The NHS in Scotland faces substantial and deep-rooted problems with declining standards of patient care after struggling with cuts in its budgets, Scotland’s official spending watchdog has warned.

Audit Scotland has revealed that the NHS missed seven of its nine key performance targets, including on accident and emergency, treatment deadlines and children’s mental health It faces severe recruitment problems in areas such as A&E and is failing to implement major reforms.

It said Scottish government funding for day-to-day NHS services and new hospital buildings had fallen by 0.7% in real terms over the last six years – despite ministers’ claims that funding had been protected. Two NHS boards needed emergency loans, with NHS Tayside forced to seek £14m last year to help meet its costs – the third year in a row that was necessary.



In a direct challenge to repeated government assurances that standards were improving, Caroline Gardner, the auditor general, said the quality of many NHS services had been steadily worsening, particularly with meeting performance targets and staffing.



Despite repeated warnings from earlier Audit Scotland reports, Gardner said that these problems “have intensified over the past year, as has the urgency for fundamental changes such as introducing new ways to deliver healthcare and developing a national approach to workforce planning.”



The report said the Scottish government’s own programme for reforming the NHS, its so-called “2020 vision” to improve home and community-based care, was failing to meet its objectives. It said there was “limited evidence of progress towards achieving the 2020 vision.”



It was unlikely, the report added, that all the necessary changes would be in place by 2020. But attempts to introduce crucial longer-term reforms was being hampered by heavy day-to-day pressures.



“Tightening budgets combined with rising costs, higher demand for services, increasingly demanding targets and standards, and growing staff vacancies mean the NHS will not be able to continue to provide services in the way it currently does. Together, these pressures signal that fundamental changes and new ways to deliver healthcare in Scotland are required now,” it stated.



Opposition parties said the annual survey showed their long-standing concerns about the Scottish National party’s stewardship of the NHS were justified, while doctors and nurses leaders said it underlined the need for urgent and far-reaching structural reform.



Dr Peter Bennie, chair of the doctor’s body BMA Scotland, said the NHS was coming under real strain. “The overriding message that must get through from this report is that substantive and realistic action is needed if our health service is to cope with the rapidly increasing pressures it is facing,” he said.



Jim Hume, health spokesman for the Scottish Lib Dems, said it showed the service was “in need of intensive care”. Jackie Baillie, Scottish Labour’s public services spokeswoman, said it established that the NHS was limping along with ministers using a “sticking plaster approach” to improving services.



“Nicola Sturgeon wants people to judge her on her record, but this damning expert report shows that the SNP government in Edinburgh has cut the NHS budget, and patients and staff have suffered as a result,” Baillie said.



Scottish ministers said that NHS funding was actually rising more quickly than Audit Scotland suggested, and implied it was downplaying successes in cutting hospital infection rates, greatly improving waiting times against previous levels and record staffing levels.



Shona Robison, the Scottish health secretary, said that based on 2015-16 prices and latest Treasury data, spending on providing day-to-day NHS services had grown by 5.8% over the last five years. Capital spending had fallen because building work on the £842m Queen Elizabeth hospital in Glasgow had ended.



Describing the report as Audit Scotland’s “annual contribution,” Robison agreed that the pace of reform needed to intensify. Since the report was written, the first minister, Nicola Sturgeon, had unveiled £200m on specialist operations for the elderly; there was a new £60m primary care fund and new GP contracts on the way.



“The Scottish government has a clear vision for the future of our NHS and we will continue to take the right action to ensure that Scotland continues to have an NHS that it can be proud of today and in the future,” she said.



“Scotland’s NHS is now performing better against tougher targets, and as Audit Scotland highlights, we have a record high workforce and the level and quality of care provided to patients has contributed to people living longer along with continued advances in diagnosis, treatment and care.”



But the Audit Scotland study said funding levels were a substantial problem with all 14 of the NHS’s regional boards experiencing significant cost pressures but being prevented from undertaking long-term financial planning by ministers.



“All territorial NHS boards are finding it increasingly difficult to meet performance targets and standards while remaining within their annual budgets,” it said, adding: “Ongoing financial pressures, combined with greater activity and demand, made achieving targets and standards more difficult.”



Ellen Hudson, associate director of the Royal College of Nursing Scotland, said the report underlined the RCN’s own warnings and its call for urgent and substantial reform. “Demand for NHS services is outstripping available resources, putting patients and staff under huge pressure; Scottish government performance targets and standards have had their day and we need to find new ways for health boards to focus on the long-term sustainability of services,” she said.

