Health and care performance and promises: the track record for Scotland’s 2026 election

Health and social care play a central role in the ongoing electoral campaign for the Scottish parliament. One in two Scots (50%) believe that these issues are among the most important facing Scotland today, with no other issue apart from the economy (62%) being chosen by even one in three. 

Reflecting this, rival politicians have been filling the airwaves with arguments over NHS performance and social care reform, and issuing promises for improvement. First Minister John Swinney says his government’s “is delivering a better NHS for the people of Scotland”, while Scottish Labour’s Anas Sarwar says “waiting lists are soaring, patients are being let down”. 

Who is right? What has really been going on in Scotland’s NHS since the last election in 2021? And are the emerging manifestos likely to set a path for improvement from here? 

This briefing draws on administrative data on health and care performance, spending and staffing in Scotland and the other countries of the UK, as well as survey data and other public information. Where possible, we draw comparisons with other UK countries with comparable data to understand how services in Scotland compare. We examine public statements from the main political parties in Scotland about the NHS to assess their commitments. We have looked at the five parties which recent opinion polls suggest will attract the most regional votes – the Scottish National Party, Labour, the Conservatives, the Green Party and Reform.

The headlines: NHS performance

Statistical analysis by the Nuffield Trust of results on health and care from the British Social Attitudes survey, which are analysed and published by the Nuffield Trust and the King’s Fund, suggests that waits in A&E and for planned care are linked to public satisfaction. These have been prominent in Scottish election discourse too.

The Royal College of Emergency Medicine for Scotland has said members are “crying out for help” as patients spend longer stuck in A&E than ever before, while Cabinet Secretary for Health and Social Care Neil Gray has claimed emergency departments are outperforming the rest of the UK. Both have a valid point. 

People in Scotland are much more likely than they were five years ago to spend more than four hours, or even more than 12 hours, waiting to be admitted or sent home from A&E. However, as the chart below shows, the same happened across the UK during and after Covid-19, and Scotland’s major A&E departments performed slightly but consistently better before, during and after this slump. 

The longest 12-hour waits show a similar pattern. They have risen alarmingly, from practically nobody at all waiting this long in 2021, to around 8,000 people a month over the recent winter – more than one in 15 of all attendees. But even that is a lower level than England, where around one in 10 have recently been waiting that long.

Interestingly, there are signs that the Scottish public may recognise this. In the British Social Attitudes survey, Scottish respondents were significantly more likely to be satisfied with the way A&E services ran – at 40%, compared to 21% in England and 14% in Wales.

For appointments and procedures planned in advance, a similar picture of collapse during and after the pandemic is seen in the data published by each UK country.

Scotland no longer collects information on the total number of people waiting after referrals, making comparisons with England and Wales difficult. But polling data suggests it lies in between the two, with Scots waiting longer than people in England, but not as long as people in Wales. The same pattern was consistently seen in the comparable data before it was discontinued in 2025. 

Looking at performance across the last parliament, progress in recovery has been slow. The Scottish NHS has seen the waiting list fall slightly over the last year for outpatients, but the number of people waiting for a planned hospital admission is not falling, and the length of time they wait is stubbornly high.

Use of resources in the NHS

Ever since the start of this century, Scotland had generally spent more per person on health than any other UK country. During the 2021-2026 parliament, that came to an end. Northern Ireland spent around the same amount in day-to-day revenue funding, for everyday costs such as salaries, while Wales spent more. In 2024/25, spending in Scotland remained 8% below its pandemic peak in 2020/21. In both Wales and England, it was already 4% higher.

For a longer period, since 2017/18, Scotland has been investing the least out of all the UK countries in health service capital, which includes hospital buildings, medical equipment or IT infrastructures, per head. Interestingly, its investment in medical research capital has become the highest in the UK over the same period, at £75 per capita, compared to just £34 in England.

The picture of historically high spend is reflected in a high level of clinical staff per person in Scotland. At 13 in every 1,000 residents, the density of registered nurses in Scotland is higher than in Wales (12) or England (10), though less than in Northern Ireland (15). The number of registered GPs per 100,000 people in Scotland, as well as the number of FTE (full-time equivalent) fully qualified GPs working in the NHS, is the highest out of all the UK countries where comparable data exists.

Despite the comparatively large workforce, most of the past five years have seen an ever-increasing workload for GPs. Analysis by the BMA suggests that a single full-time GP in 2025 is responsible for 1,681 patients – about 90 more patients than in 2019. An Audit Scotland report found that the 2018 GP contract failed to deliver on its commitments. 

