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

Chapter 1. Systems that Serve

To provide careful, kind care and better outcomes and experiences, we need systems designed to promote dignity, humanity and trust. Systems that serve well create the conditions for high-quality encounters, support staff to do good work and help people live healthier lives with minimal disruption, while respecting people’s precious resources of dignity, time, energy, trust and attention.

What is careful and kind care?

Careful care is founded on principles of quality, safety and the tailored use of best available evidence. More importantly, this approach means considering a person’s health conditions in the context of their unique circumstances and priorities, not just their biological data.

Kind care means having respect for a person’s most precious resources – their dignity, time, energy, trust and attention – and making sure that healthcare’s footprint upon these resources is minimally disruptive.

In previous reports, I have set out six enablers that guide how careful and kind care should be practised. These focus primarily on the actions, judgments and behaviours of individuals and teams. But even when people are motivated and committed, intention alone is not enough.

Enabling careful and kind care

• Focus on understanding and supporting people to achieve their goals
• Balance biography and biology when applying evidence-informed practice
• Collaboration is key to providing care that people value greater job satisfaction
• Use resources wisely to provide sustainable care for our planet
• Measure the right things including outcomes that matter to people
• Kindness and compassion sit at the heart of the way we deliver care

Every system is perfectly designed to get the results it gets. Delivering careful and kind care means acting on those six enablers in everyday practice –and the ability to act depends on the systems within which people work. Structures, processes and culture shape what is possible day to day. By promoting good access and continuity, supporting inclusion and collaboration, caring for the workforce and nurturing positive, compassionate cultures, systems can design in the conditions that protect dignity, enable humanity and sustain trust.

To improve care, we must therefore understand how system design shapes experiences and outcomes.

We manage what we measure. And it is possible that sometimes we measure too much or direct our finite capacity to measure or manage the wrong things. While we track discharges, diagnoses and waiting times, we must also capture the quality of encounters. Patient-reported outcome and experience measures (PROMS and PREMS) reflect the true purpose of healthcare – to serve people. To deliver care that matters, we must measure what is meaningful.

Mintzberg suggests modern healthcare suffers from success rather than failure. Through scientific advances, innovation and improved care, we are able to diagnose more, treat more and help people live longer lives. These are achievements to be celebrated. But they also bring consequences: greater complexity and rising costs.

Society has not kept pace with the implications of this success. We cannot afford to address this problem by imposing fixes that focus only on managing demand or tightening processes. To do so risks squeezing the very care interactions that matter most, leading to moral injury of the workforce and poorer care for those we serve.

Scotland’s Health and Social Care Service Renewal Framework offers a timely opportunity to respond differently by focusing not on doing more, but on doing what matters. Through value based health and care, we can align system design with the outcomes people value, while reducing the harm and waste that exists in every health and care system. Realistic Medicine is essential to delivering this reform: it provides the principles, shared vision and tools needed to support careful and kind care.

Conditions for careful and kind care

Compassionate systems consistently engender trust. Trust does not arise solely from the actions of individual health and care workers; it is shaped by the systems that surround them and through experiences of care. To deliver careful and kind care, we must deliberately create conditions that make such care possible and sustainable, even under pressure. These conditions include, among others, continuity and integration, accessibility, inclusivity, support for staff wellbeing and positive cultures. When systems are designed in this way, they do more than enable high-value care, they help build communityship- supporting trust, connection and shared purpose.

Continuity

Relational continuity of care allows trust to build over time. When people are known and heard, care becomes safer, more effective and more humane. Seeing a familiar clinician or team positively influences clinical outcomes across the life course. Continuity is valued both by professionals and by people who use services. It is especially vital for those facing healthcare inequalities or living with complex needs, for whom sustained, trusted relationships can be the difference between disengagement and effective care.

Continuity cannot be achieved through relationships alone. While relational continuity enables trust and safer, more personal decisions, it must be supported by strong informational continuity. People across Scotland tell me that we need digital systems which ‘speak to one another.’ Too often, people move through primary care, assessment units and specialist wards only to repeat their story again and again. This can be exhausting, risks important details being lost and undermines trust in the ability of systems to listen and be consistent.

