The annual review carried out by Audit Scotland said that more people are waiting longer to be seen, the majority of national performance targets were not met and general practice is under pressure from ongoing recruitment problems and low morale.
The Auditor General noted that, despite this, staff are committed and overall patient satisfaction is high, but costs are increasing and there is a growing demand for services.
In 2016-17, the health budget was £12.9 billion – 43 per cent of total Scottish Government spending.
Funding has increased, but operating costs are also rising and NHS boards have had to make unprecedented savings of almost £390 million in order to break even.
The report said there are some signs of progress in areas such as integrating health and social care, developing better data and embedding a “realistic medicine” approach, but key building blocks still need to be put in place by the Scottish Government, NHS boards and integration authorities.
These include a long-term framework clarifying how moving care into the community will be funded, along with greater flexibility for NHS boards on financial planning.
Other recommendations include creating a comprehensive approach to workforce planning, including a cost breakdown.
Caroline Gardner, the Auditor General for Scotland, said: “The NHS in Scotland marks its 70th anniversary next year, and there is widespread agreement that healthcare must be delivered differently if it is to withstand growing pressure on services.
“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. Involving staff, the public and bodies across the public sector will also be crucial for success.”
Scottish Labour said a decade of SNP mismanagement of the NHS was being felt by staff and patients.
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.”
However, the Scottish Government was quick to highlight the positive aspects of the report, with Ms Robison saying ministers are working to develop a medium-term financial framework and an initial health and social care workforce plan which will be in place by early 2018.
She 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 £13bn, 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.”
Dr Miles Mack, chairman of the Royal College of GPs Scotland, said it was of “deep concern” that significant inequalities remain and highlighted GP underfunding.
He said: “These findings from Audit Scotland make it absolutely clear that, as the accompanying press release states, ‘spending more to treat more people in hospital and speed up treatment is no longer sufficient’.
“Each of the four major challenges highlighted are indicators of that. It is frustrating that these same messages have to be delivered by Audit Scotland year after year.
“As Audit Scotland explains, we cannot deliver the step-change the system requires without shifting spending away from hospitals. Underfunding general practice is the root cause of so many of the issues the NHS now faces.
“We are pleased that a professional consensus is coalescing around that fact. The chair of the BMA’s UK GP committee agrees that the same underfunding in England has led to crisis … led to practices being unable to employ more staff and that, vitally, it has led to questions over patient safety.
“So it is in Scotland. That is why more Scottish patients are waiting longer to be seen.
“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?”
The auditors noted that in 2016-17 the NHS in Scotland employed almost 140,000 whole-time equivalent staff, performed 1.5 million hospital procedures and conducted an estimated 17 million GP consultations.
NHS Scotland’s budget included £250m ring-fenced funding for health and social care integration. Although this funding was specified for social care it was included in the health budget and NHS boards were required to give this funding directly to Integration Authorities. Without this element of non-health funding, the health revenue budget decreased by 1 per cent in real terms between 2015-16 and 2016-17.
Scottish Conservative health spokesman Miles Briggs said: “This report exposes just how badly the SNP has mismanaged the NHS since it came to power more than ten years ago. Hospitals are short-staffed, workers are stressed and the maintenance backlog is spiralling out of control.
“And while this happens, as this report states, people aren’t getting any healthier. What more indication could the SNP need to show it has to change its ways on the NHS.
“For years it neglected the health brief at the expense of agitating for separation, and now those chickens are coming home to roost.
“That’s a disgraceful approach to government, and one which won’t be forgiven.”