Spending in general medical services and general dental services have both decreased by 6% from 2021/22 to 2025/26, and have fallen slightly as a proportion of health spending, as shown in the chart below. Education and training of the workforce has also seen expenditure decrease by a fifth from the start of the last parliamentary election.  

However, most recently, in 2025, there has been a significant increase in both the number of GPs and the number of appointments provided. Adjusting for the number of patients registered, the number of appointments with clinicians rose by over 4% compared to the previous year, driven by the last few months. For the new financial year 2026/27, which began on April 1, the Scottish government has increased GP funding faster than the wider health budget – by £98 million as part of a three-year deal.

Comparing hospital efficiency across UK countries with any precision is impossible, and all appear to have seen their ability to treat patients damaged by the Covid-19 pandemic. The Institute for Fiscal Studies has noted that Scotland has taken longer to recover to pre-pandemic volumes of treatment – though they also note its greater reduction in spending since the pandemic.

Length of hospital stay is one measure relevant to efficiency, because if it is lower, more patients can be seen by a given number of staff overseeing a given number of beds. In Scotland, length of stay peaked at 7.1 days in 2022/23 – passing the seven-day average threshold for the first time in at least a decade – and then decreased to around 6.7 days in the past two financial years. Patients in Scotland stay almost about two days longer in hospitals than in England, though less than those in Northern Ireland.

Emergency admissions can serve as an indicator of how well a health service is doing in keeping people well. In Scotland, they decreased by 16% during the pandemic then increased by the almost same amount to 11,271 emergency admissions per 100,000 population in 2023/24, and remained at a similar level in 2024/25. Wales and England have remained somewhat further below their pre-pandemic levels of admissions.

Scotland has progressively spent more on social care per head in the last decade, overtaking Wales and rising consistently faster than England. In particular, spend per head on working-age adults with a disability has grown fast, increasing by 37% in 2022/23 compared to 2016/17, presumably driven by the expansion of free personal care to adults under 65 in 2019 taking full effect. Increases in overall spend on social care will also be driven by positive improvements to strengthen terms and conditions for the workforce, including the mandating of the Real Living Wage for staff in the independent sector – with planned increases to the Scottish Real Living Wage this year.

Although spending has increased in the last decade, pressures in the sector remain stark. Councils this year called for an additional £750 million from the Scottish government to meet their rising social care needs, as well as the costs of implementing changes to workforce pay, which councils will have to bear. While demand has likely risen, the number of people supported by local authorities has remained broadly stagnant. The consequence is that more people will be going without care and support to meet their needs, and more will fall onto unpaid carers, with repercussions on their carers’ own wellbeing.  

Pressures in social care will be felt across the whole health and social care system, for example for people who are waiting for long-term care after an acute hospital stay. In 2024/25, there were over 720,000 days spent in hospital by people awaiting to be discharged – the highest figure in the current reporting period since 2016. 

Almost a third of these delays occur because a person is waiting for a place in a community or social care setting, indicating the pressures on capacity. A further 40% are waiting for their care to be arranged or assessed – highlighting the pressure on social work arrangements undertaken by councils. 

While discharges that are delayed have reduced as a proportion of all hospital discharges, the total number of hospital bed days lost to discharge delays over the course of a year has increased by about 180,000 in 2024/25 compared to 2019/20. In other words, fewer patients experiencing delayed discharges but spending more time in hospital.

Most parties have steered clear of bold or large-scale reforms for social care and stuck to – unfunded – commitments to improve conditions for staff and unpaid carers, as well as better integration to address discharge delays, perhaps phased by the current government’s failed attempt to deliver their vision for a National Care Service. The reforms, which are legislated for, would have moved accountability for social care to the Scottish government. The withdrawal of support from councils, and scrutiny over whether the plans represented an appropriate use of public funding, led to the plan’s demise. 

The challenges ahead

The health and care sectors in Scotland have real points for pride, such as relatively good A&E waits and a more comprehensive social care system. However, the problems people face in accessing them are serious, and these problems are not rapidly improving. Whichever party or coalition of parties forms a government following the election faces the need to build up the capacity of planned care, core general practice and social care simultaneously. 

With funding from the UK government already set on an austere path in last year’s Spending Review, this will not be an easy task. Any of the competing parties would find they enter government or coalition talks with a manifesto containing many promises without money set aside; nothing in the kitty for social care; and many promises which go well beyond these core tasks.

Like all parts of the UK, Scotland suffered a serious NHS productivity hit during Covid-19, and still carries out less care per member of staff and per pound spent than it did before. The data also shows clear signs that people are spending longer in hospital. The issue of efficiency has been little mentioned on the campaign trail, but addressing it with honesty and patience will be among the few chances the new government gets to make its difficult choices easier.