The Scottish government was not adequately prepared for the Covid-19 pandemic, according to a new report by the public spending watchdog.
An Audit Scotland report said ministers had been expecting and planning for a pandemic but had based their preparations on flu.
The watchdog also found the government acted quickly to prevent the NHS from being overwhelmed by coronavirus.
Health Secretary Jeane Freeman said the report would be considered carefully.
Scottish Conservative leader Douglas Ross said the report was “damning” for the Scottish government.
It is estimated the pandemic will cost the NHS £1.67bn in 2020-21 alone.
The knock-on effects mean there is a “substantial backlog of patients” waiting to be seen in the NHS, according to Audit Scotland.
The spending watchdog found that despite a number of pandemic planning exercises, not all the actions identified in these projects were fully implemented.
These included measures to ensure access to enough personal protective equipment (PPE) and to quickly address social care capacity.
Stephen Boyle, auditor general for Scotland, praised the “extraordinary commitment” of NHS staff but said the pandemic had “highlighted the need to deal with long-standing health inequalities”.
He told Good Morning Scotland that the financial sustainability of the NHS had been under threat for years.
Mr Boyle said auditors had emphasised in a number of reports the importance of longer term planning, and shifting the balance of care away from large hospitals to community-based care.
Scotland’s initial response to Covid was based on preparations for a major influenza pandemic, with three government training exercises carried out in the past five years.
But the Audit Scotland report concludes the Scottish government was “slow” at implementing the recommended improvements from the simulations in some of the areas that would become a “significant challenge” during the pandemic response.
The report states that the Scottish government “could have been better prepared to respond to the Covid-19 pandemic” and lessons must be learned.
However, auditors also found that actions, such as cancelling non-urgent operations and increasing intensive care capacity, stopped the NHS from being overwhelmed in the first wave of Covid.
The government was expecting a pandemic.
It had rehearsed scenarios, carried out table-top exercises and simulations, all of which identified the need to better prepare care homes and to improve stockpiles of PPE.
And despite assessing a flu pandemic as a high risk, the government did not identify it as a stand-alone factor when considering the biggest challenges to the health service.
Scotland is not alone in being caught off guard, and the report points to some of the things that went well.
Speedily increasing the capacity of intensive care and hospital beds for example, and rapidly rolling out the use of digital technology.
But this is the first time we’ve seen in black and white from an independent body that there were shortcomings in the preparations.
A public inquiry will later look at the decisions that were made.
Dr Lewis Morrison, chairman of the BMA Scotland, said there was “some concern” that the government could have been better prepared, especially when it came to PPE for doctors.
He said pre-existing challenges for the NHS had been “exacerbated by Covid”, and that restarting services was going to be a “substantial challenge”.
Covid has caused or contributed to the deaths of about 9,000 people in Scotland so far, with those from the most deprived areas or ethnic minorities among the worst affected.
The forecasted £1.67bn cost of Covid in 2020-21 includes £324.5m on PPE and a near 10% rise in staffing costs.
Responding to the report, the Royal College of Nursing said lessons needed to be learned and the “immense pressure” staff had faced for sustained period should be recognised.
It said nurses were concerned about potential long-term risks to their physical and mental health, including PTSD and long Covid.
Health Secretary Jeane Freeman highlighted the rapid increase in intensive care capacity, the completion of NHS Louisa Jordan within three weeks and the continuous operation of emergency, urgent and trauma services during the pandemic.
She added that at no point had the NHS been overwhelmed.
Her government’s approach had been constantly adapted to stay up-to-date with the most recent advice, she said. Lessons learned will, Ms Freeman said, inform future pandemic planning.
“Our focus now remains on suppressing Covid-19 to the lowest possible level in Scotland, to protect our health and care services, and the people of Scotland while the vaccine is delivered as quickly and as safely as possible,” she said.
Mr Ross, Scottish Conservative leader, told Good Morning Scotland that the reason pandemic preparation exercises are undertaken is to “prepare and you take on board the advice and the recommendations”.
He added: “The fact that particularly on PPE and addressing the social care capacity these were ignored, these had huge implications in the first wave of the pandemic.
The auditor general’s recommendations should be implemented, he added.
Scottish Labour’s interim leader Jackie Baillie said it was clear that the NHS was in a “weakened position before the pandemic”.
She said the “abject failure to act on pandemic planning recommendations” was “damning”, and criticised “years of underfunding” and “chronic mismanagement” of the NHS by an SNP Scottish government.
Alison Johnstone of the Scottish Greens said direct investment was needed to help the NHS recover from the pandemic, and added that changes were needed to support health and social care staff who had been working “tirelessly”.
Scottish Liberal Democrat Alex Cole-Hamilton said “fatal errors” had been made in planning for a pandemic, and called for an effective plan to make sure the NHS caught up on missed care.