Holyrood should give NHS Scotland its independence

GOVERNANCE OF NHS SCOTLAND has long been centralised, with the Scottish Government exercising considerable influence over Health Boards. Currently, the Chair and all non-executive members of each Health Board are formally appointed by the Cabinet Secretary for Health and Social Care. Even though non-executive directors are intended to provide independent oversight, their structural accountability to the government limits the degree of genuine independence they can exercise. In practical terms, no member of a Health Board is fully autonomous from government influence.

Each health board is, in essence, all the King’s men.

This arrangement has advantages. Centralised appointments ensure that Health Boards align with national health priorities and execute government-led strategies efficiently. But it also presents a trade-off: non-executive members, who are supposed to challenge decisions, scrutinise budgets, and hold executives to account, are constrained by the system that appoints them. The consequence is a board structure that prioritises policy alignment above oversight, and one where the checks and balances within the system are arguably weaker than in other governance models.

Imagine, then, a radical alternative: non-executive members are appointed on a cross-party basis and report directly to the Scottish Parliament rather than the Cabinet Secretary. Such reform would fundamentally shift the balance of accountability in NHS Scotland. Instead of being primarily answerable to the government of the day, non-executives would operate as an internal yet independent oversight body, accountable to elected representatives across the political spectrum.

The potential benefits of this model are significant. First, it would enhance board independence, allowing non-executives to challenge executive and policy decisions without fear of political repercussions. Cross-party appointments would help ensure that boards are not dominated by a single political perspective, creating a broader and more balanced view of health priorities. This structure could provide more robust scrutiny of strategic decisions, from budget allocation to service redesign, and foster a culture of transparency and accountability that goes beyond ministerial oversight.

Second, reporting to Holyrood rather than a minister would increase democratic legitimacy. Parliamentarians from multiple parties, representing the electorate, would have a direct channel to monitor the performance of non-executive directors and, by extension, the Health Boards they serve. This could strengthen public confidence in the NHS as a national institution and reduce perceptions of politicisation in appointments. Non-executives would effectively become guardians of system integrity, tasked with safeguarding patient care and organisational standards above party priorities.

One could argue debacles such as the Sandie Peggie case, and the heartsink experience of the Queen Elizabeth Hospital in Glasgow, could have been dealt with sooner and better with such oversight. We will never know.

However, there are also challenges to consider. Cross-party appointments may introduce complex dynamics into board decision-making. Political disagreement could slow strategic decisions or create conflicts between non-executives and executives. Boards would need to establish clear protocols to maintain operational efficiency while preserving the independence of non-executives.

Furthermore, this model could be criticised as politicising appointments in a different way: while it reduces ministerial control, it introduces parliamentary politics into the boardroom, which could risk decision-making being influenced by political negotiation rather than evidence-based healthcare priorities.

Comparisons with other parts of the UK provide valuable context. In England, NHS Foundation Trusts already feature a form of local accountability: their boards, particularly non-executive directors, are appointed by a Council of Governors representing the public and staff. This gives boards a degree of independence from central government that Scottish Health Boards lack. A cross-party, parliamentarily accountable model in Scotland would combine elements of this independence with a uniquely political form of oversight, offering a potential hybrid that is both nationally coherent and democratically accountable.

The practical implementation of such reform would require careful design. Appointment panels could be established with representatives from multiple parties, ensuring balanced selection. Terms of office might be staggered to avoid mass turnover aligned with election cycles, and reporting mechanisms to Holyrood would need to balance transparency with operational autonomy. Guidelines would be necessary to clarify how non-executives interact with executive leadership, ensuring that independence does not compromise the boards’ ability to implement policy or manage day-to-day operations effectively.

Ultimately, the case for cross-party, parliamentarily accountable non-executives is not about undermining government policy. It is about strengthening the governance of NHS Scotland by embedding independence, scrutiny, and accountability into its boards. In a system where public trust is paramount, and where decisions can have life-or-death consequences, enhancing the ability of non-executive members to act as a check on executive and ministerial power could represent a meaningful step forward.

Scotland has long led the way in healthcare innovation and policy experimentation. Reforming non-executive appointments to create boards that are independent, cross-party, and accountable to the parliament rather than the minister could be the next frontier – one that rebalances power, strengthens oversight, and reaffirms the NHS’s commitment to serving the public above politics.