Scotland’s Health Secretary, Shona Robison, has given what appears to be the clearest signal yet that a review of the structure of the NHS will be on the list of priorities of a new SNP government.

Speaking during a lively election hustings event in Edinburgh organised by the Health and Social Care Alliance Scotland, Ms Robison also made it clear that it would not just be the 14 territorial boards under the microscope but the national NHS bodies as well.

Ms Robison said she felt shifting the balance of care to community settings, and building outcomes-focused community care systems, needed to be speeded up. And, in response to a question about why some boards sent patients to the Glasgow-based Centre for Integrative Care[i], while others did not, she said:

“I have visited the Centre. We need to make sure that boards know of the work it offers. Some boards have decided not to refer, while others have.”

She added that, now the integrated health and social care partnerships (Integration Authorities) are up and running, “we are having to look at the world of governance. We still have 22 boards. Within that we are looking at some if the services that will lend themselves more easily to becoming national services.”

There have been predictions of a reduction in the number of NHS boards in the past, including from me, but their number has remained at 22[ii]: 14 territorial boards varying in size[iii] from Greater Glasgow and Clyde (serving a population of 1.1 million) to Orkney (serving a population of 21,500); and seven “Special NHS Boards” and one public body (Healthcare Improvement Scotland).

Rationalisation is clearly on the agenda for a party that delivered a single police force and a single fire and rescue service. Equally, it would be easy to see how the Scottish Government has not rushed into redrawing the map of NHS boards until they had the Integration Authorities in place.

It is no secret that minsters have been exasperated by the way that many NHS boards have on many occasions paid only lip-service to government policy, have followed the letter but not the spirit of instructions in letters from government officials and allowed local decision-making to look like ‘postcode lottery’ variation. A previous health secretary wondered out loud why Scotland needs 14 Area Drug and Therapeutic Committees to make decisions on decisions already made by the national Scottish Medicines Consortium. At the Alliance hustings, Ms Robison, meanwhile, made a veiled criticism of those NHS board chief executives who had failed to sell the integration agenda to their staff.

While Ms Robison only mentions a review of governance in passing, others have been more forthright.

SNP MSP Kenneth Gibson saw the frustrations of national policy not always being reflected in local action when he was convener of the Scottish Parliament's Finance Committee. Had time allowed, the SNP’s conference last month would have discussed a resolution from the Cunninghame North MSP urging consideration be given to merging health boards and local authorities to “create more strategic bodies”.

Mr Gibson can safely be regarded as being in tune with those leading the SNP. Although his resolution was not discussed, he shared his intended speech with Holyrood Magazine[iv] [declaration of interest[v]].

Mr Gibson said he regarded the structure of local government and health boards as “neither sustainable nor desirable”, and proposed that health should fall under the control of “reinvigorated” local authorities, which might be merged “where appropriate”.

Referring to the evidence from many different witnesses to his committee, Mr Gibson intended to tell the conference:

“What has been repeatedly emphasised is that ‘silo’ mentalities are still prevalent in too many areas, with budget design in isolation and single outcomes approached from different directions across different performance frameworks with inconsistencies across the country.

“Whether one considers the delivery of services, economic development or improved health, the current model of 14 health boards and 32 local authorities is neither sustainable nor desirable. 

“Curiously, the current structure has many local authorities that are not quite big enough to drive optimal economic development, whilst at the same time being seemingly remote from the citizen.

“So how do we square this circle? Firstly, by taking health under re-invigorated local authority control whilst merging – where appropriate – local authorities.”

It would be a surprise given Ms Robison’s comments if some sort of ‘review of governance’ of the NHS – and logically local councils as well – is not in the SNP’s manifesto.

The SNP will certainly form the next Scottish Government so the wording of the manifesto promises matters, whether it commits the party to a review or a reduction. How such plans are framed will also be important. A narrative around reducing the number of managers and directors and increasing investment in carers and ‘front line services’ will go down well with patients and service users but less well with managers and directors. All are voters.

The central question for any review of the NHS map thereafter will be: from 22 to how many?

One popular discussion subject amongst Scottish health policy watchers in recent years has been about how many territorial NHS boards Scotland needs. The Cancer Networks with their oncology centres of excellence are sometimes cited – there are three such networks for Scotland, although one operates across two centres. Another model might be based around merging smaller Boards with larger ones where there are already some shared services. This gives you perhaps eight or four, and the potential for a lot of rancour.

My belief is that, in terms of Primary Care – community health services and General Practice – the number will be, and already is, 31. For all intents and purposes, the new integrated partnerships will take over local provision from territorial boards.

For everything else done by the current boards, secondary care (hospital services) and tertiary care (specialist centres), I increasingly believe that there will be single national authorities, albeit with accountability to the local integrated partnerships as well as the government.

There will be many people reading the SNP’s manifesto with interest.

[i] Centre website http://www.nhsggc.org.uk/patients-and-visitors/main-hospital-sites/gartnavel-campus/nhs-centre-for-integrative-care/

[ii] NHS Bodies http://www.gov.scot/Topics/Health/NHS-Workforce/NHS-Boards

[iii] Scottish Public Health Observatory http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-projections

[iv] Holyrood Magazine article March 2016 https://www.holyrood.com/articles/news/structure-local-government-and-health-boards-neither-sustainable-nor-desirable-claims

[v] I was editor of Holyrood magazine in 2001 - 2003 then Chief Executive in 2005