Surgeons, nurses and NHS staff have reacted with anger to a secret blueprint for a massive overhaul of orthopaedic surgery in Scotland.
Most only learned of the bombshell report's existence when The Herald revealed it on Friday.
The confidential Scottish Government draft, Transforming Elective Orthopaedic Care in Scotland 2026–2031 calls for a huge expansion of capacity, likely to need more than 100 extra outpatient clinics and roughly 15 extra theatres a month.
It would require longer theatre days and weekend working and comes at a time of severe staffing pressure.
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The medics and staff who would be asked to deliver the new strategy have not been asked to contribute.
The Scottish Committee for Orthopaedics and Trauma (SCOT), which represents orthopaedic and trauma surgeons across Scotland, said it was "disappointed not to have had sight of, or the opportunity to contribute to, a document of this significance".
The Royal College of Nursing (RCN) said it had not seen the detail, while Unison accused ministers of treating a "hugely experienced workforce with contempt".
The new plan would see planned orthopaedic surgery, such as hip and knee replacements, split from emergency trauma care. The two currently share theatres, beds and surgeons.
It does not say which hospitals would lose operations. It does name where the investment would go, including three extra theatres at Queen Margaret Hospital in Dunfermline and extra capacity at Victoria Hospital in Kirkcaldy and the Royal Infirmary of Edinburgh's neurosciences department.
As set out by John Swinney in his Programme for Government, instead of 14 health boards planning separately, two regional groups, Scotland East and Scotland West, would manage capacity as one system.
There were 3,115 nursing and midwifery vacancies across NHS Scotland at 30 June 2026,
It sets a target of a 26-week wait for orthopaedic surgery by March 2031. That is double the statutory 12-week guarantee the Scottish Government has promised to restore by March 2029.
The plan argues that the changes would cut cancelled operations, because planned surgery would no longer be bumped when hospitals fill up with emergencies.
It also argues they would end the postcode lottery, with patients in one part of Scotland waiting no longer than patients in another.
The draft plan says that delivering six- and seven-day working would need changes to consultant terms and conditions, and "team service job planning" for orthopaedic surgeons and anaesthetists.
In a statement, SCOT said it had "noted with interest and some disappointment the report in The Herald concerning a draft five-year plan for elective orthopaedic care in Scotland".
They warned that national plans can miss the real reasons for long waits.
"SCOT's long-held view is that the most effective way to improve orthopaedic care is to diagnose and address problems at Board and regional level," the Committee said.
"Waiting times are shaped by local factors, including theatre capacity, workforce, sterile services, bed availability and the balance between elective and trauma work.
"National plans risk overlooking the detailed, local reasons why problems arise, and with them the opportunity to address root causes."
SCOT said that there had been progress made already thanks to "close collaboration between the Scottish orthopaedic community, Health Boards and the Scottish Government, supported by targeted funding".
However, it warned that there was "risk that these gains will slow".
SCOT added: "There has been insufficient follow-up to that funding package to understand what worked and what did not, and that learning is essential to sustaining and building on the progress made."
It said May's election, and the later announcements that health boards would be merged, had been "a considerable distraction" and may have taken attention away from the day-to-day work of reducing waits.
Unison Scotland co-lead for health Matt McLaughlin said the plan raised significant questions: "This is another big government announcement which lacks detail and fails to consult unions.
"Staff want investment in services to improve them, rather than government making targets politically easier. The whole thing treats a hugely experienced workforce with contempt.
"More centralisation and weakening targets might look like it saves money on an abstract flow chart, but it doesn't improve real services for patients and won't be popular with the workforce.
"We don't have enough staff for orthopaedic services as it stands, how can we extend services without a massive injection of additional workers?"
He said the government needed to "sit down with unions and have a real conversation about how to meet the hip and knee surgery waiting times that we already have, not look at how we redefine what is acceptable".
There were 3,115 nursing and midwifery vacancies across NHS Scotland at 30 June 2026, (Image: Agency)
On staffing, the RCN said the nursing workforce in Scotland had simply not kept pace with the demand for health and care services.
It pointed to data from NHS Education for Scotland, which shows 3,115 nursing and midwifery vacancies across NHS Scotland at 30 June 2026, including almost 2,000 registered nurse vacancies.
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Colin Poolman, the nursing union's Executive Director, said his members agreed that "change is needed" but that "if we are truly going to reform health and social care, it is vital that the workforce is engaged and has an opportunity to shape the plans".
He added: "This is a disappointing start to the process. Scottish Government must do better in relation to engagement and communication. They must bring the workforce with them, if they are to have any chance of their proposals for change improving access and outcomes for patients.
"Nursing staff will be central to the delivery of any expansion in elective care but Scotland's nursing workforce is under significant pressure. Any proposals that rely on increasing activity must be accompanied by a credible workforce plan. Likewise any plans to concentrate activity in specialist centres must include careful consideration of the implications for nursing staff and their colleagues."
Health Secretary Angela Constance said: “Health boards have been working to create new national orthopaedic plans, following a commission from the Scottish Government, designed to build on the progress we’ve seen in reducing the number of long waits and ensure patients get treatment at the earliest possible date.
“We are clear we have always planned to engage directly with staff and trade unions on this draft plan - they have a vital role in shaping the reform of our NHS.”