Tens of thousands of Scots waiting in pain for hip and knee replacements face waiting twice as long under new NHS plans after health chiefs put the cost of restoring a statutory 12-week guarantee at £401 million.
A confidential draft blueprint obtained by The Herald reveals planners are now working towards a maximum 26-week wait by 2031.
The leaked five-year plan, Transforming Elective Orthopaedic Care in Scotland 2026–2031, also sets out a sweeping reorganisation of orthopaedic care, concentrating operations in specialist regional “centres of excellence” and National Treatment Centres and telling patients that travelling for surgery is “to be expected".
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"There is no getting away from the reality that concentrating investment in the way described here will mean that some people travel further for their once-in-a-lifetime surgery," the document states.
It recommends ministers run a PR campaign to persuade the public to accept the idea of journeying to the new regional super-hubs.
It is not clear how patients without a car, or those who are older, disabled or living alone, would get to a hospital further away, or who would pay for it.
By March 2027 more than 4,100 orthopaedic patients covered by the Treatment Time Guarantee will still be waiting longer than a full year (Image: PA)
The 42-page blueprint was drawn up by the regional planning bodies responsible for NHS services across the East and West of Scotland and sets out the difficulties with tackling one of the longest waiting lists in Scottish healthcare.
According to figures in the document, health chiefs predict that by March 2027 more than 4,100 orthopaedic patients covered by the Treatment Time Guarantee will still be waiting longer than a full year just to receive inpatient or day-case surgery across eastern and western Scotland.
Planners warn that these long waits create severe "failure demand" across the wider health service, leaving patients in debilitating pain, driving repeated GP visits, and triggering emergency hospital admissions when people suffer falls while waiting for joint replacements.
The Scottish Government re-committed to the three-month standard in January, with the Scottish Spending Review specifically saying the government was working on "plans that will see orthopaedic waits reduce to the treatment time guarantee of 12 weeks by March 2029".
However, in his Programme for Government, set out in September, First Minister John Swinney promised that "by the end of 2031, no one waits more than 26 weeks for treatment".
That now looks set to supersede the earlier commitment, with ministers telling The Herald that the creation of the new national orthopaedic plan is to support the promise that "nobody waits more than 26 weeks for the treatment they need".
Patients will be told to expect to travel for knee and hip operations (Image: PA)
The 12-week Treatment Time Guarantee is written into law. It was introduced by the SNP under the Patient Rights (Scotland) Act 2011 and came into force in 2012. It has never been met.
The document says meeting the 12-week standard by 2029 would require 46,941 extra inpatient and day-case procedures over three years, at a cost of £401 million.
However, it estimates that meeting the 26-week standard by 2031 would need 29,648 extra operations over five years, at a cost of £255 million.
Orthopaedic surgery is currently carried out across 31 sites, with 87 theatres and 330 whole-time-equivalent consultants.
The plan proposes separating planned orthopaedic surgery from emergency trauma work. It would do this by creating sub-specialty hubs and "a small number of revision arthroplasty centres".
It claims these "elective 'centres of excellence' will be able to concentrate on improving outcomes and efficiency".
The document does not say which hospitals would lose operations, but it does name where the investment would go.
In Scotland East, it lists three extra theatres at Queen Margaret Hospital in Dunfermline, one at the Department of Clinical Neurosciences in Lothian, and expanded capacity at Victoria Hospital in Kirkcaldy. It says this would come with capital spending of around £25 million.
In Scotland West, it points to the remaining theatres at the Golden Jubilee, the Highland National Treatment Centre and Forth Valley's treatment centre. It also says that "some capital" will be needed for enabling works in the existing estate, which "is being costed".
The blueprint also sets out big changes for staff.
It calls for "six-day working and extended theatre days". It says extra capacity in the West would come partly from "extending operating hours to Saturdays and Sundays". It also expects extra outpatient clinics in evenings and at weekends.
It says delivering this would need changes to consultant terms and conditions, and "team service job planning" for orthopaedic surgeons and anaesthetists.
