Our Path Ahead: Chief Medical Officer for Scotland Annual Report 2025–2026

Introduction

The health of Scotland’s people is at a critical juncture. We are facing huge challenges as a country - some long-standing, others new and rapidly emerging. The pace of change in care delivery and technology is accelerating. The complexity of the people we care for and the treatments they require is deepening, and our resources are finite. Taken together, these pressures are reshaping not only what people need from health and care, but also how our systems respond. These influences can be unsettling. To meet these challenges and create a better future, we must be prepared to disrupt the status quo and forge a new path that retains our focus on caring for people.

Across every part of the health and care system, the environment in which we work is shifting faster than our traditional models were designed for. The magnitude of challenge- from demographic change to digital disruption, from widening inequalities to the planetary health crisis- demands clarity of purpose and the courage to act differently. The complexity we now face is not a temporary surge; it is the new normal. No health system has unlimited resources so stewardship is a core responsibility, essential to achieving the outcomes that matter most.

But there is real cause for optimism. With patients and communities at the heart of what we do, change and adaptation can be a force for good, even in unsettled times. The development of a Population Health Framework reflects a growing, shared commitment to preventative approaches to illness, while emerging technologies offer new ways of supporting better care and experiences. These developments signal a moment of opportunity. If we are willing to lean in, bringing our experience, insight and care to the table, we can harness new approaches, challenge models that no longer serve and shape systems that better support careful, kind care for the future.

Change will not be immediate. Like water flowing over rock, deep channels are cut with time. But by deliberately diverting the course, by choosing where we focus, how we lead and how we work alongside the people of Scotland, we can carve a different path. This moment requires not only innovation, but realism; not only ambition, but stewardship; not only new tools, but renewed trust. Harnessing the benefits of disruptive innovation whilst protecting the human element of care will allow us to take these next steps on our path with hope.

This report frames the journey ahead: how our systems can support careful, kind care in the face of rising need, how we respond to disruption and how we create the conditions for health beyond clinical walls. The challenge is significant but so too is our collective capability and capacity to meet it. Realistic Medicine reminds us that progress must be guided not only by innovation, but by trust, shared decision-making and a relentless focus on what really matters to people. Careful and kind care must remain at the heart of everything we do.

This is not an argument for blind optimism. It is an argument for optimism that is careful, rigorous and analytical – often hard-won but grounded in evidence and lived experience. By keeping people at the centre of every decision, we can ensure that adaptation strengthens care rather than diminishes it, even in challenging and uncertain times.

A Changing Landscape

The pace and scale of healthcare progress over the last century have been extraordinary: from antibiotics to global vaccination programmes, from the discovery of DNA to modern gene-editing technologies that offer hope for conditions once deemed incurable.

Our workforce has changed and diversified just as profoundly, and this matters because representation matters. When the workforce reflects the society it serves, care benefits from a richer breadth of perspectives and lived experience. Today, Scotland’s health and care workforce is more ethnically diverse than ever before and includes people who have come to Scotland from outwith the UK, bringing international insights to our work. Nearly one in fifty across the health workforce declares a disability. While structural barriers persist, diversity strengthens our collective capacity to improve, innovate and deliver care that meets the needs of the entire population.

In 2024, female doctors outnumbered males on the GMC register for the first time in history. This milestone builds on the legacy of trailblazers such as the Edinburgh Seven, medical students who were the first ever female matriculated undergraduate students at any British university. Their struggle opened the door for future generations. In Scotland, females have made up the majority of doctors since 2017, reflecting earlier changes in participation.

‘Rivers’ by clinical research fellow Dr Charlotte Squires; animated by animation students Lauren Sharma, Isa Philipou and Leon Smith from Edinburgh College of Art.

This poem was created as part of the Edinburgh Medical School 300 project, marking 300 years of medical education at the University of Edinburgh.

Alongside scientific and social change, expectations of health and care have evolved. People expect care that is safe and effective, but also accessible, respectful and responsive to the realities of their lives. Trust is shaped not only by clinical outcomes, but by whether people feel listened to and treated with dignity.

A Decade of Realistic Medicine

Ten years ago, Scotland set out a new vision for care through Realistic Medicine. Over the decade since, this approach has reshaped how we think about care: embedding shared decision making, personalised care, reduction of unwarranted variation, risk management, innovation and stewardship. What began as aspiration has become everyday practice, supported by measurement frameworks, toolkits, best practice casebooks and positive feedback from Citizens’ Panels. Value-Based Health and Care has widened this focus to system level, guiding us toward the outcomes that matter most.

The context has, however, grown more challenging: more complexity, more demand, faster change and tighter resources. To continue improving outcomes and experience, we must remain committed to these principles. Realistic Medicine provides a steady compass in times of disruption, enabling us to navigate change with purpose, clarity and compassion.

Trust

Trust is the bedrock of care. We will all rely on care at some point in our lives, and it works best when people trust professionals and systems to act with compassion, respect, integrity and confidentiality. That trust extends across the whole workforce—from clinicians and care staff to administrators and system leaders—and into the structures that surround care: how information is handled, how decisions are made and how reliably care is delivered.

Trust has both a personal and a public dimension. People must be able to trust individual professionals when they feel vulnerable and uncertain. But trust is also placed in institutions: in health services, in public authorities and in the way resources are stewarded on behalf of the population. In an era of rapid change, misinformation and pressure on public services, this collective trust cannot be taken for granted.

Trust is foundational, yet fragile. For some individuals and communities, it has been weakened by repeated experiences of not being heard, by barriers to access or by systems that feel remote or unresponsive. When trust is weakened, it affects not only how people engage with services, but whether they feel able to take up the advice and treatment offered, or whether they feel safe seeking help at all.

Trust is not self-sustaining; it is earned through action. It is built by listening well, making decisions with people rather than for them, protecting confidentiality and being honest about uncertainty and limits. At a system level, trust is earned through fair and transparent use of resources, secure handling of information, reliable processes and open communication—especially when things go wrong. In a period of profound disruption, protecting trust is not a constraint on change, but a precondition for it.

Our Path Ahead

We begin with a simple, clear conviction: careful and kind care is not a luxury to be set aside in difficult times, but a foundation for a resilient and sustainable health and care system. As pressures grow and choices sharpen, values matter more, not less.

Across this report, I set out why systems must be designed to serve people; how disruptive forces such as digital innovation and the changing information landscape challenge trust and demand active stewardship; and why long-term health depends on the conditions of everyday life. These themes are deeply interconnected. With people at the heart of what we do, adaptation can strengthen care rather than erode it.

What follows is not a technical blueprint, but a shared statement of purpose. Here I call for honest conversations about not only what we can do, but what we should do; for courage to do things differently; and for humility to listen to what matters to those we serve. In this way, we will create the conditions for careful, kind care to flourish, day by day, even in unsettled times.

Professor Sir Gregor Smith

Chief Medical Officer for Scotland