Accessibility

Great care only helps if people can reach it. Those with the greatest health needs often face the greatest barriers to accessing quality care.

One way to improve access is to understand who is missing from our systems and why. Missingness describes the repeated non-uptake of care in ways that negatively affect health and life chances. It is more common among people with lower health literacy, social complexity or mistrust of services, and it exacerbates existing health inequalities.

Missingness is shaped by life circumstances and structural barriers, not personal choice failure. It is the responsibility of the system to deliver healthcare in a way that is inclusive, flexible and accessible - not the responsibility of the individual to fit the system. This reinforces the need for outside-in design: with services built around the realities of people’s lives. The Population Health Framework reflects this approach through its commitment to a Healthcare Inequalities Action Plan.

Case Study: Palliative Care Services across Fife Health and Social Care Partnership

An evaluation of Fife Specialist Palliative Care (FSPC) revealed rising demand, unmet need and inequitable care delivery, with 80% of FSPC budget allocated to inpatient hospice care where just 4% of the population died. Patients and families called for more responsive palliative care at home. Over the last 5 years, transformation of palliative care services in Fife, in FSPC and across the Health and Social Care Partnership, has improved access to care for people across all settings.

This integrated approach includes:

• A 24/7 District Nursing Palliative Care Helpline facilitating prompt support. In the last 5 years, 86% of people using this were able to die where they lived, rather than in hospital or hospice.
• The Marie Curie Nursing Service providing evening / overnight care in the community
• A 24/7 Single Point of Access for professionals requiring Specialist Palliative Care advice
• 7-day Specialist Palliative Care presence across all care and residential settings, enabling greater continuity

This radical change to care delivery has been realised through resource reallocation, reducing inpatient hospice bed numbers and establishing an agile, responsive, multidisciplinary Outreach Team, equipped to meet complex needs. Twice as many people now benefit from FSPC support, and twice as many people under FSPC now die at home. Importantly, people with the most complex needs remain able to access hospice care.

Recent findings from the Scottish Primary Care Cancer Group and the Scottish Deep End Project show how essential continuity and accessibility are. Socioeconomic deprivation strongly influences cancer outcomes, with higher cancer incidence, late-stage diagnosis and mortality rates in the most deprived areas. Risk factors such as obesity and smoking are more common in these areas, and vaccination uptake, including Human Papilloma Virus (HPV) vaccination which prevents cervical cancer, is lower. These inequalities lead to higher rates of preventable cancer. Differences in screening uptake, survival and earlier onset of multimorbidity further widen the gap.

In this context, continuity and accessibility are not optional: they build trust, enable earlier detection, reduce diagnostic delay and missed opportunities for prevention. Together, they are essential for narrowing inequalities and improving outcomes, particularly for those most at risk. To deliver these enabling conditions, an intentional approach to addressing inequalities is needed, and this intent must be translated into consistent action, including with how resources and workforce are distributed in line with population need and the principles of proportionate universalism.

Access to care is also shaped by how well the system uses its capacity. Clear, consistent pathways matter, particularly when people are unwell or vulnerable. I am encouraged that the Service Renewal Framework commits to creating national referral guidance. By reducing unwarranted variation and improving co-ordination between primary and secondary care, national guidance can help free up capacity and ensure people receive the right care, at the right time, in the right place.

Inclusion

Kind care cannot depend on discretion. When kindness varies according to who we identify with or feel sympathetic toward, it risks reinforcing existing inequities. Inclusive systems actively mitigate bias, for instance through anti-racism, and intentionally embed compassion, equity and nonmaleficence (the ethical obligation to do no harm).

Inclusive systems bring in diversity of perspective by involving those who use services, not just those who deliver them. This means seeking out underrepresented voices, including people who use services, families and communities. Representative codesign and equitable collaboration strengthen trust and lead to better solutions because they reflect the realities of those the system serves.

