2nd September 2026
There is a potentially huge change coming to the way Scotland's NHS is organised, and it could have particular consequences for places such as Caithness.
The Scottish Government is developing a new East and West structure for NHS Scotland. Until now, Scotland has operated with 14 territorial health boards, each responsible for providing and planning services across its own area. The emerging model is intended to make boards work together across larger geographical areas, pooling resources and planning services jointly.
But reports now suggest the government is considering going much further, with Scotland's 14 territorial health boards eventually being replaced by just two large strategic organisations, one covering the East and one the West.
That would be one of the biggest reorganisations of the NHS in Scotland for decades.
The distinction matters because the Scottish Government's published documents currently talk about sub-national planning structures, rather than simply announcing that 14 boards are being abolished. Official NHS papers show that East and West groups are already operating, with boards being asked to work collectively on financial planning, clinical services and other priorities.
The government says the purpose is to get health boards to plan services together rather than allowing organisational boundaries to dictate how services are delivered. Its own description of the reform is about moving towards services designed around people and communities rather than around the boundaries of individual organisations.
That sounds entirely sensible.
The NHS does not become more efficient simply because there are 14 chief executives, 14 boards and multiple sets of administrative structures. There are obvious opportunities to share procurement, information technology, finance, workforce planning and other functions.
There is also a financial reason for looking at the structure. The Scottish Government has told boards that they must increase recurring savings and find ways of dealing with financial pressures across the new sub-national areas. The official guidance specifically envisages financial plans being brought together for the East and West groupings.
But there is another question which matters greatly in the Highlands.
What happens to local influence when the organisation becomes much bigger?
For someone living in Glasgow, a larger NHS organisation might not necessarily feel very different. For someone living in Caithness, it could be a very different story.
NHS Highland already covers an enormous geographical area. It has to provide healthcare across communities separated by long distances, difficult weather and relatively small populations. The health problems of Caithness cannot simply be managed in the same way as those of a densely populated urban area.
If the eventual structure puts NHS Highland into a huge NHS West organisation, the concern will naturally be whether Caithness gains access to greater resources or simply becomes another small part of a much larger management structure.
That is the great paradox of centralisation.
Centralisation can make an organisation more efficient. It can also make it easier for the centre to overlook the edges.
Anyone who has lived in the Highlands will recognise the problem. Decisions made in a large central organisation can look perfectly logical on a spreadsheet while making considerably less sense when applied to a remote community.
The government says the new arrangements are supposed to work around communities rather than organisational boundaries. That principle is welcome. But the test will be whether it survives contact with the reality of a health service covering thousands of square miles.
There is also an interesting question about what "two NHS Scotlands" would actually mean.
Would the East and West organisations merely coordinate the existing boards? Would they eventually absorb them? Would NHS Highland continue to have its own chief executive and board? Or would decisions about major services, staffing and investment increasingly be taken at the regional level?
At the moment, the precise final structure has not been published.
There are already signs, however, that the East and West concept is much more than a line drawn on a map. Government papers refer to East and West delivery committees, cross-board governance and joint work on areas including emergency healthcare, orthopaedics, digital systems and other services.
The government has also established Public Services Delivery Scotland, bringing together functions such as digital services, data, training and procurement. That points towards a wider strategy of removing duplication from the public sector rather than simply tinkering with individual organisations.
There is a strong argument for doing exactly that.
The NHS should not protect administrative structures simply because they have existed for years. If money can be taken out of management and bureaucracy without reducing frontline care, it should be.
But there is a danger in assuming that a bigger organisation automatically means a more efficient one.
Large organisations can create their own bureaucracy. They can require additional layers of management to coordinate the people below them. They can also become less accountable to the communities they serve.
That last point is particularly important.
If a local health board makes a decision that people in Caithness dislike, there is at least a recognisable local organisation to challenge. If the ultimate decision-maker is part of a giant West Scotland organisation, accountability could become much more remote.
And there is an even bigger issue.
Will the money follow the population, or will it follow the political and clinical priorities of the largest centres?
A remote community does not necessarily need fewer resources simply because fewer people live there. Providing a hospital service, ambulance cover or specialist healthcare across a sparsely populated area can cost considerably more per head than providing the same service in a city.
This is where the reform could either become a success or a problem.
