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26 October 2017, 07:53 | Updated: 26 October 2017, 14:26
Scottish Labour has called for the Health Secretary to be removed from post after a watchdog report found "Scotland's health is not improving".
Audit Scotland's annual review of the NHS said there has been progress but fundamental areas still need to be addressed and warned "the way healthcare is planned, managed and delivered at all levels in Scotland must change".
Existing challenges including increasing costs, growing demand and pressure on public finances continued to "intensify" in 2016/17, the report said.
Overall patient satisfaction is high, it found, staff are committed and the NHS is held in high regard but demand continues to increase and more people are waiting longer to be seen - including a 99% increase in people waiting more than 12 weeks for a first outpatient appointment - and the majority of national performance targets were missed.
The review found: "Scotland's health is not improving and significant inequalities remain, while general practice faces significant challenges, including recruiting and retaining GPs and low morale.
"In the face of this, NHS staff have helped maintain and improve the quality of care the NHS provides. Yet there are warning signs that maintaining the quality of care is becoming increasingly difficult."
Audit Scotland said health budget funding rose in 2016/17 to £12.9 billion, 43% of the total Scottish Government budget, but in the face of rising operating costs NHS boards had to make "unprecedented" savings of almost £390 to break even.
The report warns previous approaches such as more funding to speed up treatment is no longer sufficient and more fundamental change is needed.
Auditors praised progress including in the integration of health and social care and reducing delayed discharges but made a series of recommendations for the government, NHS boards and integration authorities.
These include a long-term framework clarifying how moving care into the community will be funded and money required along with greater flexibility for NHS boards on financial planning.
Other recommendations are creating a comprehensive approach to workforce planning including a cost breakdown.
Caroline Gardner, Auditor General for Scotland said: "There is no simple solution, but these fundamental areas must be addressed if reform is to deliver the scale of transformation that's needed across the NHS."
Labour's health spokesman Anas Sarwar said: "This report underscores that it is time for Shona Robison to go as Health Secretary.
"A year ago Audit Scotland published the worst state of the NHS report since devolution. Twelve months on and standards have either stalled or declined."
Ms Robison said: "Under this administration there have been significant improvements in Scotland's health system, driven by our clear vision for the future of the NHS in Scotland.
"Life expectancy is rising, our A&E departments have outperformed the rest of the UK for over two and a half years, and survival rates for chronic conditions such as heart disease have improved.
"We have long been realistic about the challenges for the NHS and the need for change. Alongside record investment of over £13 billion, including almost half a billion pounds of NHS spending being invested in social care services alone, we are looking at new ways of delivering services that meet the changing needs of people across Scotland."
She said the government is working to develop a medium-term financial framework and an initial health and social care workforce plan will be in place by early 2018.
Liberal Democrat health spokesman Alex Cole-Hamilton said: "This 'state of the health service' report warns that maintaining the quality of care in our NHS is a herculean task.
"The SNP's stewardship of our NHS for the last decade indicates that it is one they won't be capable of meeting."
The Scottish Conservatives accused the SNP of having "mismanaged" the NHS by focusing on independence at the expense of health.
Dr Peter Bennie, chairman of doctors union BMA Scotland, said: "Substantive action on the increasing gap between resources and demand is needed if Scotland's NHS is to be able to cope with the challenges it faces."
The Royal College of Nursing Scotland said the report indicated a need for "significant change" to working practices to meet demand and maintain the quality of care and backed calls for improved workforce planning, echoed by the Royal College of Physicians of Edinburgh.
The Royal College of GPs said under-funding GPs is the root cause of many problems.
Chair Dr Miles Mack said: "A lack of GP time with patients explains why Scotland's health is not improving and it is of deep concern that 'significant inequalities' remain.
"We have had over a decade of consistent cuts to the percentage share of NHS Scotland budgets going directly to general practice services.
"How can Accident and Emergency targets hope to be met when people feel they have to attend A&E, being unable to secure an appointment at their GP practice?
"We see a failure to match the rapidly increasing numbers of hospital doctors with GPs in the community despite ever increasing demands to care for people out of hospitals."
On Labour calls for the Health Secretary to go, a spokesman for Ms Robison said: "It's disappointing that Anas Sarwar has tried to detract from his own Labour leadership campaign woes with childish attacks, filled with schoolboy errors.
"We're taking our NHS forward with a twin programme of investment and reform.
"On health funding the SNP has the highest investment plan of any party, while Labour's plans for the health service would have seen them commit even less