TO say the NHS is under pressure is not new and the financial watchdog Audit Scotland often tells it straight.

The report it has issued today, however, brings together all the problems ailing the service and says they are likely to get worse. It also raises serious questions about whether the course of treatment prescribed by the Scottish Government - the 2020 vision - can be realised.

The words in the Audit Scotland press release are more sober than usual: "NHS boards are finding it increasingly difficult to cope with growing pressures."

While all health boards apparently broke even in the 2013-14 financial year, this is only because four received loans from the Scottish Government.

In fact, the report tells us eight boards have received such "brokerage" in the last five years and seven still have to repay the cash, "reducing the amount they will have available to spend on services" in the near future.

At the same time the accountants have to make larger payments to staff pension schemes, meet the rising cost of new treatments and foot a wage bill estimated to increase by about £30 million a year from next April.

Yet over the next two years, Audit Scotland tells us, the planned health budget will reduce by 0.9 per cent in real terms.

Meanwhile, demand, which is already rising because of the increasing number of frail elderly patients, will continue to climb.

According to the report, the number of people on a waiting list for a new outpatient appointment rose 34 per cent between March 2010 and 2014. However, the number of new outpatients seen during the same period increased 13 per cent. Not surprising, then, that the queue is growing and the Scottish Government targets to treat people within set time frames are not being met.

Audit Scotland acknowledges the considerable effort made by health boards to hit these goals, but says last March only three out of nine waiting times promises were delivered.

No frontline health board met the target for offering those referred to hospital their first outpatient appointment within three months.

Boards are also finding it difficult to give everyone treatment within the Scottish Government's 12-week goal, which has been enshrined in law. Performance against the cancer waiting times and accident and emergency waiting times targets also deteriorated last year.

As for discharging patients when they are well enough to go home - a crucial area when it comes to coping with the growing elderly population - the report says delays have been increasing for five years and rose notably in 2013-14.

It reveals a number of NHS boards carried out snapshot audits reviewing the healthcare needs of all patients in hospital on one day. These found that, for about 25 per cent, there was no clinical reason for them to remain on wards. They were, instead, waiting to be seen by a consultant, assessed by social work or for a care home place to become available.

With difficulties recruiting enough doctors also highlighted, the report paints a picture of the NHS fighting fire at the very time when it needs to change to avoid an inferno.

Two things are missing. One is good insight into the pressures on council social care services. How are their staff coping with the number of NHS patients who need their attention either in hospital or at home and how are their budgets coping with demand?

The other? A detailed plan showing what is needed, as more elderly people require care, to keep the NHS out the quagmire.