The Scottish health service is geared up for reform, but even before the dust has settled some wish the changes had gone further. Mark Crail reports

When the Scottish parliament assembles for the first time in its new home at Holyrood after next May's election, it will inherit a health service very different from that taken on by Labour ministers at Westminster in 1997.

Last week's announcement by Scottish secretary Donald Dewar that trust numbers will be reduced from 46 to 28 from next April confirms a direction of travel he and his colleagues had set even before the general election.

But voices are already calling for further reform, with some wondering how long it will be feasible to retain 15 health boards.

Speaking in the wake of last week's announcement, Fife Acute Services trust chair David Stobie predicted: 'I think that in four or five years' time when this has had a chance to settle, we shall see the number of boards reduced.'

He suggests that just three or four regional boards might be more 'acceptable and sensible'.

It is a view echoed by Rex Taylor, chair of Dumfries and Galloway Primary Care trust and a former professor of social policy, who says he wishes the changes had gone further, with fewer bodies covering larger areas.

But it is not just in terms of numbers that the system is set to change: except in Glasgow and Edinburgh, where special circumstances apply, there will in future be a clear separation between acute healthcare and 'the rest'.

The creation of primary care trusts - one in each health board except Argyll and Clyde, which gets two - is unique to Scotland. They are intended, says Scottish health minister Sam Galbraith, 'as vehicles for change in our community'.

Encompassing local healthcare co-operatives - the grouping of GPs favoured over the primary care group model developed in England - they will, he says, put family doctors 'in the driving seat'.

On the hospital side, the new acute trusts - again, one for each board, except Glasgow - have a more co-ordinated change agenda than their English or Welsh counterparts in chief medical officer Sir David Carter's acute services review.

There will also be separate, if similar, plans to deal with on clinical governance - or 'corporate accountability for clinical performance', as Mr Galbraith put it at last week's Scottish Association of Health Councils' conference.

He promised the gathering of patients' representatives that plans for a new national standards group would be announced later this year, and that they would include 'a strong lay element'.

With chairs now in place for all Scotland's trusts - six new names and 22 who move over from the 'old' trusts - appointments to fill other board posts can go ahead.

Over the past year, with ministers' intention to cut the number of organisations clear, chief executive and other board-level posts falling vacant have been left empty. Some top managers have retired early.

The result is that there will be no redundancies as a result of the shake- up, promises Mr Galbraith, and the number of further early retirements will be small.

But there are concerns about the hoops managers have been made to jump through if they want jobs in the new system. Chief executives had to face a competency assessment to be shortlisted; once on the list, their details will be circulated to trust chairs for selection. Now other board-level directors will have to go through the same process.

'We are fully signed up to the process,' says Donald McNeil, secretary of the Institute of Health Services Management in Scotland, 'but it has raised issues for some individual managers'.

Non-executive directors - to be called 'trustees' in the new system, according to Mr Galbraith - can also be appointed. This is due to happen in October, with shadow boards starting work on 1 January and taking over on 1 April.

In the meantime, health councils are coming under pressure to work with, rather than against, health boards and trusts.

Reminding SAHC conference delegates that a funding review had already taken into account their enhanced consultative role, Mr Galbraith stressed their role as the patients' voice in service development decisions. Their efforts were 'already having a positive effect on boards' and trusts' willingness to involve councils in strategic planning', he said.

But the SAHC is uneasy with the idea that it should move away from individual advocacy, arguing that it needs to retain this if it is to be credible on broader issues.

Director Patricia Dawson also sees the advent of the Scottish parliament as providing an additional route through which health councils can influence policy.

'The key task now is to come up with some credible way to influence the agenda and make sure the patients' voice is heard in parliament,' she says.

That may be no easy task, as Malcolm McLeod, convenor of the Centre for Scottish Public Policy's health commission, told SAHC. Typically, voters from deprived areas were the least likely to turn out for local elections.

Come the Scottish parliament, said Dr McLeod, 'it will be the very people who have most to gain from effective healthcare who will be the least likely to participate'.

It is an issue which has not escaped those drawing up plans for how the parliament will work.

Esther Robertson, a member of the constitutional steering group, said it wanted open access to most official papers, documents written in plain English, and enhanced powers for committees.

Alongside specialist committees, the new parliament could have others working on a 'holistic' basis - such as a public health committee which could encompass education, housing and social work alongside NHS work.

All of which should ensure that the trip from health board or trust offices to appear before MSPs in Edinburgh becomes a familiar one for chairs and chief executives. Season tickets may well be in order.