THE message could not be more blunt, and it could not be clearer. Given the growing pressures on the National Health Service, says Audit Scotland, “fundamental changes and new ways to deliver healthcare” are required. And they are required now.

Even its critics might concede that the Scottish Government has recognised as much. There are, as Audit Scotland’s report on the NHS accepts, long-term plans for reform being developed. There is also a growing consensus, as Holyrood’s health committee asserted earlier this month, that a fixation with targets is probably not the best use of public money.

The problem is that every challenge for the NHS happens in real time. Every repair must be attempted, as it were, while the engine is running. An £11.4 billion budget has been declining in real terms. Staffing equivalent to 137,600 posts is at its highest level, but recruitment and retention remain “significant” (and costly) problems while demand is increasing.

Those who charge the Government with failure need to be precise. In finance, for example, NHS boards have done well if the only yardstick is the near-catastrophe witnessed in England. The situation there allows no excuses here, but it provides some perspective.

Overall savings of £285 million and a tiny (£10m) Scottish underspend might not sound like much. The fact that two boards required financial support to break even is disquieting. Increasingly, meanwhile, boards are relying on non-recurring savings. But eight in 10 English trusts are in the red. In the first quarter, they ran up a £930m deficit. That’s a crisis.

Nevertheless, the Audit Scotland report, NHS in Scotland 2015, reminds us that by March seven of nine key waiting time targets and standards had been missed. This reflects “a general decline in performance in recent years”. With the number of outpatients waiting more than12 weeks for their first appointment increasing from three per cent to eight per cent, that truth is beyond question. But hard facts describe a harder challenge.

Audit Scotland does not contest the Government’s “2020 vision” envisaging a shift in the balance of care towards the home and the community. There is no criticism of the “national conversation” launched in August. The view remains that the Government “has not made sufficient progress”; that the pace of change must quicken; that better, longer-term financial planning is essential; and that the issue of targets must be addressed.

The last of these recommendations should act as a reminder to politicians: what seems like a quick and simple fix can have long-term implications. Targets can raise standards, but they can also become expensive distractions. The risk, as Audit Scotland states, is a conflict between short-term actions and long-term plans.

On Tuesday, the First Minister will give the Health and Social Care Academy’s inaugural lecture. As a former health secretary, Nicola Sturgeon takes the standing of the NHS in Scotland personally. Next week she will have the chance to say how she means to meet the profound challenges described by Audit Scotland.