A TARGET-DRIVEN culture within the NHS is standing in the way of a radical overhaul that is needed to equip the health service for the challenges of the 21st century, according to a damning new report.

Audit Scotland warned that "fundamental changes" to the health service were needed to alleviate pressure and ensure the provision of high-quality services in the future in the face of soaring demand and a growing elderly population.

It said health boards were finding it increasingly difficult to meet key waiting times targets, with seven of nine missed and performance declining in recent years.

It also raised concern over increased staff vacancies and tightening budgets, reporting that total NHS spending had seen a real-terms cut of 0.7 per cent between 2008/09 and 2014/15.

According to the NHS in Scotland 2015 document, which called for health boards to be given greater financial autonomy, the "extensive effort and focus" on targets "may be detrimental to the longer-term ambitions of redesigning services" .

It found not enough progress was being made to achieve the Scottish Government's 2020 vision, a blueprint for changing the balance of care to a more preventative model which would see less use of acute hospitals and a greater focus on community-based care.

Shona Robison, the health secretary, admitted that the government needed to speed up the pace of change but added that staffing numbers were at a record high and Scotland's NHS offered some of the highest quality and safest healthcare in the world.

However, doctors said "substantive action" was needed to address the report's findings while opposition parties went on the attack over the SNP's record on the NHS.

Dr Peter Bennie, chairman of BMA Scotland, said: "The overriding message that must get through from this report is that substantive and realistic action is needed if our health service is to cope with the rapidly increasing pressures it is facing."

Ellen Hudson, Royal College of Nursing Scotland associate director, said Scottish Government performance targets and standards have "had their day" and called for a greater focus on the long-term sustainability of services.

The report found that the NHS was relying more on the private sector to treat patients, while it was increasingly turning to expensive agency staff to deal with high numbers of vacancies, with sickness absence and staff turnover also up. Many health boards are resorting to making one-off savings to hit financial targets, an approach that is unlikely to be sustainable.

Caroline Gardner, auditor general for Scotland, said: "We all depend on the NHS and its staff who provide high-quality care. But it will not be able to provide services as it does at present due to the number of pressures it faces within the current challenging financial environment.

"It is important that the Scottish Government and health boards work closely together to help alleviate these pressures and also increase the pace of change necessary to meet its longer-term ambitions."

Labour's public services spokeswoman Jackie Baillie said the report showed that despite the claims of SNP ministers, the health budget had fallen on the nationalists' watch. She added: "We are seeing an increased use of private staff to cover shifts and vacancies for A&E staff lying unfilled for six months. Under the SNP NHS staff are undervalued, under resourced and under intolerable pressure."

Ms Robison said she had recently announced a £60 million primary care fund as well as £200m to create six new elective treatment centres that would help health boards meet demand.

She added: "We have met and indeed exceeded our commitment to protect funding for front-line health services, with the total health budget growing to over £12 billion for the first time and resource spending growing by 5.8 per cent in real terms in the five years to 2015-16.

"We are carrying out far-reaching reforms to our health service, and we continue to consult on how these can be further developed."