If a larger regional NHS structure allows specialist services to be shared, staff to be moved more easily between hospitals, procurement costs to be reduced and expensive equipment to be used more effectively, Caithness could benefit.
If it results in more decisions being made further away, with investment concentrated where the population is greatest, Caithness could lose out.
There is also a political lesson here.
For years Scotland has talked about localism while simultaneously creating larger and more centralised public organisations. The NHS reform presents an opportunity to test whether ministers really mean what they say about putting communities at the centre.
The government has said the new system should be designed around people rather than organisational boundaries.
Caithness residents should be asking a very simple question:
Who will make the decisions about healthcare in Caithness five years from now?
If the answer is "people closer to the community than before", then the reform could be a genuine improvement.
If the answer is "a much larger organisation based further away", then the word "reform" may simply be another name for centralisation.
There is nothing inherently wrong with having fewer NHS boards. Scotland may well have too many separate administrative structures for a population of around 5.5 million.
But the number of boards is not the real issue.
The real issue is where power goes when the boards disappear.
That is something people in Caithness should be watching very closely.
Caithness Has Been Here Before
For people in Caithness, there is another reason why the proposed restructuring of NHS Scotland deserves careful scrutiny.
This is not the first time that local health administration has been absorbed into something much larger.
There are still many people in the county who remember the former Caithness and Sutherland health structure as something that worked reasonably well. It was much closer to the community and, importantly, there was a strong belief locally that it managed its finances responsibly.
Historical government figures show that the Caithness and Sutherland NHS Trust had a surplus of more than £1 million at the start of 1997-98.
When the separate arrangements disappeared and Caithness became part of the much larger NHS Highland structure, there was a feeling locally that Caithness had lost not just its own organisation but some control over its resources.
It is difficult to prove that every pound of a local surplus was subsequently spent elsewhere, and it would be wrong to suggest that without evidence. But the perception has persisted that money generated or saved locally became part of a much larger pot in which Caithness had considerably less influence.
What people can point to much more easily is the gradual change in local services.
Maternity is probably the most obvious example.
Caithness once had consultant-led maternity care. Following a review after the death of a full-term baby in 2015, NHS Highland decided that the service should move to a midwife-led model. The Scottish Government says the decision was based on safety considerations and external reviews.
But for local families the result has been very real.
Many women have had to travel to Raigmore in Inverness for maternity care. That can mean a journey of around 100 miles each way, with all the additional difficulties that distance creates in a rural area.
Highland Council members have previously raised concerns about the impact of centralisation, including the need for patients and families to travel to Inverness, transport arrangements, severe weather and the capacity of Raigmore to accommodate additional patients.
The Scottish Parliament has also heard the argument directly from Caithness campaigners that the disappearance of the local health structure was followed by what they described as a "death by a thousand cuts" to local NHS services.
There is therefore a lesson here which should not be ignored as Scotland considers another major reorganisation.
Centralisation is often presented as a solution to duplication. Put organisations together, remove management layers, share specialist staff and equipment, and supposedly the NHS becomes more efficient.
That may be true.
But there is another possibility.
The bigger organisation becomes more efficient at making decisions for the majority of its population while the smaller and more remote communities gradually lose services because their needs are different and their political influence is weaker.
That is the fear in Caithness.
And it explains why the phrase "two NHS Scotlands" could mean something rather different here than it does in Edinburgh, Glasgow or Aberdeen.
Caithness has already experienced the move from a smaller local health organisation into a much larger Highland structure.
So before anyone tells people that another round of centralisation will make the NHS better, there is a perfectly reasonable question to ask:
What evidence do we have that the last round of centralisation actually improved healthcare for Caithness?
If the answer is that some specialist services became safer and more sustainable, that should be acknowledged.
But if the answer also includes longer journeys, fewer local services and less local influence, then those costs need to be included in the calculation as well.
Efficiency cannot simply mean saving money inside the NHS organisation.
For a patient in Caithness, the cost of centralisation may be measured in petrol, ferry fares, lost working days, overnight accommodation, family disruption and, in the case of maternity, the anxiety of travelling a hundred miles when something goes wrong.
Those costs may not appear on an NHS balance sheet.
They are nevertheless real costs.
And that is why Caithness should be watching the proposed NHS restructuring particularly closely.
The question should not simply be whether Scotland needs fewer health boards. It should be whether fewer health boards will give people in Caithness better healthcare.