Scotland's Public Services Face a Radical Shake-up: Could Councils and Health Boards Eventually Come Together?

4th November 2026

Scotland could be heading for the biggest reorganisation of its public services in more than two decades. The Scottish Government is looking at reducing the number of NHS health boards from 14 to just two, while also proposing a major restructuring of local government.

Although these are separate reforms, they are part of a much wider ambition to change how public services are organised, managed and delivered.

The stated objective is to reduce duplication, simplify administration, make better use of public money and improve services. But there is a bigger question: could Scotland eventually move towards a system in which councils, health services and social care are brought together under fewer regional organisations?

For communities in the Highlands, where distances are considerable and local needs can differ considerably from those in the central belt, the consequences could be particularly significant.

The NHS: 14 health boards could become two
The Scottish Government announced on 1 September that it intends to replace Scotland's 14 territorial NHS health boards with two strategic boards, one covering the east and the other the west of Scotland.

The 11 mainland health boards would be absorbed into these larger organisations. Separate arrangements would be considered for Orkney, Shetland and the Western Isles, recognising their particular circumstances.

Ministers argue that the present arrangements create unnecessary duplication, make planning more complicated and can prevent resources being used effectively across geographical boundaries.

The new structure is intended to provide more consistent planning, allow resources to be shared and make it easier to organise specialist services across larger areas.

The Government says local healthcare delivery will continue. The intention is to centralise strategic planning rather than remove healthcare services from local communities.

There is, however, an important distinction between deciding where services are planned and deciding where patients actually receive treatment. A larger administrative organisation does not automatically mean that local hospitals, health centres and community services will be protected from future changes.

The proposals are still being developed, with a business case and implementation timetable to follow.

Local government could also be transformed

The proposals for councils may prove just as significant.

Scotland currently has 32 local authorities, a structure that has remained in place since the major local government reorganisation of 1996.

The Scottish Government now believes that the existing arrangements need to be reconsidered.

Its initial proposals, published in September, suggest replacing the present system with between six and ten larger regional authorities, supported by approximately 120 to 160 smaller community authorities.

The regional organisations would concentrate on strategic responsibilities and services that benefit from operating over larger geographical areas. Community authorities would provide a more local focus, dealing with matters affecting individual towns and neighbourhoods.

Councillors could sit on both levels, avoiding the need to create another separate tier of elected representatives.

The Government argues that some decisions are best taken nationally, others regionally and many much closer to the communities affected.

It is an attempt to combine the advantages of larger organisations with a greater degree of local involvement.
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Councils are not convinced that changing boundaries is the answer

The proposals have already prompted a response from COSLA, the organisation representing Scotland's 32 councils.

At the end of October, council leaders called on the Scottish Government to rethink its approach.

COSLA accepts that public services need to change, but argues that simply replacing existing councils with larger regional authorities will not necessarily improve services or reduce costs.

Its alternative approach places greater emphasis on cooperation between existing councils, sharing resources and giving more responsibility to local communities.

COSLA also wants a wider examination of how responsibilities and funding are distributed between central government, councils, the NHS and other public bodies.

This is an important disagreement. Ministers are proposing a fundamental change to the structure of local government, while councils are arguing that better cooperation and a review of funding could achieve many of the same objectives without completely redrawing the map of Scotland.

There is also a democratic question. If larger regional authorities take over responsibilities currently exercised by local councils, how much influence will individual communities retain over decisions affecting them?
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Could councils and health boards eventually come together?

This is where the two reform programmes become particularly interesting.

The Government has not announced a plan to merge NHS health boards and local authorities into single organisations across Scotland. However, it is examining how health, social care and wider public services could work more effectively together.

One possibility being explored is the Single Authority Model, which would bring important public services together under one local governance structure.

The Government has also confirmed that the future of Integration Joint Boards (IJBs) is under review.

These bodies already bring NHS and council representatives together to plan and oversee integrated health and social care services.

Their future is therefore an important part of the wider debate. Rather than maintaining several organisations with overlapping responsibilities, ministers want to examine whether a simpler structure could provide clearer accountability and make better use of available resources.

