Trouble at the top - the crisis of confidence in Scotland's NHS leaders

By

Scotland health and social care correspondent

The verdict from Scotland's healthcare watchdog on NHS Grampian could hardly have been more damning.

Major problems at Dr Gray's Hospital in Elgin, but deficiencies stretching across the whole region, a failure to learn from mistakes and "recurring patterns of harm".

Thursday's report from Health Improvement Scotland is more evidence that frontline NHS staff feel they are carrying the can for poor leadership by highly-paid, powerful people at the top of Scotland's health boards.

Centre stage this time is chief executive Laura Skaife-Knight, who earns between £170,000 and £175,000 a year. She ordered this review, but does not escape blame.

The report reveals she was forced into a humiliating apology earlier this year, for giving misleading information about a review into a patient's death during surgery.

Not only did Health Improvement Scotland find the investigation into the death was inadequate, it also found the chief executive then misled Health Improvement Scotland by saying senior executives had not seen the review or signed it off.

In fact, executive medical director Hugh Bishop had been sent the review, and had discussed it in a meeting, but claimed he had "no recollection" of this.

He left his post in recent weeks.

Misinformation provided by Skaife-Knight to the watchdog caused "significant distress" to staff at lower levels, who felt the management had tried to shift the blame onto them.

She apologised to both HIS and the affected staff, and took steps "intended to rebuild trust".

Healthcare Improvement Scotland has described this as the most serious review it has ever had to undertake – and it details a pattern of management failure that goes beyond a single individual.

Weak leadership across the whole of NHS Grampian led to failures in recruitment, in management, in governance.

It highlights repeated failures to act on warnings about patient safety or to learn from mistakes.

For now, the Health Secretary Angela Constance has said she is keeping faith in Skaife-Knight, saying "she has operated with candour" and "put her hands up when she made mistakes".

Constance said almost half of the board had changed, a new chairperson is about to step in and she expects them to hold senior executives to account.

With NHS Grampian already in special measures because of financial difficulties, further escalation is inevitable.

The health secretary said she will update parliament next week on what further action the government will take.

Public perception around their performance will be a talking point for the government and MSPs as they move forward with plans announced in September to cut the number of health boards from 14 to two.

There is a debate about whether this is the right move for patients, but there is also a question over whether huge structural changes can improve the accountability of NHS leadership or not.

For now it is the north east of Scotland in the spotlight, but these are themes that will resonate with NHS staff right across the country.

In July, emergency medicine consultants in Glasgow wrote to Health Improvement Scotland warning of a risk of "whole-system failure" and ongoing risks to patient safety.

The doctors said the situation in the emergency department at the Queen Elizabeth University Hospital had deteriorated since an inspection in 2024.

They, too, held health board executives responsible, noting staff had scored their confidence in leadership at 32/100 in a recent survey.

They questioned the transparency of their chief executive, Prof Jann Gardner, claiming she encouraged them to engage with a 2025 independent review of culture and relationships, the results of which have never been published.

NHS Greater Glasgow and Clyde said it continued to address the issues raised and that a programme of improvement work was ongoing.

Elsewhere, the chief executive of NHS Ayrshire and Arran also stepped down this year, after it suffered financial near-collapse

No-one can doubt NHS bosses have a tough job but they are all paid generous six-figure salaries.