THE NHS in Scotland is heading for a £207 million gap in its finances within two years as the public spending watchdog warns there is “little evidence” that a reliance on hospital care is reducing.

The annual report by Audit Scotland reveals that health boards in Scotland have gone from being able to balance their books or end the year in surplus as recently as 2015/16, to a majority – nine of the 14 territorial boards – reporting a deficit by 2018/19.

The total shortfall last year was £150m, but by 2020/2021 this is predicted to balloon to £207m, including a £90m deficit at NHS Lothian and £61.5m at NHS Greater Glasgow and Clyde.

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Health boards are running out of options to cut costs with half of all savings achieved last year through one-off measures, meaning NHS bosses will face increasing pressure to axe services instead.

The report also said there could be a £1.8 billion shortfall in the funding of social care by 2023-24 if changes are not made.

Caroline Gardner, the Auditor General for Scotland, said: “The NHS in Scotland is running too hot, with intense pressure on staff and a service model that will remain financially unsustainable without a much greater focus on health and social care integration.

“We’re beginning to see examples of new ways of delivering healthcare but they’re some distance from the system-wide reform the NHS needs.”

The Audit Scotland report notes that despite an integration agenda geared to shifting services and spending away from hospitals towards less costly community and social care, “there is little evidence to date that this is happening”.

The report also complains that the Scottish Government published its five-year initiative, the Health and Social Care Delivery Plan, in 2016 but has yet to publish an update on progress against its aims.

Audit Scotland said this should be done “as soon as possible”.

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Hospital activity data shows that A&E attendances have been climbing steadily, reaching nearly 1.7m last year, with emergency admissions up three per cent in four years.

The number of beds days lost to patients who were well enough to leave hospital but unable to do so, for example because there is no social care package in place or they are on the waiting list for a care home, was up 9% year-on-year to more than 420,000.

Across Scotland, nearly 8% of consultant posts were empty, rising to 44% in NHS Orkney. Despite this, spending on medical locums across NHS Scotland – excluding general practice – has fallen from a peak of £114m in 2016/17 to £98m last year.

In contrast, spending on agency nurses to plug rota gaps is higher than ever, costing the health service £26.2m last year.

Theresa Fyffe, director of the Royal College of Nursing Scotland, said their members felt undervalued and “frustrated by the slow pace of change” towards health and social care integration.

She added: “Audit Scotland recognises the importance of leadership and workplace culture. Yet too often we hear from the nursing profession how the pressures on the system can lead to burn out and a culture of bullying.”

Other financial pressures include a £1 billion of maintenance backlog affecting NHS facilities and £45m for the New Medicines Fund, which helps health boards to pay for medicines for patients with very rare or end-of-life conditions.

However the overall drugs bill has stabilised at £1.8 billion, due to initiatives such as swapping high-cost drugs for cheaper alternatives that have the same effect, more frequent medication reviews to reduce waste and restricting the list of medicines available for prescribing.

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Jenny Marra, convener of Holyrood’s Public Audit Committee, said: “Last year’s report from the Auditor General said NHS Scotland’s position was not financially sustainable, and now we see the NHS deficit spiralling.

“The Audit Committee will be prioritising our scrutiny of this report to understand more fully how the Scottish Government and health boards plan to tackle the £200m plus deficit predicted for 2021/22.”

Health Secretary Jeane Freeman said health and social care integration is "progressing, but it needs to happen faster".

She stressed that investment in NHS Scotland has grown by 6% above inflation over the last 10 years.

She said: “This is all part of our twin approach of investment and reform to meet increasing demand and to deliver balanced and sustainable services.”

ANALYSIS

SPENDING on the NHS in Scotland has never been higher.

The health service receives £42 of every £100 spent by the Scottish Government, far more than any public service.

Over the past decade, the budget has increased in real-terms by six per cent and now exceeds £14 billion.

And yet health boards are under pressure to cut costs like never before, achieving savings of £390m last year and £450m the year before.

Reliance on one-off savings that cannot be replicated the following year is growing - accounting for 35% of savings in 2016/17 to 50% last year - and more and more health boards are turning to emergency Scottish Government loans, known as brokerage, to plug the gaps.

The strain is seen with 28% of patients waiting more than 12 weeks for a day case or inpatient procedure (the Government says no one should wait longer than 12 weeks) and nearly two in every ten cancer patients waiting more than 62 days between referral for diagnostic tests to the start of treatment.

Audit Scotland insists that the tide will not be turned unless the "too slow" pace of health and social care integration is accelerated.

This is challenging at a time when care homes are folding and the total number of care home places in Scotland is the lowest in a decade, leaving many elderly people and adults with physical or learning disabilities, in limbo. The care-at-home sector, meanwhile, is struggling with recruitment exacerbated by Brexit uncertainty.

Hospitals have also borne the brunt of more than a decade of disinvestment in general practice. Between 2005/6 and 2017/18, the share of health spending which went into general practice in Scotland dwindled from 9% to 6.8%, and even with recent increases remains far short of the 11% the profession says it needs.

In the process, GP earnings have been squeezed, practices have closed and many family doctors on the frontline have been left feeling overwhelmed. The result has been a deterioration of the crucial 'gatekeeper' GP role at a time when Scotland's population is ageing and the need to avoid needless hospital referrals, tests, and scans could not be greater.

Patients unable to see a GP, whether because of long waiting times for appointments or because the out-of-hours service (which GP practices are no longer financially penalised for scrapping) has vanished, are also more likely to end up resorting to A&E instead.

It is testament to those working in Scotland's NHS then that there have still been gains: a 14% reduction in hospital mortality, a 16% year-on-year decline in the number of cancelled planned operations and a steady fall in infections caused by the hospital superbugs MRSA or C. diff.

Overall, 86% of patients admitted to hospital in Scotland said they were happy with their care.