However, no final decisions have been taken about replacing Integration Joint Boards or introducing wider combined authorities.

The Scottish Government has also indicated that legislation may be needed to support wider public service reform, including the possible merging or abolition of public bodies and transferring responsibilities between organisations.
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What might this mean for the Highlands?
For Highland communities, the implications deserve particular attention.

Highland Council covers an enormous geographical area, while NHS Highland provides healthcare across much of the Highlands and parts of Argyll and Bute.

Both organisations face the difficulties of delivering services to scattered populations, often over considerable distances.

A larger regional structure might offer opportunities to share specialist staff, purchasing arrangements, administrative services and professional expertise.

There could also be advantages in planning health and social care together, particularly for older people who need support from several different services.

But there is a danger that decisions become increasingly concentrated in Inverness or even further afield.

The experience of many rural communities is that services which appear efficient when viewed from a central office can be considerably less convenient for people who have to travel to access them.

Wick and Thurso are not simply smaller versions of Inverness. Their populations, transport connections, employment patterns and access to healthcare are different.

A regional organisation might understand the overall figures, but it must also understand the practical consequences of decisions for individual communities.

There is a further question about democratic accountability. Highland Council currently has elected councillors representing local wards. If responsibilities move to larger regional organisations, it will be important to establish how residents can influence decisions and challenge those responsible.

The Government's proposals recognise the importance of community-level involvement, but the detail of how that would work remains to be settled.

Will it actually save money?
Reducing the number of organisations does not automatically reduce the cost of providing public services.

There may be savings from fewer management structures, shared administrative systems, combined purchasing and better coordination of resources.

However, reorganisations themselves cost money. Computer systems have to be integrated, staff responsibilities changed, buildings and offices reconsidered and new management arrangements established.

There is also the possibility that savings in administration are outweighed by additional costs elsewhere.

The NHS proposals acknowledge this. The Government says that the business case will set out the costs and benefits, with a framework to monitor whether the changes actually improve services and provide value for money.

It is also worth remembering that Scotland has undergone several reorganisations of public services over the years. Each has promised improvements in efficiency and accountability, but structural changes alone cannot solve problems caused by insufficient funding, staff shortages or growing demand.

The real test will be whether money saved on administration is redirected into services that people actually use.

A major change, but who will be accountable?

There is another issue which deserves attention.

Scotland already has a complicated system of public administration, with responsibilities divided between Holyrood, local councils, NHS boards, Integration Joint Boards and numerous national agencies.

The Scottish Government says there are more than 130 public bodies in Scotland and believes that overlapping responsibilities can make the system unnecessarily complicated.

Its intention is to simplify that landscape.

But fewer organisations do not necessarily mean clearer accountability. If a service fails, the public must still be able to establish who is responsible and who has the authority to put things right.

There is also the question of whether larger organisations will be more responsive to local concerns or whether communities will find themselves further removed from the people making decisions.

These are issues that should be addressed before new structures are introduced, rather than discovered after the reorganisation is complete.

Scotland has an opportunity to rethink how it is governed

The Scottish Government is attempting something considerably more ambitious than reducing the number of NHS boards or changing council boundaries.

It is looking at how the different parts of public administration fit together, how responsibilities are divided and whether services could be delivered more effectively through fewer organisations.

There is a reasonable case for examining arrangements that have remained largely unchanged for decades, particularly when public finances are under pressure and demand for health and social care continues to grow.

But there is an equally important argument for protecting local knowledge, democratic accountability and the ability of communities to influence decisions.

For the Highlands, the challenge will be to find a balance between the potential advantages of regional planning and the need to ensure that Wick, Thurso, Caithness and Sutherland are not overlooked when decisions are made elsewhere.

The Government wants to reach agreement on the broad direction of local government reform before the end of 2026, although detailed decisions and implementation will take longer.

One thing is already clear: Scotland is beginning a debate about the future shape of its public services that could have consequences for generations.

The question is not simply whether Scotland needs fewer organisations. It is whether a different structure will actually deliver better services, better value for money and a stronger voice for the communities those services exist to support.