Realistic Medicine and Value Based Health and Care for senior systems leaders
This page is for executive or non-executive leaders, including board members or directors, and others who hold strategic leadership roles within an organisation and who are responsible for high-level decision-making, governance, and organisational strategy. This page may also be helpful to those aspiring to take on such roles and contribute to system-wide transformation.
Purpose
This page has three key sections to support senior leaders in driving transformation across Scotland’s health and care systems. First, it sets out a clear, shared vision for embedding Value Based Health & Care (VBH&C) across services. Second, it articulates the distinct roles and responsibilities of senior systems leaders in delivering this vision. Finally, it offers practical conversation starters for use at Board level to prompt action and alignment.
Through curated educational resources, case studies, and practical guidance, this page helps leaders to:
champion Realistic Medicine by promoting Shared Decision Making, reducing unwarranted variation, waste and harm, and by focusing on delivering the outcomes that matter to people.
embed VBH&C principles to ensure optimal use of resources, improving experiences and outcomes for those we care for.
align leadership practices with Scotland’s strategic health and care priorities, ensuring consistent policy implementation and meaningful impact.
By engaging with our shared vision, clearly defined roles, and a spirit of collaboration, senior leaders will be equipped to lead with confidence, foster a culture of stewardship, and drive value-focused, person-centred transformation. This approach will help to shape a sustainable and equitable future for health and care in Scotland.
A clear vision for Value Based Health and Care
Our vision aligns with the First Minister’s commitment to NHS renewal to ensure our health service is sustainable for the future.
Realistic Medicine and Value Based Health and Care share a common ambition – to deliver the best possible outcomes that matter to people, using healthcare resources wisely, fairly, and sustainably. They are distinct but mutually reinforcing. One shapes how care is delivered, the other structures how value is achieved and measured.
Realistic Medicine is about personalising care, reducing unwarranted variation, managing risk better, and strengthening the partnership between professionals and the people we care for. It encourages health and care professionals to ask, “What matters to you?” rather than “What’s the matter with you?”
Value Based Health and Care delivers better outcomes and experiences for the people we care for through the equitable, sustainable, appropriate and transparent use of available resources. It focuses on maximising outcomes that matter to the people we care for, by working in partnership with them to agree and deliver interventions that really make a difference. At the same time, we must practise in a sustainable and cost-effective way, achieving the greatest possible benefit for individuals and populations with the resources available. This sits at the core of Value Based Health and Care, and we can deliver it by practising Realistic Medicine.
Realistic Medicine is the cultural approach—the way we practise, the way we deliver care—that enables Value Based Health and Care to happen.
Focus and scale
Realistic Medicine operates mainly at the individual and team level, focusing on relationships between professionals and the people we care for. It promotes shared decision-making, personalised care, and reducing unnecessary variation in the way we practice.
Value Based Health and Care functions at the organisational and system levels, aligning strategy, outcomes measurement, and resource use to maximise value for populations.
Stewardship means taking shared responsibility for financial, environmental, and clinical resources to deliver care that truly matters. It underpins accountable leadership and informed decision-making, as set out in Delivering Value Based Health and Care: A Vision for Scotland. Public support for Realistic Medicine and for Value Based Health and Care is strong. The Fourteenth Citizens' Panel Report confirms people strongly support getting involved in Shared Decision Making and recognise the need for NHS Scotland to make better use of health and care resources.
Environmental sustainability is integral to stewardship. The NHS Scotland Climate Emergency and Sustainability Strategy 2022–2026 outlines how to meet net-zero goals while delivering responsible care. By embedding RM and fostering stewardship, you can lead system-wide transformation, improve outcomes, and maintain public trust, ensuring Scotland’s health and care system delivers what matters most.
Board level roles and responsibilities
This section outlines key responsibilities and links everyday decision-making to system-wide impact, helping you and your colleagues see your role in driving value and improving outcomes. Together, Executive and Non-Executive leaders hold shared responsibility for setting strategic direction, fostering a culture of stewardship, and ensuring the delivery of personalised, Value Based Health and Care across the system.
The distinct roles and responsibilities of both Executive and Non-Executive leaders in delivering Value Based Health & Care across Scotland’s health and care services are outlined in the document below. It provides clear examples of how each leadership role contributes to stewardship, Realistic Medicine, and delivery of better value care, offering practical guidance to support implementation, accountability, and cultural transformation at Board and organisational levels.
