A recipe for real reform

In her latest TFN column, our Chief Officer Sara Redmond reflects on the proposal to collapse Scotland's 14 regional health boards into two.

Real health and social care reform isn’t built by redrawing administrative maps. It is built on people, partnership, and lived experience. At the ALLIANCE, we represent over 3,500 members, from grassroots community groups and national third sector charities, to individuals sharing their personal lived experience of their conditions and health and social care. In almost every conversation I have across our network, what I hear is the same. People are exhausted by navigating the current system – one that feels fragmented, under-resourced, and distant. 

That is why the proposal to collapse Scotland’s 14 regional health boards into two “superboards” caught my attention for all the wrong reasons. My first thought went straight to the grassroots organisations and carers I speak with every week. Handing down top-down, “oven-ready” plans as a done deal ignores the reality of public service reform; you can’t cook up lasting change in isolation. If government wants to build a system that actually delivers, they need to invite us into the kitchen to help write the recipe. 

If we have learned anything from the recent, difficult lessons of the National Care Service process, it is that sweeping administrative centralisation solves very little on its own. Merging 14 boards into two sounds bold on paper, but unless government and authority boards commit to working together with lived experience at the heart, we risk making the same mistakes. The question that rings in my ears most is: will redrawing administrative maps actually make life any better for a person waiting in pain for treatment, an unpaid carer on the brink of burnout, or a local charity struggling to keep its services running? 

The blunt truth is that administrative shuffling rarely transforms frontline reality. Changing letterheads, merging executive teams, or adjusting management structures might look like radical action from behind a cabinet table. But it does nothing on its own to cut waiting times, tackle entrenched health inequalities, or prevent people from hitting crisis point.  

Over my time at the ALLIANCE, I have learned that people in Scotland do not fear reform. What they fear is change that is done to them rather than with them. People do not want change to be decided upon in isolation, change that will end up making their daily lives harder. 

If government is serious about genuine reform, the focus must shift to what actually keeps communities well, whether it is investing in prevention, securing fair, multi-year funding for the voluntary sector, or embedding human rights into service delivery. Our members and the rest of the third sector are not an optional extra to the NHS; they are the bedrock of community health. Yet too often, they are left picking up the pieces whilst facing their own financial precarity. 

That is why the way government operates must fundamentally change. The expertise to fix our services already exists. It lives in our communities, within our third sector, and among the people who draw on support every day. If the government wants this Programme for Government to succeed, it must match radical ambition with radical partnership.  

At the ALLIANCE, our members stand ready to bring their expertise to the table. The true measure of success will never be how few health boards exist on paper, but whether a person seeking care experiences a fairer, kinder, and more responsive system. It is time to open the doors, bring people into the room, and build that system together. 

This article first appeared in the September edition of Third Force News.

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