Collaboration for Better Outcomes

Health and care services can better deliver the outcomes that matter if they are created with, rather than for, the people who use them. Co-design brings together professional expertise and lived experience to understand what the real issues are and shape solutions that make a meaningful difference.

Codesign is more than gathering opinions. Done well, it creates a constructive partnership that values both professional expertise and the knowledge gained through everyday experience of the system. This partnership often brings together people with different roles, perspectives and levels of influence. Equity of participation requires addressing power imbalances between those around the table, as well as widening who is able to be there in the first place. Because involvement is not equally easy for everyone, meaningful participation requires sustained action to mitigate barriers linked to power, structural racism, language, income and social circumstances, alongside recognition and support that reflects what people value. Listening, understanding and acting on this insight is essential.

Case Study: Homes, Heat and Healthy Kids: From Participation to Partnership

The Homes, Heat and Healthy Kids project aims to understand how cold and damp homes affect children’s health. Researchers brought together parents with lived experience to help focus on what matters to families.

Meetings are planned around school hours, expenses are paid upfront, meetings are online where possible and, when in-person, free on-site childcare is provided.

Lived experience is a form of expertise. In research, public contributors are usually compensated for their time; that is important. In this study, together with the Parent Group, the team wanted to go beyond financial recognition, building confidence and creating opportunities. The group created an animation and personal videos about their experiences.

Through their involvement in the study, members of the Parent Group achieved accredited qualifications, giving recognition for skills developed and supporting participants beyond this project. Parents developed skills and confidence through co-presenting at national events and contributing to national policy discussions.

By combining financial recognition with accredited development, the team is building partnerships that strengthen research and the communities involved.

Collaborative approaches are becoming more common. Frameworks such as Public Health Scotland (PHS)’s 2025 public health innovation strategy emphasise the importance of this way of working. Communities and the voluntary sector have critical roles in enabling transformation. This is reflected in the Population Health Framework, which recognises that meaningful change depends on people shaping decisions about their communities, drawing on local experience and assets.

As Professor Don Berwick notes, involving people with lived experience directly in improvement work should feel uncomfortable; it exposes gaps between what we assume matters and what actually matters to people. But by asking ‘What do you need from this system?’ rather than ‘How can we get you to fit into it?’, leaders model shared decision making at a systems level and make it easier for others to take this approach.

Supporting Good Work

Workforce wellbeing is both a moral imperative and a prerequisite for delivering careful and kind care. Across Scotland, health and care professionals are already motivated to provide quality care with kindness. Every day we stretch consultations, skip breaks and make space to listen, bridging the gap between the care we want to provide and what the system enables.

But reliance on goodwill is not a just or sustainable workforce strategy.

When good care depends on staff consistently going beyond what is designed or resourced, the consequences can be chronic overload and compassion fatigue. Burnout risk and distress, notable across health and care professions, are not personal failings but a signal of how work is designed and supported. Closing the gap between what careful and kind care requires and what current systems allow is central to sustaining both workforce wellbeing and care quality.

Wellbeing is not simply the absence of burnout. Good work requires the presence of conditions that enable people to thrive and feel valued: manageable demand, clear and meaningful purpose, supportive leadership and relationships, and professional agency. When systems enable these conditions, wellbeing follows; when they do not, strain, distress and moral injury become more likely.

Workforce wellbeing is integral to care quality, financial performance and the experience of those we care for. Poor workforce wellbeing was estimated to cost the UK £12.1 billion in 2022. A well workforce is more productive, experiences lower turnover and delivers better, safer care.

Delivering careful and kind care sustainably depends on workforce wellbeing being designed in, not left to personal resilience. Adequate capacity—enough staff, time and space—creates the foundation, while strong teams with a shared sense of purpose help good work flourish. Within such teams, it becomes easier to notice when colleagues are struggling and to have the courage to start a conversation, offer support and help connect people with trusted resources such as Practitioner Health, before difficulties escalate. When work is well-designed, unnecessary friction is reduced, work aligns more closely with professional values and people have greater agency. Supported, connected and equipped teams, with time to think, learn and rest, are better able to deliver careful and kind care each and every time.

