17th October 2026
The proposed shake-up of Scotland's NHS raises important questions about local accountability, rural healthcare and whether reorganising management will actually improve services.
The Scottish Government's plans to reorganise Scotland's health boards have already raised concerns in the Highlands. Reports that NHS Highland was not consulted before First Minister John Swinney announced the proposals add another question: is the Government moving too quickly with a major change to the way healthcare is managed?
The answer is not necessarily that the proposed mergers are wrong. There may be sound reasons to reconsider how Scotland's health boards work. But a reorganisation affecting services across the country needs to be based on evidence, proper consultation and a clear understanding of local circumstances.
For the Highlands, those circumstances are particularly important.
A major change to Scotland's NHS
On 1 September, John Swinney announced plans to replace Scotland's 14 territorial health boards with two large strategic boards, one covering the east and one the west.
The proposals would place NHS Highland within a much larger western structure, alongside other health boards. The arrangements for island communities also need careful consideration.
The Scottish Government argues that a smaller number of strategic organisations could reduce duplication, improve coordination and make it easier to share staff and specialist resources across existing boundaries.
These are reasonable objectives. Scotland's NHS faces pressures from waiting lists, staff shortages, rising demand and the growing cost of providing healthcare. No system should be immune from examination simply because it has been in place for many years.
However, reducing the number of boards does not automatically mean better healthcare. The important question is whether the new structure will improve services for patients.
Why the lack of consultation matters]/b]
According to reporting by The Press and Journal on 16 October, freedom of information responses indicated that NHS Highland had not been consulted before the announcement. NHS Grampian and the island boards also reported that they had not been consulted beforehand.
That is troubling because local health boards understand the practical challenges facing their areas. Their experience should help shape any changes to the system, particularly when the proposed new organisations will cover such large and varied geographical areas.
There is an important distinction between announcing a broad political intention and completing the detailed work needed to implement it. The Scottish Government has said that design work, engagement and impact assessments are part of the process still to be undertaken.
Not being consulted before an announcement does not prove that the proposal is unworkable. But it does raise questions about how much local knowledge informed the original decision and whether consultation will genuinely influence what happens next.
Consultation should be more than an opportunity to explain a decision that has already been made.
[b]The Highlands are not the Central Belt]/b]
For communities in Caithness and Sutherland, the debate is about more than administrative boundaries.
NHS Highland serves a vast geographical area, with scattered communities, long journeys and difficulties recruiting some specialist staff. Patients may already have to travel considerable distances for appointments and treatment.
A larger western board might be able to share specialist expertise, coordinate services and use resources more efficiently. But it could also create a risk that decisions become more remote from the communities affected by them.
Highland's needs could struggle to compete with those of larger population centres unless local representation and decision-making are properly protected.
There is also a danger that administrative efficiency could be confused with better access to care. A saving made at management level is of little benefit to a patient if it results in longer journeys, reduced local provision or greater difficulty getting an appointment.
That does not mean these outcomes are inevitable. It means the Government must demonstrate how its proposals will avoid them.
[b]Will the changes save money?
Reducing the number of boards could remove some duplicated management, procurement and administrative functions. In principle, that might release money for frontline services.
But reorganisations also have costs. Staff time is diverted into planning and restructuring, new systems have to be established, responsibilities must be transferred and uncertainty can distract organisations from their daily work.
The Government therefore needs to publish a credible assessment of both the costs and the expected savings. It should explain when any savings might materialise and how they will be measured.
Most importantly, it should distinguish between savings generated by reducing duplication and savings that might come from cutting services.
If the main benefit is simply a different management structure, the case for such a sweeping change will be much weaker than if it demonstrably improves patient outcomes.
Five questions the Government must answer
Before the new structure is finalised, there are five questions that deserve clear answers.
First, what measurable improvements in waiting times, patient outcomes and access to specialists are expected?
Second, how will local decision-making and budgets be protected for Highland communities, including Caithness?
Third, what safeguards will prevent services and resources from becoming increasingly concentrated around larger hospitals and population centres?
Fourth, what will the reorganisation cost, how much is expected to be saved, and when will the benefits reach patients?
Finally, how will NHS staff, patients, councils and local communities influence the final arrangements? Will the Government be prepared to change its plans if the evidence shows that aspects of the proposed structure will not work?
These are not arguments against reform. They are the basic tests that any major public-sector reorganisation should pass.
Improve the NHS, not just its management structure
Scotland's health service undoubtedly needs to find better ways of working. Sharing specialist staff, improving coordination and reducing unnecessary bureaucracy are worthwhile ambitions.
But the number of organisations on an organisation chart is not a measure of the quality of healthcare.
The Government should be judged on whether patients receive treatment sooner, whether staff can do their jobs effectively, whether public money is used wisely and whether people in rural communities can access services without unreasonable difficulty.
For Caithness, there is a particular reason to watch developments closely. Local people have long been concerned about the consequences of decisions being made further away from the communities they affect. A new regional structure must not weaken the ability of Highland communities to make their case.
The lack of consultation before the announcement is a warning about the process, rather than proof that the whole proposal is misguided. What happens next will be crucial. If the Government listens, publishes the evidence and builds meaningful local accountability into the new arrangements, the reorganisation may prove worthwhile.
If it simply presses ahead and expects local organisations to adapt, it risks losing valuable knowledge and public confidence before the changes have even begun.
The choice is not between accepting the existing system unchanged and accepting whatever structure ministers propose. There is room for reform, but it must be reform that can demonstrate its value.
The NHS should get on with improving healthcare. The Government should not assume that merging health boards is, by itself, the improvement patients need.
The changes to come may take years to come about but the budget pressures being face by NHS Highland need watching as they have depended heavily on bailouts by Scottish government in the last few years. For NHS Highland and other financially stressed boards that may be coming to an end as the governments both Scottish and UK have their own growing deficits to deal with.