NHS recovery in Scotland is lagging behind England’s

Introduction

Healthcare is the Scottish Government’s largest area of spending. The NHS Recovery, Health and Social Care budget is plannedto be £20.6 billion this year, around one-third of the total Scottish Government budget – and close to half of day-to-day spending on public services. Decisions about health spending are therefore crucial for the upcoming Scottish Budget, as they influence how much money is available for other public services and how much needs to be raised through devolved taxes.

One of the key priorities of the Scottish Government is ‘ensuring high quality and sustainable public services’. In this comment, as part of our wider work in advance of the 2025–26 Scottish Budget, I update our analysis of Scottish NHS performance from earlier this year. I first show that hospital activity remains substantially below pre-pandemic levels. I then show that various measures of waiting time performance have worsened over the last year.

Throughout, I compare NHS performance in Scotland with performance in England. Scotland has long spent more publicly on healthcare per person than England, though this gap has closed substantially over the last two decades. Health services in both Scotland and England were similarly affected by the COVID-19 pandemic, and so England is an important benchmark against which to assess the performance and recovery of the Scottish NHS.

NHS activity

Let us first examine how NHS activity (i.e. the number of patients receiving treatment) has changed over time in Scotland. Figure 1 shows how various measures of NHS activity have changed relative to the final quarter of 2019 (the last full quarter unaffected by the COVID-19 pandemic). Panel A shows four important types of hospital activity: day cases (procedures delivered within a day), elective inpatients (pre-planned procedures delivered with an overnight stay), emergency inpatients (emergency patients admitted to hospital) and outpatient appointments (treatment or assessment in a clinic that only takes a short time to complete). Panel B repeats this analysis for two experimental measures of primary care activity: direct contacts (direct contact between clinical staff and patients, such as in-person and telephone appointments) and indirect contacts (including prescription management, interactions with hospitals, test results and administration).

Figure 1. NHS activity in Scotland relative to 2019Q4

Panel A. Acute hospitals

Panel B. Primary care (experimental measures)

Note: Outpatient appointments only include attended appointments.

Source: Public Health Scotland – acute hospital activity and NHS beds information (quarterly) and general practice in-hours activity visualisation.

Panel A shows that all four types of hospital activity fell sharply during 2020 as the NHS prioritised capacity to treat COVID-19 patients. Although activity has recovered somewhat in subsequent years, the numbers of patients treated by hospitals for most types of activity remain substantially below pre-pandemic levels. In the latest available data, for April to June 2024, overall acute hospitals in Scotland delivered 15% fewer elective inpatient admissions, 9% fewer emergency inpatient admissions and 6% fewer outpatient appointments than in October to December 2019. An exception is day cases, where hospital activity has increased substantially over the last year, and was almost the same (0.3% higher) in April to June 2024 as pre-pandemic. Nonetheless, total inpatient and day case activity was 6% lower in April to June 2024 than in October to December 2019. 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.

The NHS in Scotland has taken steps to reduce demand on hospitals, which may partly explain why activity has not recovered to pre-pandemic levels. For example, the Centre for Sustainable Delivery (a national unit commissioned by the Scottish Government to improve Scotland’s healthcare system) aims to eliminate 210,000 unnecessary outpatient appointments this year. The Scottish Government also wants to reduce what it sees as unnecessary hospital admissions for older people. But alongside these efforts, the Scottish Government has many other objectives to increase hospital activity – for example, by using National Treatment Centres to deliver 20,000 extra surgery procedures. The Scottish Government’s NHS Recovery Plan, published in 2021, aimed to increase inpatient and day case activity to 15% above pre-pandemic levels by 2024–25. The Scottish NHS is far from achieving this target, and Audit Scotland has warned that it is not being transparent about performance.

Although the number of patients treated in hospital is lower, the average length of stay in hospital has risen since the start of the pandemic. This means that the overall number of inpatient hospital bed days is almost the same (0.7% higher) as pre-pandemic in Scotland. Higher length of stay could be driven by patients requiring more complex treatment than pre-pandemic, and therefore might suggest that hospitals are providing more healthcare than activity numbers alone would indicate. This may be in part because of the continued presence of patients with COVID-19 in hospital, a driver of higher average length of stay in England earlier in the pandemic. But higher length of stay could also be driven by challenges with system flow, in particular delays in discharging patients who are medically ready to leave hospital. In September, there was an average of 1,968 beds in the Scottish NHS occupied by adults who could not be discharged, compared with 1,521 in September 2019.

One factor unlikely to explain the failure of acute hospital activity to return to pre-pandemic levels is a shortage of staff. NHS staffing in Scotland is much higher than pre-pandemic. For example, the NHS in Scotland has 13% more consultants (senior doctors) and 12% more nurses and midwives in June 2024 than in June 2019. As we discussed in our previous report, this provides suggestive evidence that the labour productivity of hospitals in Scotland is substantially lower than pre-pandemic, as is also the case in England. Rather than staffing, it may be that a lack of available hospital beds is preventing further increases in inpatient activity in Scotland (the number of acute hospital beds is 5% higher than pre-pandemic, though the total number of hospital beds is 1% lower than pre-pandemic).

