Inflation, Covid, budget cuts – Is Scotland's NHS recovery crumbling?

Plans for a network of elective surgical and diagnostic hubs, known as National Treatment Centres, were a core element of the Scottish Government's NHS recovery plan.

Two years on, a report by Audit Scotland has warned that it is no longer clear whether all of the projects will go ahead and what the impact on costs – and waiting lists – will be.

What's happened to the 'NHS recovery'?

When the Scottish Government published its NHS recovery plan in August 2021, it envisioned that nine specialist hubs would become operational between 2022 and 2026.

These were to be standalone elective facilities dedicated to providing planned operations in areas which had accrued some of the worst backlogs during the pandemic, such as orthopaedics, general surgery, urology, and ophthalmology.

Some, such as Grampian's NTC in Aberdeen, would be focused on outpatients, scans, and endoscopy.

The objective was to ring-fence elective resources – staffing, theatres, and beds – in centres separate from acute hospital sites so that planned procedures would not be cancelled to free up space for emergency admissions.

This kind of arrangement already works well at Scotland's existing elective-only hospital, the Golden Jubilee in Clydebank, where the number of elective procedures carried out had already returned to pre-pandemic levels by the beginning of 2021.

In contrast, elective activity for NHS Scotland as a whole continues to lag 8% behind pre-pandemic levels. Instead of reducing, the number of people on inpatient/day case waiting lists has climbed to a record 149,255.

It was not supposed to be this way. The 2021 plans projected that new NTCs would be carrying out 19,000 inpatient and day case procedures by 2023/24, with activity in existing NHS facilities up by 15,500. Combined, that would have equated into a 13% increase in inpatient/day case activity compared to pre-Covid averages.

Then Omicron came along. A much more transmissible variant meant Covid outbreaks were harder to control – especially in older hospitals with open plan 'Nightingale' wards instead of single bay rooms – although there have been calls for tougher mitigations, such as high-grade FFP3 masks, improved ventilation, and much more extensive use of air filtration technologies in healthcare settings in a bid to minimise Covid-related disruption.

Figures obtained by The Herald revealed that at least 237 hospital wards were closed to new admissions between January and July this year due to Covid outbreaks, compared to 93 combined for all other infection control incidents (flu, RSV, norovirus etc).

On top of this has come the soaring cost of infrastructure projects due to inflation, net zero building standards, labour market shortages linked to Brexit, and global supply chain issues caused by Covid and the Ukraine war.

Finally, an anticipated 7% real-terms cut over the next three years in the capital block grant that Holyrood receives from the UK Government is leaving the Scottish Government facing difficult decisions on which infrastructure projects to fund, and how.

The original plan for NTCs laid out in the August 2021 NHS Recovery Plan (Image: ScotGovt)

Where does NTC plan stand now?

Since opening in March this year, Fife's NTC – specialising in orthopaedics – has carried out 807 planned procedures. Highland's 24-bed NTC, in Inverness, opened in April specialising in cataract surgery and hip and knee replacements.

There is no official data currently on how many procedures have taken place at the NTC, but overall elective activity in the Highland region was up 43% between May and August this year compared to the same period in 2022 – well ahead of increases for NHS Scotland as a whole.

Both centres can accept referrals from elsewhere in Scotland to help tackle the backlogs of patients who have been waiting more than two, or even three, years.

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Forth Valley's NTC, originally scheduled for 2022, is now aiming to be operational by the end of the year. The Golden Jubilee's expanded Surgical Centre – providing extra capacity for orthopaedics and general surgery – is also due to open this year.

Another two NTCs are subject to "scoping" exercises and four are in the "planning" phase (this includes a £123 million replacement eye hospital in Edinburgh, which is now counted as a tenth NTC).

Audit Scotland's infrastructure report, dated September 28 2023, highlighted question marks over the NTC plan (Image: Audit Scotland)

However, Audit Scotland says it is "not clear whether these six projects will go ahead and if they do, what the impact on cost will be".

The estimated price tag for NHS Tayside's NTC in Perth has ballooned by 117% and is expected to rise further once the business case is approved.

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The projected cost of Lothian's NTC, in Livingston, has also more than doubled from £70.9m to £184m.

NHS Ayrshire purchased Carrick Glen – a former private hospital – for £1.8 million and received planning permission in July to convert it into a NTC orthopaedics hub, but with the Scottish Government now assessing "the impact of market conditions" the redevelopment may be paused or revised.

Question marks similarly hang over the future of Grampian's NTC, originally due to open in 2025, and Lanarkshire's NTC in Cumbernauld, initially timetabled for 2026, not to mention the competing pressure of a £1.1 billion NHS estate maintenance backlog and an unknown bill for fixing RAAC.

Like the latter, the 2021 NHS recovery goals are crumbling.