Meaningful improvement is achievable, and progress is happening across professions. Case studies show how changes to culture, workload, leadership and environment can strengthen good work and improve care. There is national alignment on the importance of improving wellbeing, leadership and culture, with initiatives such as Leading to Change contributing to improvement. But lasting impact depends on whether systems at every level create the everyday conditions—capacity, time, purpose, support and agency—that allow teams to do good work.

My ask of our workforce is clear: practise careful and kind care. The ask of our systems and leaders must be equally clear: create the conditions so this is possible on an ordinary day, allowing careful and kind care to flourish and be sustainable.

Cogs demonstrating relationship of engaged patients, supported workforce, compassionate leaders, culture of stewardship

Culture That Enables Care

Culture is the architecture of a caring system, revealed in everyday interactions and decisions, especially under pressure. It shapes how care is delivered and experienced. Civility- treating one another with courtesy and respect- is a fundamental element of that architecture and is consistently linked to quality and safety.

Culture, however, is neither uniform nor static. Care settings contain many evolving and overlapping subcultures shaped by teams, professions, histories, pressures and expectations. Recognising this complexity is essential. Culture matters deeply, but it is not the explanation for every system failure, nor can it be transformed through simple statements of intent.

Rather than treating culture as a fixed attribute or a convenient culprit, we need to understand which components of culture influence which aspects of performance. Virtuous circles of high performance can contribute to cultures of high expectations; the reverse is also true.

Cultural reform cannot be pursued in isolation. It is fundamentally influenced by the conditions in which we work. Individual effort still matters. Daily acts of professionalism, compassion and care reinforce positive norms. But these flourish only in environments where people are supported to speak up, ask questions, raise concerns and learn- where challenge is welcomed and mistakes are met with curiosity rather than blame.

This report does not attempt to provide a full thesis on culture. Many others have done so with depth and care. Instead, I wish to emphasise that culture matters, and it is everyone’s responsibility to shape it. Change is possible. And it does not start with grand programmes or slogans, but with everyday behaviours and the conditions that enable them.

The call to action is simple, but not easy:

• Collectively, we must shape environments that support people to speak up, question practice and learn together, with leadership focused on enabling communityship rather than acting heroically in isolation;
• Teams must pay attention to daily behaviours- kindness, respect, listening- that shape how it feels to give and receive care;
• Individually, each of us has influence: what we model, tolerate and reinforce contributes to the culture we create.

By each playing our part, we move from aspiration to practice and from practice to systems where careful and kind care is enabled every day, not by exception but by design.

Conclusion

Systems can make careful and kind care possible, or they can make it difficult. Throughout this chapter, we have explored conditions that enable careful and kind care: continuity that builds trust; accessibility that ensures people can engage with care when they need it; inclusion that brings diverse perspectives into shaping solutions; workforce wellbeing by design; and cultures that normalise mutual respect and the ability to speak up, question and learn. These are not abstractions. They are vital system features that determine whether careful and kind care becomes the default or the exception.

Much has already been written about the importance of these conditions, and we do not lack insight. Where improvement is needed is in how consistently we design for these fundamentals and how fully we commit to them across the system. The gap is no longer knowledge, but implementation: ensuring that what we know to be important is reflected in the way services are organised, delivered and experienced every day.

This is not the responsibility of one person or one organisation. Everyone who works in care, whatever their job title, shapes the experiences of the people we serve. And those with lived experience must shape the system alongside us. As Osler reminds us:

‘Listen to your patient; he is telling you the diagnosis.’

The insight of people with lived experience is not supplementary; it is central to designing care that matters.

In the words of Stephen Covey, ‘Change comes at the speed of trust.’ We must each take responsibility for building that trust, so that careful and kind care becomes the everyday reality of systems that serve.