Previously chief executive of the smallest territorial health board in Scotland, NHS Orkney, and with a career spanning over 20 years with some of the biggest and busiest and most challenged acute teaching hospitals in England, Skaife-Knight took up the reins at NHS Grampian on 22 September 2025.
As the only board in Scotland currently escalated to level four under the NHS Scotland support and intervention framework, Skaife-Knight acknowledged NHS Grampian was a ‘hugely challenged organisation'. She was now part of a team absolutely determined to focus on continuous improvement in order to map its path to de-escalation and making the sustainable improvements that are necessary for patients, communities and staff.
'If I look at my last three roles, in particular, they have been in hugely challenged organisations, not just financially challenged, but in terms of quality and safety, staff, experience and engagement and culture,' Skaife-Knight said.
NHS Grampian is one of the biggest boards in Scotland with over 18,000 staff serving a population of over half a million in the remote north east, as well as urban Aberdeen.
'I think my experience working in a range of systems, from being board chief executive at NHS Orkney, to a medium-sized district general hospital in West Norfolk as well as working at board-level in some of the biggest acute teaching hospitals in Europe in the East Midlands (Nottingham, Leicester and Derby), and in high-performing and struggling organisations as well as urban, remote, rural and island boards, served me well to take on this role.
'At NHS Orkney I had good relationships with Grampian colleagues before I started here recognising many Orkney patients come to NHS Grampian and indeed rely on our clinical teams for care and treatment, and while the organisation has its challenges, in my interactions with NHS Grampian I was impressed with the many staff I came into contact with and saw real talent and just knew there was real potential. I know what we can achieve together, by working with our system partners and by working in collaboration, so we can make improvements for our patients, staff and the communities we serve - which is what we all want.'
Looking at the specific challenges she faced, Skaife-Knight highlighted three key areas: finance, unscheduled care (urgent and emergency care) and planned care.
Finance
Skaife-Knight made clear she was under no illusions about the scale of the challenge she has taken on. She said: 'For the last two years, we've had the highest overspend in the NHS in Scotland in value terms. We are now on track to achieve our savings target of £61.8m for this year as well as come within the maximum deficit of £45m – which will be a very significant achievement.'
Operational overspend year-to-date in the first eight months was £22.1m. On pay, the board overspent by £24.8m with £5.9m on medical pay and £9.2m on nursing pay.
'We've made excellent strides on reducing premium pay spend thanks to the efforts of our clinical leaders and teams across the organisation,' Skaife-Knight added. 'We have far less reliance on the expense of agency staff and a big, big focus on substantive recruitment, which is what we all want, both from a financial driver, but also from a continuity of care patients' perspective.
'What's really important is that we don't look at our own savings in isolation, because we need to work as a whole system. We've got three Integrated Joint Boards (IJBs) in Grampian, we've got our local authority partners and we need to make sure a decision we make in one part of the system doesn't have any unintended consequences for our patients and communities in another part of the system. So we've done some really fantastic integrated financial planning work with our IJBs and with our local authorities and we're looking forward to working further together and building on this collaborative work, which is crucial for a sustainable working model.'
The chief executive said the partners were looking at joint savings of around £150m in 2026/27 which will require some difficult decisions and which is why a cohesive approach is needed to ensure any consequences are understood by the entire system when it comes to impact assessing the overall risks and having a shared and agreed understanding of this.
Aside from workforce, Skaife-Knight said NHS Grampian's savings included pharmacy - switching to lower cost medications that have the same impact and procurement - getting the best value out of clinical supplies and non-clinical supplies.
Planned care
Planned care challenges were further compounded by over a week of heavy snowfall in Grampian. The severe winter blast had a significant impact on health services in the north east of Scotland, resulting in 2,600 operations, outpatient clinics and diagnostic appointments (tests and scans) postponed. A major incident response was declared in Aberdeenshire such were the challenges, and outstanding partnership working kept communities safe.
Further challenges have included the four-month shutdown of the board's central decontamination unit (CDU) over a potential contamination issue with theatre trays.
Skaife-Knight said over 1,500 operations (including planned operations and dental appointments) had regrettably been impacted and she reiterated her apologies for patients and their families for this.
'Notwithstanding the challenges of the weather and CDU, which are outwith our control, our teams and system partners have responded superbly which makes me incredibly proud,' the chief executive said.
'We are making really good progress in terms of getting on top of our longest wait patients.'
