HEALTH bosses will be forced to make cutbacks worth up to £450 million over the next two years, according to a report compiled by NHS finance directors.

The document shows NHS managers will have to find savings of between £400m and £450m by April 2017 and warns health boards do not have the powers to make the changes they believe are required to balance the books.

It was compiled by health board finance directors and John Matheson, director of finance for health and social care with the Scottish Government, and is due to be presented at meetings involving top NHS executives.

The report has been leaked days before the referendum as some health service staff are increasingly frustrated by suggestions from Yes campaigners that Scotland needs independence to protect NHS funding.

In the document, the finance ­directors raise concerns that issues such as smaller annual budget increases, the growing elderly population and the rising bill for drugs are already putting resources under massive pressure. The paper lists these along with other financial obligations as the reasons for the shortfall, which it says will force managers to find savings equating to about 3.5 per cent of the total budget.

It says there is a "projected change in the financial position which will require boards to achieve cash-­releasing savings ... at a level significantly in excess of that previously required and without the mandate and authority to implement the scale of change and redesign required."

It also implies a pressing need to centralise services, like A&E departments or some forms of specialist ­treatment. The report says there is agreement across managers and clinicians that "radical and urgent decisions need to be made regarding the shape and configuration of services. The status quo and preservation of existing models of care are no longer an option given the pressing challenges we face."

This is not only because patient numbers are growing at a time of tighter public spending, but also because of a shortage of doctors. The report demands a "frank and realistic appraisal of future workforce requirements".

The Herald's NHS Time for Action campaign is similarly calling for a review of capacity in both health and social care services to ensure staff and resources are in the right place at the right time to cope with the rising number of frail elderly people.

In the leaked report, the Scottish Government is tacitly accused of making policy decisions that require health boards to keep spending more on hospital services, when the unanimous vision for the future of NHS Scotland is to look after patients better at home.

The document says that "continued commitments are being made which are directing increasing levels of resource into hospital- based provision counter to the ambition for enhancing preventative/ self-care and local community-based provision."

These commitments include the legally binding waiting-time guarantee, the creation of four trauma centres and maintaining current numbers of hospital beds and nurses.

It calls for the NHS to "stop investing time and resource" on marginal initiatives and focus on the actions that will make a difference.

A Scottish Government spokeswoman added: "Like all healthcare systems around the world, Scotland's NHS needs to continue ­evolving. This is why we have already legislated to integrate health and social care, delivering the new Glasgow Southern and are planned further investment in Aberdeen to transform cancer and maternity services."

"With a record number of staff working in the NHS and our world-leading patient safety programme, Scotland's NHS is delivering real changes for patients."