SCOTLAND must plan to shut some accident and emergency departments or risk "firefighting" as services struggle to survive, a leading NHS figure has warned.
Andrew Robertson, the former chair of the UK's largest health authority, NHS Greater Glasgow and Clyde, has called on politicians to take potentially unpopular decisions to reduce the number of major hospitals and invest in better care in the community.
In a rare interview, he warned without decisive action some services would become unsustainable and money would not be released to improve the way the frail elderly are looked after at home.
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The Scottish Government and opposition parties have agreed community care should be improved to try to keep people out of hospital and prevent the growing elderly population swamping ward beds.
But Mr Robertson said the plan had not be realised, describing Scottish Government community funding initiatives as "too small and too spasmodic". He said: "We all know the rhetoric about shifting the balance of care, the transfer of resources (from hospitals into the community), but until there is a deliverable strategy it is only words with time running out."
He said resources could not be shifted to the community unless people were prepared to "close acute service units and reinvest the proceeds".
Mr Robertson, who stood down after eight years as NHS GGC chairman at the end of last year, said Scotland had 29 acute receiving hospitals for a population of 5 million. In the UK, he said,
the recognised standard for delivering a full specialist medical service was one hospital for 400,000 people.
He acknowledged dispersed rural communities meant this ratio could not always be applied to the Scottish NHS. However, he continued: "Twenty-nine hospitals for 5 million people with us having five acute receiving in the West of Scotland for 1.2 million will not stand up to long term sustainability...
"You cannot man confident rotas across a proliferation of hospitals. If there is too little through flow you cannot maintain accreditation of specialist practitioners."
Mr Robertson, who was awarded an OBE in 1994 and an honorary degree by Glasgow University last year, has chaired NHS authorities in the West of Scotland for more than 20 years.
In that time he has overseen the closure of hospitals for patients with learning disabilities and long term mental health problems and the more recent reduction of the number of A&Es in Glasgow from five to two.
He admitted the new Queen Elizabeth University Hospital, where services have been centralised on the Southern General site, has had a difficult start. Waiting times in its A&E department have been among the worst in Scotland. But, Mr Robertson predicted centralising there would release resources for community care in Glasgow in around five years.
He praised former Scottish Labour health secretaries for agreeing the controversial shake-up, saying: "You have to plan boldly well in advance if you are going to be able to deliver calmly. There was tremendous distress is various communities before the plan was agreed by the health board in 2002 and fortunately (former health secretaries) Malcolm Chisholm and Sam Galbraith before had been completely supportive and they were able to carry the day in the Holyrood parliament."
He says without their help hospitals in Glasgow would still be "back in the 1980s now".
While this implies criticism of the SNP who reversed decisions to centralise hospital services in Lanarkshire and Ayrshire in 2007, Mr Robertson's call to take bold decisions goes across the political spectrum.
He said: "You cannot blame the Scottish Government any more than the opposition parties in Scotland. There is a strategic inertia. There is a reluctance to acknowledge the full impact including the benefits of structural change which includes the closing of units and therefore there is a continuing failure to develop a strategy of change."
He added: "You cannot go on placating those who will not face up to all the elements of change. You have to take difficult decisions so you can deliver them in a calm atmosphere otherwise you will end up firefighting."
A Scottish Government spokeswoman said it had "a strong track record on modernising health and social care services" citing the opening of the new Forth Valley Royal Hospital, the Queen Elizabeth University Hospital and the new Royal Hospital for Sick Children in Glasgow. She also pointed to the forthcoming merger of NHS and council social care budgets.
The spokeswoman added: “Our national clinical strategy, launched last week, also outlines our vision for transformational change to enhance the quality of care, improve outcomes and ensure we have a sustainable service for all."