The document says "senior stakeholders" across all 14 health boards have been involved in developing the proposals, but does not spell out what consultation has taken place with frontline theatre staff or trade unions.
Instead, "staff-side involvement" is listed among the conditions needed for the transformation to succeed.
The proposals also raise significant questions about whether the NHS has enough surgeons, anaesthetists, nurses and theatre staff to deliver the additional activity.
The blueprint itself acknowledges that workforce shortages "continue to present a significant risk to the sustainability and resilience of orthopaedic services" and says a supporting workforce plan has yet to be developed.
There are also questions around money and the affordability of the new plans.
"These improvements and new ways of working alone will not alter that there will be a requirement for significant additional investment," the document states.
John Swinney recently visited an orthopaedic treatment centre in Fife (Image: PA Wire)
The blueprint separately estimates £265 million in recurring revenue requirements and a total five-year cost of £277 million, without clearly reconciling the two figures. It also says the cost of additional sterilisation capacity has yet to be calculated and would come on top.
The report defends the restructuring on clinical grounds, arguing that untangling planned operations from emergency hospital pressures will put an end to short-notice cancellations when crises hit acute wards.
Health chiefs also insist that while patients may have to travel for their operation, the surgery itself represents just one step in a wider treatment journey involving up to 20 appointments.
Under the blueprint, the remaining 90% of care — including initial GP consultations, diagnostics, pre-op checks, and post-surgery rehabilitation — would stay local or be handled digitally via video calls and apps.
A source told The Herald: "What I find particularly upsetting is that elements of this approach have already been pursued at board level, seemingly driven by senior executives with little or no meaningful consultation with the workforce expected to deliver them.
"If senior NHS leaders know the workforce and resources are not there to deliver what is being promised, there needs to be transparency rather than presenting politically attractive plans that may not be achievable in practice. Patient safety, professional credibility, and honesty must come first."
Scotland's 14 territorial health boards are already working under severe financial pressure. Last month, Mr Swinney announced plans to slash the number of boards to two.
Scottish Labour health spokesperson Jackie Baillie said SNP ministers needed to "come clean on the future of orthopaedic care in Scotland".
She added: "Either they knew it would cost £401 million and shamelessly guaranteed orthopaedic operations within 12 weeks knowing they wouldn't deliver or they didn't do the sums and made an uncosted commitment which they will now abandon. This forces people to wait for 26 weeks for surgery, double the time promised.
"What's more is this draft plan fails to take into account the support for patients who are unable to travel outside their local service for surgery, and provides no clarity for the workforce who are expected to carry out these services. The same old SNP — no sums, no transparency, no plan and patients suffer."
Health Secretary Angela Constance said the reforms would "make the best use of capacity across Scotland". (Image: Jane Barlow/PA)
Scottish Liberal Democrat health spokesperson Adam Harley called on the government "to be honest with people about how long they might actually wait for each different health condition".
He said: "The SNP's promise to treat patients within 12 weeks looks increasingly meaningless. That must be especially tough for those in pain waiting on surgical waiting lists.
"With Angela Constance taking over as health secretary there is an opportunity for the Scottish Government to level with people about the state of the health service. I think people would appreciate some honesty rather than PR campaigns and pledges that the government has no intention of meeting.
"Scottish Liberal Democrats want to see a waiting times model which is honest with people about how long they might actually wait for each different health condition."
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Health Secretary Angela Constance said: "Our Programme for Government in September committed to ending waits in our hospitals and ensuring nobody waits more than 26 weeks for the treatment they need.
"To support this we have been working alongside health boards to create a new national orthopaedic plan, designed to build on the progress we've seen in long waits coming down and ensure patients get treatment at the earliest possible date. Final details of a plan will be set out in the coming weeks.
"Our reforms of Scotland's NHS boards will make the best use of capacity across Scotland, to drive down waiting times and ensure people get the right care, in the right place at the right time."