Then there is staffing. The NHS has both record numbers of staff and record numbers of vacancies, and spending on agency nurses and medical locums is growing.

NHS Fife spent £45m out of its £900m budget – 5% – on supplementary staff last year (the combined cost of all agency and bank nurses and doctors). Reducing these costs to help balance the books is "a real priority", said Ms Potter. Achieving it will be another matter.

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