NHS Scotland is struggling to maintain quality of care with patients waiting longer for treatment, targets missed and no improvement in the nation's health amid unprecedented budget pressures, according to Audit Scotland's annual performance report.

The watchdog stressed that while patient satisfaction is at an all-time high, bed blocking is reducing and hospital death rates are down, it is becoming "increasingly difficult" to sustain standards as health boards run out of one-off cost savings.

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The number of patients waiting more than 12 weeks for an outpatient appointment has soared four-fold since 2013 and by more than 800 per cent for planned inpatient and day case treatments, and life expectancy has remained "static" since 2012.

Seven out of the Scottish Government's eight priority targets - including the four-hour A&E target and the referral-to-treatment times for cancer - were missed for the second year in a row in 2016/17. Only one - that 90 per cent of patient with drug and alcohol addictions should wait no longer than three weeks to begin a recovery treatment - was achieved.

Dr Peter Bennie

BMA Scotland chair, Dr Peter Bennie, said: “This latest report makes clear that it is getting harder and harder for the NHS in Scotland to cope with continued austerity. Demands on the NHS are increasing rapidly every year and sufficient resources are simply not being made available to meet the needs of patients.”

The annual report said that despite achieving "unprecedented" savings of £387.4 million in 2016/17 - up 33 per cent on the previous year - the health service in Scotland still fell short of its savings target by £18.9m. NHS Lothian accounted for around half the deficit after missing its savings target by 28 per cent, or £9.8m.

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Non-recurring savings, which boards can only deliver on a one-off basis, accounted for 30 per cent of all savings last year compared to 13 per cent five years ago. They accounted for 71 per cent of the cost-cutting at NHS Fife and 86 per cent at the State Hospital, Scotland's high-security psychiatric facility. Audit Scotland warned that "boards that make high levels of one-off savings will have to find more savings in future years".

In 2016/17, the health budget was a record £12.9 billion, 43 per cent of the total Scottish Government budget, but health funding has not been able to keep pace with the surge in operating costs as demand for healthcare increases. Despite increasing to £13.1bn during the current financial year, this equates to a real terms cut of 0.1 per cent.

Spending on agency staff, including locum doctors, has increased 79 per cent over five years to £171m. Spending on drugs is also up 7.1 per cent in real terms compared to 2014/15, to £1.68bn, but the amount of funding ring-fenced for health boards under the New Medicines Fund to prescribe drugs to treat very rare and end-of-life condition fell from £85 million in 2015/16 to £53 million in 2016/17. The report said this was placing pressure on health boards' drugs budgets, adding that the amount of NMF funding available to boards in 2017/18 "is not yet known".

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Audit Scotland said Scottish Government should shift from one-year funding allocations to three to five year funding cycles.

It said: “The lack of financial flexibility, with NHS boards required to break even at the end of each financial year, and lack of long-term planning are barriers to moving more care out of hospitals.”

The number of GP practices has fallen by three per cent in the past five years, to 963, forcing patients to join new surgeries. As a result, the average practice list size has increased by six per cent to 5,881. However, the number of GPs in Scotland has increased only one per cent over the same period, piling extra workloads onto remaining family doctors.

Caroline Gardner, Audit Scotland

Caroline Gardner, Auditor General for Scotland, said: "The NHS in Scotland marks its 70th anniversary next year, and there is widespread agreement that healthcare must be delivered differently if it is to withstand growing pressure on services.

"There is no simple solution, but these fundamental areas must be addressed if reform is to deliver the scale of transformation that's needed across the NHS."

Health Secretary Shona Robison said: “We have long been realistic about the challenges for the NHS and the need for change. Alongside record investment of over £13 billion, including almost half a billion pounds of NHS spending being invested in social care services alone, we are looking at new ways of delivering services that meet the changing needs of people across Scotland. Over £8 billion that was previously managed separately by Health Boards and Councils is now managed jointly by Health and Social Care Partnerships, enabling local systems to ensure people have access to the right care at the right time in the right place, and are supported to stay in their own homes and communities for as long as possible.

“This investment is backed by a huge rise in staffing levels – up nearly 12,000 in the last decade – including significantly increased investment in GP services since 2007."