Hospital activity remains below pre-pandemic levels in Scotland, but this is not the case in England. As we have recently reported, NHS hospital activity in England is now substantially above pre-pandemic levels. For example, in April to June 2024 (the latest period we have data for Scotland), the number of elective admissions delivered in the English NHS was 8% higher than pre-pandemic, the number of emergency admissions was 2% lower and the number of outpatient appointments was 11% higher than in October to December 2019. Taking all of this together, hospital activity in both Scotland and England is increasing, but Scottish activity remains substantially below pre-pandemic levels. This is despite the fact that hospital activity in England has been reduced by frequent and widespread industrial action, which has not occurred in Scotland.

Measures for primary care activity are experimental. But they suggest that primary care activity in Scotland has recovered by more than hospital activity (Panel B of Figure 1). In the latest available data, for July to September 2024, GP practices in Scotland delivered 8% fewer direct contacts than pre-pandemic, but they delivered 16% more indirect contacts. The primary care sector therefore seems to have recovered better from COVID-19 than hospitals, although appointments remain below pre-pandemic levels.

NHS performance

NHS activity is an important measure of how well the health system is performing and how well it is translating its resources – staffing, beds, funding, and so on – into healthcare outputs. But what matters for a person needing treatment is the ease of accessing treatment and the quality of the treatment they receive. While it is hard to measure the quality of treatment in general, one important measure of NHS performance is how long patients need to wait for treatment.

Table 1 therefore shows how a range of NHS waiting times measures have changed over time in Scotland and England. The first column for each nation compares current performance with pre-pandemic performance, while the second column of each pair shows how performance has changed over the last year.

Starting first with changes since the start of the pandemic, NHS performance is currently worse than pre-pandemic across all measures considered in Scotland. The elective waiting list is higher (having risen from 362,000 in December 2019 to 725,000 in September 2024) and waiting times are longer. For example, the share of patients waiting less than four hours at A&E is lower (falling from 81.6% in December 2019 to 65.9% in September 2024). The same is also true in England – across all measures considered, performance is worse than pre-pandemic.

There is a clearer difference between Scotland and England when it comes to performance over the last year. 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.1

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

Table 1. Key NHS performance metrics, relative to pre-pandemic and last year

^aEmergency departments in Scotland and type 1 major A&E departments in England.

^bThere has been a change to how cancer target performance is recorded over this period, combining different targets together. But performance on the new target is substantially worse than performance on all of the previous related targets.

^cIn Scotland this is reported as the number waiting six weeks or less, while in England it is reported as the number waiting less than six weeks.

Note: Included treatments and definitions of waiting times can differ between Scotland and England. ‘Relative to pre-pandemic’ compares the latest available data with December 2019, or the quarter including December 2019, depending on the frequency of the data. ‘Relative to last year’ compares the latest available data with 12 months, or 4 quarters, prior to the latest data. The latest data for all Scottish measures are for September 2024, apart from cancer waiting times, which are for June 2024. For fairness of comparisons, the English columns always use the same period as the Scottish columns.

Source: Public Health Scotland – NHS waiting times - stage of treatment, NHS waiting times - 18 weeks referral to treatment, accident and emergency, cancer waiting times and NHS waiting times - diagnostics; NHS England – referral to treatment (RTT) waiting times, A&E attendances and emergency admissions, monthly diagnostic waiting times and activity and cancer waiting times.

Conclusion

Performance in the Scottish NHS remains below pre-pandemic levels across many measures. Even more concerningly, many measures of performance have continued to worsen over the last year. In large part, that is because most NHS hospital activity remains far below pre-pandemic levels, far from the ambitious targets in the Scottish Government’s 2021 NHS Recovery Plan. Since hospitals are overall treating fewer patients than pre-pandemic, with only slow improvement over the last year, it should come as little surprise that waiting times are not improving. Indeed, across most measures of waiting times, performance has worsened over the last year.

One reason for this failure to increase hospital activity above pre-pandemic levels is that average length of stay is much higher than pre-pandemic. This might reflect the increased complexity of the patients that hospitals have to treat, including the continued presence of patients with COVID-19 in hospitals. But the failure to increase hospital activity likely also reflects challenges in discharging patients. However, it is likely not explained by a shortage of staff – the NHS in Scotland has many more staff than pre-pandemic (though the increase in staff since the start of the pandemic in Scotland is smaller than that in England).

The pattern in the English NHS is different. In short, while performance in both countries is below pre-pandemic levels (and lower than governments and populations would like it to be), things are, if anything, still getting worse in Scotland, whereas they have started to improve in England. Many types of hospital activity in England are now higher than pre-pandemic, though still far from recovery targets, and most of the performance measures considered here have improved over the last year. In England, there has been a large focus from both the previous and the current government on improving NHS performance and productivity. Similar focus is needed in Scotland.

Looking ahead to the Scottish Budget, the key question is to what extent this poor NHS performance will force the Scottish Government to prioritise further increases in health spending relative to other services. Then, aside from any funding decision, there remains the ongoing challenge of ensuring that money is spent well, staff are deployed effectively, and productivity in the NHS is enhanced – all essential if waiting times are to be reduced.