The Scottish NHS is struggling to cope and the flagship vision for its future is in jeopardy, according to the public spending watchdog.

Audit Scotland has expressed grave concern that health boards are battling to stay in the black and deliver timely care as patient numbers soar, in a report published today.

Waiting-times targets and the demands of staying in budget may also be undermining the ability of boards to deliver the changes required to look after the increasing elderly population, according to the analysis.

With words that echo The Herald's NHS: Time For Action campaign, the auditors call for a clearer picture of NHS capacity - including staff and bed numbers - and how these need to change to meet the swelling demand.

The report shows that despite the Scottish Government's reassurances about protecting the NHS budget, spending per person has decreased in real terms in the last four years and further squeezes are ahead.

There is a maintenance backlog that will cost £858 million to fix, while last year 421,157 days of bed capacity were taken up by patients who were ready to go home, costing an estimated £78m.

Out of nine waiting-times goals set by ministers, only three have been met.

Caroline Gardner, Auditor General for Scotland, said: "NHS boards need to deliver major changes to meet the future needs of patients. The effort invested in meeting annual targets, within tightening budgets, makes it difficult for NHS boards to reshape care in line with an ambitious national policy. The Scottish Government should review whether the current financial and performance targets for the NHS can be achieved at the same time as implementing its vision for health and social care."

The over-arching plan for the future of NHS Scotland, known as the 2020 vision, was agreed with cross-party support three years ago and involves improving community services to help people avoid hospital admissions.

However, the Audit Scotland report NHS Scotland 2013/14 raises questions about the plans in place to deliver it.

Jillian Matthew, one of the report authors, said: "We have looked at some of the planning around this and it varies from board to board in how detailed it is. Some boards do have detailed plans around what their services look like in five years, but there is not a lot of detail about how they are actually going to do that."

She added that it was not clear how boards were going to be able to fund the double-running costs that come with launching new services before existing services can be cut back.

The report says: "The NHS needs a better understanding of its current capacity, current and future demand, and patient flows, to inform the major changes to services that will be required to ensure they are sustainable and meet the long-term needs of the population."

Responding to the report, Theresa Fyffe, director of the Royal College of Nursing Scotland, said: "The Scottish Government is more than aware of the pressures on the NHS

but, unfortunately, its response has been to set up lots of national working groups, task forces and initiatives that are unco-ordinated and so pulling the NHS in different directions. They are also often focused on addressing the pressures on hospital care, rather than on the NHS as a whole."

Neil Findlay, Scottish Labour's health spokesman, described the report as a "damning indictment of the SNP's record in Government" while Jackson Carlaw, health spokesman for the

Scottish Tories, said the NHS was at "breaking point".

The Scottish Government has said it will refresh the strategy for achieving its 2020 vision, but described the audit as showing "good progress".

Health Secretary Alex Neil said: "Protecting frontline health services is a priority for this Government and we will do this by increasing the NHS frontline budget despite cuts in the overall budget from Westminster.

"The NHS is not perfect, and we are always seeking to make improvements."