Senior Systems Leader Roles and Responsibilities
The Auditor General’s NHS in Scotland 2024 report calls for the Scottish Government and NHS Boards to work together to implement the Value Based Health and Care: Action Plan. A recent workforce survey confirms that health and care professionals want more support from senior leaders to practise Realistic Medicine. Given the challenges our health and care system faces, it is imperative that you continue to support health and care professionals to practise RM and deliver Value Based Health and Care. You can do this by ensuring they have the right information, training, and resources to deliver meaningful outcomes.
Senior leaders across our system must also consider the recommendations that accompany the Citizens’ Panel 14 findings and reflect on how our current and planned activities will contribute to delivering them. Practising Realistic Medicine and delivering Value Based Health & Care are essential requirements of NHS Boards’ Annual Delivery Plans. Senior system leaders must support health and care professionals to practise Realistic Medicine and deliver better value care. You can do this by ensuring that professionals have the information, training and resources they need to be able to deliver the outcomes that matter to the people we care for. This will also help Boards deliver the Population Health Framework and the Service Renewal Framework, which set out how our health and care system will be transformed to become the outcomes-focused, sustainable system that we all wish to see. This work will also help you deliver the 15-box grid of priorities agreed by the Director General of Health and Social Care and NHS Board Chief Executives.
Discover how Board-level leadership directly contributes to VBH&C. The senior leaders' stories below illustrate the lived experience of embedding a culture of VBH&C through leadership roles.
Senior systems leaders' stories
Senior systems leaders come with their own perspectives of Realistic Medicine and Value Based Health and Care. In this section, we present a series of senior leaders' stories presented through interviews with Julia Mackel, Realistic Medicine Lead at NES.
National Clinical Lead for Urgent and Unscheduled Care Shobhan Thakore shares the experience of his mother Hansa to illustrate the importance of Value Based Health and Care in prioritising dignity and Shared Decision Making.
Scott Davidson, Executive Medical Director at NHS Greater Glasgow and Clyde, elaborates on why Realistic Medicine is about common-sense care—putting individuals’ values at the centre and empowering clinicians to make shared decisions with confidence.
Neena Mahal, Chair of NHS Forth Valley, shares the steps taken to drive cultural change, and how quick wins and collaboration are transforming patient outcomes and staff experience.
Scott Urquhart, Director of Finance at NHS Forth Valley, discusses how senior leaders can shift mindsets to use resources differently, avoid low-value care, and create meaningful outcomes through Realistic Medicine and Value Based Health and Care.
Shobhan Thakore, National Clinical Lead for Urgent and Unscheduled Care, explains why Realistic Medicine is about doing what’s right for individuals who access our services through empowering frontline teams.
Manira Ahmad, Chief Officer at Public Health Scotland emphasises the importance of collaboration, inclusivity, and a systems mindset to deliver Value Based Health and Care.
Key resources for understanding Board-level roles and responsibilities
Framework Document for NHS Boards: The Framework defines the roles of Accountable Officers and outlines expectations for performance, collaboration, and risk management, supporting stronger planning, accountability, and alignment with national priorities.
Members of devolved public bodies: model code of conduct – December 2021: The standards of behaviour expected from members of devolved public bodies in Scotland, including integrity, accountability, and respect. It guides how members should act in their public role, covering decision-making, conflicts of interest, and collective responsibility.
Board Development Turas page : A national support hub for NHS Board members in Scotland, offering expert-led resources, guidance, and tools co-created with governance leaders to strengthen leadership, governance, and quality improvement across the system.
Leadership Success Profile: A practical, inclusive framework designed to help leaders across health, social care, and social work in Scotland reflect on their behaviours, values, and development needs to build inclusive cultures and lead with impact.
Prompts for collaboration
Use the below discussion starters to spark meaningful conversations across teams and organisations. These prompts are designed to foster shared learning, reduce unwarranted variation, and encourage collective stewardship.
Select the image to access the slides and download them.
Key resources for supporting collaboration
Scotland’s Atlas of Variation: highlights differences in health outcomes, service use, and quality across Scotland’s regions. It helps identify unwarranted variation, supporting more equitable, efficient, and person-centred care through data-driven decision-making.
The Blueprint for Good Governance in NHS Scotland – Second Edition: provides updated perspectives on effective healthcare governance introduce key concepts such as good, active, and collaborative governance. These are accompanied by a stronger emphasis on the systems and strategies that drive continuous improvement and support best practice across the sector.
Reducing Waste, Harm and Variation – Realistic Medicine Casebook: showcases practical examples from across Scotland that illustrate how personalised, evidence-informed care reduces harm, waste, and unwarranted variation while delivering outcomes that matter most to people.
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