While acknowledging the NHS board will not be able to reach the Government's target of zero 52-week waits by March 2026, Skaife-Knight said ‘strong progress' had been made towards the target as well as reducing the number of 104-week waits, thanks to the efforts of staff across the organisation who continue to focus on improvement opportunities, mutual aid support from health boards across Scotland and support from the independent sector.
The board has received over £12m in additional funding from the Scottish Government over the last year to support improvements to planned care with a further £4m+ allocation this month to enhance independent sector support in order to return the best possible results for patients in 2025/26.
The chief executive said NHS Grampian was a ‘significant outlier' in terms of 52 week waits when she joined but forecast numbers will be halved from 10,000 to just over 5,000 by March 2026 for new outpatients, marking huge strides in their waiting lists.
The chief executive added cancer care performance was a 'mixed picture but moving in the right direction'.
Over nine in ten patients (91%) were being seen within the standard 31-day target, she noted.
'One of the main pressure points in cancer is urology and capacity, and that's a challenge across the entirety of Scotland,' Skaife-Knight said.
On the 62-day target, just over two-thirds of patients (68.5%) were being seen but Skaife-Knight said the board planned to get the figure above 75% by March 2026.
'We know what our most challenged tumour sites are and we're doing everything we can to look at additional capacity, including support from other boards in that, knowing we need to do better for our patients.'
Technology and innovation has played a major role in reducing planned care waiting times. NHS Grampian is the only health board in Scotland using AI on cancer pathways and getting people on their treatment journey sooner. This has resulted in 95% of lung cancer patients who start their journey from a GP referral, receiving treatment 30 days earlier and 12% more patients being identified with treatable cancer.
Unscheduled care
Of the board's three main challenges, Skaife-Knight said unscheduled care was currently ‘the biggest', adding this had been compounded this winter by extreme weather and the flu epidemic.
The board has received an additional £5.98m funding to improve unscheduled care performance in 2025/26 which has enabled the development of a whole system Improvement Plan which aims to avoid hospital admissions, shift the balance of care from acute (hospital) to the community where possible and improve flow through and out of the hospital and system so that patients receive more timely emergency care.
Noting NHS Grampian's Unscheduled Care Improvement Board is chaired by the Aberdeenshire IJB chief officer, Skaife-Knight said: 'I think unscheduled care is sometimes looked on as an acute problem when it is a system-wide problem, so having one of the IJB chief officers leading that meeting is absolutely the right signal.'
The board's leadership in this priority area has also been boosted with the appointment of a site director for ARI along with a deputy medical director for unscheduled care.
Huge challenges remain, however, with too many patients waiting unacceptably long times in our Emergency Department and in ambulances.
Skaife-Knight acknowledged four-hour performance was ‘nowhere near where we want it to be' with latest first week of January 2026 performance of just 50% in June 2025 and just 40% at ARI.
'We've got a huge distance to go there, and too many patients waiting over 12 hours in particular, and this remains our highest priority recognising we are letting our patients down. We must start seeing the incremental improvements that we need to see for our patients and drawing on good practice models from other boards.'
As with other services across the UK, Skaife-Knight conceded some corridor care and boarding had become the norm during high demand rather than the exception which is something that she wants to see addressed as part of the system's Improvement Plan.
'Corridor care and boarding, sadly, has become all too much of a regular occurrence, not a rarity, because we are always well over 100% bed occupancy,' Skaife-Knight acknowledged.
'Dr Gray's hospital in Elgin has been operating at 130% bed occupancy this month with ARI regularly at 105-110% capacity, which isn't a sustainable position. We have to do all we can to address and unlock the gridlock we are experiencing by ensuring good discharge practice happens early in the day so movement of patients and flow, happens consistently.'
Patient flow
As of 8 January, NHS Grampian had 155 delayed discharges with 63 in acute services, roughly the same level as the previous year.
Skaife-Knight emphasised that an improvement plan was in place to learn from best practice across the UK, including some NHS boards in Scotland, most notably NHS Lothian, NHS Tayside and NHS Lanarkshire who have been setting the standard.
In addition, the chief executive has led a ‘big focus' on discharge practice, including the ‘10 before 10' initiative, pre-noon discharges with a strong focus on ensuring all patients have predicted discharge dates and that weekend discharges keep pace with those in the week so there is 7/7 continual movement of patients through the healthcare system.
