A leading think tank has warned that performance in NHS Scotland "is still getting worse" more than three years after the Scottish Government first set out its Covid recovery plan.

In a scathing pre-Budget analysis comparing activity in Scotland's healthcare system to England, the Institute for Fiscal Studies noted that while both countries continue to lag behind their self-imposed recovery targets hospital activity in NHS England "is now substantially above pre-pandemic levels".

In contrast, Scottish activity "remains substantially below pre-pandemic levels".

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The IFS report found that acute hospitals in Scotland had delivered 15% fewer elective inpatient admissions (those requiring an overnight stay) between April and June this year compared to October to December 2019 - the last full quarter unaffected by the pandemic.

In addition, there were 9% fewer emergency inpatient admissions and 6% fewer outpatient appointments compared to the pre-Covid period.

Day case admissions - where a patient undergoes a hospital procedure and is discharged on the same day - have "increased substantially" over the past year and now slightly exceed pre-pandemic levels by 0.3%.

However, taken together, total inpatient and day case activity was 6% lower overall in April to June this year compared to October to December 2019.

The report adds that "at the rate of increase in activity seen over the last year, it would take another two years for inpatient and day case activity to just return to pre-pandemic levels, and three years for outpatient activity".

It notes that "this is not the case in England" where "hospital activity is now substantially above pre-pandemic levels".

Only day case admissions in NHS Scotland have fully recovered back to pre-pandemic levels Only day case admissions in NHS Scotland have fully recovered back to pre-pandemic levels (Image: Institute for Fiscal Studies) Between April and June this year, the IFS found that the number of elective admissions delivered in the English NHS was 8% higher than pre-pandemic, emergency admissions were 2% lower, and the number of outpatient appointments was 11% higher "despite the fact that hospital activity in England has been reduced by frequent and widespread industrial action, which has not occurred in Scotland".

Spending on health and social care accounts for around half of day-to-day public spending in Scotland, and spending on health per head has long been higher in Scotland than England.

The IFS says the decline in activity in NHS Scotland compared to pre-Covid is "unlikely" to be explained by staff shortages, with consultant numbers up by 13% and nurses and midwives up by 12% in June 2024 compared to June 2019.

The number of acute beds is up by 5%, although total NHS bed numbers - including those in community hospitals - is down by 1%.

It notes that delayed discharges and the average length of hospital have both increased, squeezing bed availability.

As of September, an average of 1,968 beds in the Scottish NHS were occupied by adults ready to leave hospital but waiting for support such as a care home place or home care package.

This is up by 29% compared to 1,521 in September 2019.

The NHS was hugely disrupted by the Covid pandemic in 2020, and by subsequent waves of the virusThe NHS was hugely disrupted by the Covid pandemic in 2020, and by subsequent waves of the virus (Image: Getty) The IFS stresses that in both Scotland and England, performance against the four-hour A&E target remains worse than before the pandemic and in both countries the number of people on waiting lists for an operation is significantly higher than it was in 2019.

But the report goes on to note that "there is a clearer difference between Scotland and England when it comes to performance over the last year".

It adds: "In Scotland, almost all measures of NHS performance have worsened over the last year.

"For example, the elective waiting list has continued to grow (from 692,000 in September 2023 to 725,000 in September 2024), and the share of patients waiting less than four hours at A&E has fallen slightly (from 66.5% in September 2023 to 65.9% in September 2024).

"The only measure considered that has improved in Scotland is for diagnostic tests, where the share waiting six weeks or less has risen (from 49.8% in September 2023 to 53.6% in September 2024).

"But in England, most measures have improved over the last year.

"For example, a smaller share of patients are waiting more than four hours at A&E, a larger share of patients are being treated within 62 days for cancer, and a larger share of patients are receiving diagnostic tests within six weeks.

"This therefore suggests that hospital performance is still worsening in Scotland, while it is improving in England."

Compared to before the Covid pandemic, performance against most targetCompared to before the Covid pandemic, performance against most targets is worse than before the pandemic for both Scotland and England. However, England has improved on most benchmarks over the past year, while Scotland has mostly deteriorated (Image: Institute for Fiscal Studies) The Scottish Government’s NHS recovery plan, published in 2021, envisaged inpatient and day case activity in NHS Scotland would be 15% above pre-pandemic levels by now through the creation of National Treatment Centres and increased productivity within existing NHS sites.

This was followed in July 2022 by pledges to clear the backlogs of patients who had been waiting the longest for planned surgeries.

By September 2024, one year waits for inpatient and day case procedures were supposed to have been "eradicated".

However, data published this week revealed that there were more than 38,300 people on waiting lists in NHS Scotland who had been waiting over a year for an operation - the highest number on record.

There are also more than 17,700 people with waits in excess of 18 months, compared to 2,703 in England where greater priority has been given to clearing the backlogs of longest waits.

And while National Treatment Centres have opened in Fife and Highland, most of the network has been paused due to capital budget constraints.

Max Warner, a research economist at IFS who carried out the analysis, said: "The Scottish and English NHS are now recovering differently from the Covid-19 pandemic.

"In Scotland, hospital activity remains below pre-pandemic levels, and waiting time performance has worsened over the last year.

"The same is not true in England, where performance remains poor but is at least moving in the right direction.

"The UK government has been honest about the poor performance of the English NHS and has made understanding and improving NHS performance and productivity a major priority.

"It is vital the Scottish Government does the same, particularly given the concerning divergence in recovery between England and Scotland."

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Asked to comment on the report, First Minister John Swinney said the Scottish Government is "focused very strongly on delivering improvements in the National Health Service".

He said more needed to be done around prevention to "intervene earlier" in the onset of illness. 

He added: "Obviously, we have significant challenges to overcome as a consequence of Covid but we also have got to recognise that comparatively speaking, and this is the underlying challenge of the health service, we have comparatively greater challenge in the health of the Scottish population compared to population of the rest of the United Kingdom.

"Now that is an underlying, long standing issue that we have to overcome, which is why we have such an emphasis on the public health message that we take forward."

Dr Iain Kennedy, chair of BMA Scotland, said the findings were "extremely concerning" and underline the need for "proper investment, better planning and a clear vision for reform to deliver improvements" 

Jackie Baillie, Scottish Labour's health spokeswoman said Scottish hospitals were "buckling under the strain of SNP incompetence", while Sandesh Gulhane - health spokesman for the Scottish Conservatives - said the report should be an "urgent wake up call" for Health Secretary Neil Gray.