SCOTLAND’S “polarised political climate” on independence is standing in the way of the controversial decisions and reforms needed to ensure the health service remains sustainable, according a major think tank report.

The authors also warn that NHS Scotland is facing a “serious financial predicament” with deeper savings required compared to south of the Border, but that there is no medium or long term plan to deal with the squeeze faced by health boards.

While the report by healthcare think-tank, the Nuffield Trust, stressed that the NHS in Scotland offers templates of good practice that the other UK nations should learn from, it cautions that "there is a risk that the financial situation will undermine the best aspects of the Scottish NHS" as politicians "panic and focus on meeting targets and keeping local acute services open at the expense of longer-term change".

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In particular, the authors said a "toxic" political culture in Scotland made difficult decisions such as centralisation or bed closures "seem almost impossible", as the SNP Government seeks majority support for independence while coming under attack over its record on the NHS.

It added: “Limited national planning for the next few years and a polarised, hostile political context make an honest national debate difficult. While the strengths of the Scottish NHS could help it to save money, there is also a risk that they are undermined by the intense financial squeeze.”

The report is based on feedback from academics, health service managers, leaders and experts from the health and social care sector in Scotland, and senior Scottish Government officials, including civil servants.

On average, health boards in Scotland must find efficiency savings of 4.3 per cent on average this year, higher than England and Wales. Some health boards must cut spending by as much eight per cent. The underlying driver is "rapid rises in costs and the need for care, coupled with historically low funding increases as across the UK".

While England, Wales and Northern Ireland have all developed multi-year plans setting out how much funding will be available, how much needs to be saved and what services may become undeliverable, health boards in Scotland were said to be juggling the books year-to-year and increasingly relying on one-off savings. The lack of a long-term forecast in Scotland was "postponing a debate with the public and politicians on the blunt choice that ultimately faces Scotland and all its neighbours: whether the NHS is going get more money than planned, or do less".

However, the report also highlights a number of strengths, including the patient safety programme which has reduced deaths, stillbirths, hospital infections and driven improvements in sepsis and surgical mortality. It also highlighted Scotland's better engagement with trade unions than the NHS in England. In particular, the report says the ongoing negotiation of the new GP contract reflects "goodwill from both sides and an active effort to avoid conflict" compared to "distant and rancorous" industrial relations in England

Scotland has also led the way with "pioneering initiatives" such as the use of video links for outpatient care on remote islands or the deployment of advanced nurse practitioners in rural areas struggling with GP shortages who can administer chemotherapy and dialysis in patients homes.

Lead author Mark Dayan said: “We’re urging healthcare leaders from England, Wales and Northern Ireland to think about what elements they might want to import from Scotland.

“However, the dark cloud on the horizon threatening these strengths is potentially serious financial problems. Scotland’s NHS has the same resource constraints as England and Wales, but doesn’t yet have a medium-term plan for dealing with them – and in a harsh political environment, open debate and difficult decisions can seem impossible. This risk could overshadow many of the strengths that other countries can learn from”.

Health Secretary Shona Robison welcomed the praise for NHS Scotland, adding that the integration of health and social care was "one of the most significant reforms since the establishment of the NHS".

She added: "By bringing these services together we are ensuring people get the right care and support for their individual needs, and that staff across health and social care are equipped to work together to make full use of their shared skills and resources.

“Our ambitions for the NHS are founded on the twin approach of investment and reform, making the changes needed for future backed by record levels of investment and staffing.”