National funding was used to move 17 ‘ready to discharge' patients out of hospital before Christmas to long-term care locations as part of a ‘firebreak' to relieve pressure on Aberdeen Royal Infirmary (ARI), create flow and acute capacity to break the gridlock cycle.
In another initiative, out-of-hours primary care support has been incorporated into the board's flow navigation centre rota. This means patients can be moved from a hospital setting into a community setting or - even better - home, with the appropriate care package if needed.
The flow navigation centre has achieved a 46% redirection from the emergency department. Additionally, ‘Call Before you Convey' calls for ambulance crews to triage patients to hospital and alternative services have increased from 110 to around 138 each week, resulting in a 59% redirection of patients from the emergency department.
The health board has also expanded its ‘Hospital at Home' and ‘Discharge to Assess' service in Aberdeen.
Patient flow has also been improved by introducing a geriatrician (frailty model) at the front door of the ARI emergency department which has resulted in around 30% of patients being redirected to more appropriate services.
Skaife-Knight said integration was ‘well embedded' with the three local IJB Chief Officers having herself and the local authority chief executive as their line managers and strong daily rigour of escalation in place in order to expedite discharge to social care services.
Keeping the conversation open and transparent is key for NHS Grampian. 'It's about having really healthy relationships; being able to see the greater good in a system and having that truly integrated approach to working collaboratively, whether it's operational performance or financial performance and service planning – every voice is heard equally.'
Community shift
NHS Grampian is proud to be the only health board in Scotland to adopt the Community Appointment Day prevention and population health model, which was launched by Sussex NHS Trust in 2023.
'It's a really innovative approach to community-based services: bringing all of the right people - clinical colleagues, third sector colleagues and patients – into one room,' Skaife-Knight said.
'It's an absolutely fantastic, holistic way of delivering care and reducing waiting lists and system pressures, while promoting self-management and really encouraging people to manage their own health within reason, as well as encouraging behavioural change.'
Appointment days have been held for musculo-skeletal issues, men's and women's health, podiatry, chronic pain, dementia and COPD.
In addition, Scotland is pursuing its own take on the shift from hospital to community through the promotion of GP walk-in centres.
Skaife-Knight said NHS Grampian had teamed up with other health boards and GPs on a proposal on what that might look like in her region, with this Government commitment mentioned in the Scottish budget statement last week.
A brighter future
Looking ahead, Skaife-Knight was clear on what her ‘big focus' would be: 'For me, visible and compassionate leadership is the golden thread stitching all of the pieces together. I love being out on the shop floor listening to staff, responding to feedback and beginning to change organisational culture for the better – making time makes a difference.
'As a challenged board, it is really important we also have the right support package around us, so that we have every chance to succeed, learn from best practice and benefit from additional resources, which is what we're certainly receiving,' Skaife-Knight noted.
In addition, NHS Grampian has mutual aid arrangements on capacity, learning and peer support with other boards.
Acknowledging there was a point when it had to stand on its own feet, however, Skaife-Knight said NHS Grampian was held to account every two weeks by its assurance board which is chaired by the Scottish Government.
The health board has also begun implementing an improvement plan to meet the recommendations of a KPMG diagnostic report which was published in October 2025, which was designed to help to further improve financial efficiency, identify opportunities to further improve governance and leadership and to understand in detail the causes of the deficit position
'Lots of those recommendations were already underway but some of those were new ideas and suggestions for improvement, which we absolutely must remain receptive to and which we embrace and welcome,' Skaife-Knight said.
The chief executive noted the crucial importance of ‘building strong, and in some cases resetting, relationships with key partners' when setting out to improve performance.
She said she was optimistic about the future given the significant progress NHS Grampian has already made and can evidence.
'If you look at the three priority areas this year – unscheduled care, planned care and finance – in two of those areas (planned care and finance) we can more than evidence progress,' said Skaife-Knight.
'It's about sustained progress now in these areas and building on what we have already achieved, and I have every confidence that if we apply the same discipline and rigour, including governance and clinical leadership arrangements to unscheduled care, which is what we're doing, we'll begin to see results in that area as well.
So what next for Grampian? Skaife-Knight concluded: ‘Our future is bright and there is much to be optimistic about. This is because we are working as a team, leading with hope and optimism and working together as a whole system to get to where we need to be. Good people who feel invested - help change happen, and thankfully I am surrounded by those.'
