The pandemic has exposed stark choices necessary in health and social care. 

Although many such challenges existed pre-Covid the backlogs caused by people (initially) staying away combined with the system pivoting to addressing the virus, led to significant trade-offs within the NHS, between the NHS and social care and even between health and the economy

Yet, despite the analysis of choice being the essence of health economics, health economists have been absent from real-time policy advice during the pandemic. 

Perhaps laying bare such trade-offs is not seen as helpful to politicians who, at the podium, do not want to recognise the consequences of their actions. 

Even with respect to vaccines, although not much cost-benefit analysis is required as to introduction a vaccination programme, questions could be asked about how much we have paid for vaccines and the health pay-off from extending roll-outs to particular groups, such as younger people. 


Now, debates continue over availability of free testing kits when the real question should be how to deliver an effective and efficient test-and-trace system to combat future outbreaks. 

What’s done is done and now we must look to the future of health and social care in Scotland

But this requires some radical discussion and subsequent action. Initial signs are not good. Promised investments in health and social care will likely be wiped out by inflation. 

The more that has to be funded privately by individuals, the less fair it will be

Reporting in May 2021, the Lancet-LSE Commission of the Future of the NHS estimated that much larger increases in spending, pre- and post-pandemic and including social care, are required to keep pace up to 2030 and beyond. 

With funding increases from the upcoming National Insurance increase going initially to the NHS, politicians, as usual, are not taking a system wide perspective. 

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Investment in social care services would permit the movement of patients out of NHS beds, allowing such people to be cared for at home or in their community, and even prevent others entering the NHS in the first place. 

Thinking of investment in health and social care allows us to ask the question of what is to be the balance between the two and how will it all will be organised? 


(Marissa Collins)

The current integration model, in place since 2014, has not worked in taking down barriers of culture and relative power between social care and the NHS and has been slow to meet the aim of shifting the balance of care from acute to community. 

There are also issues of terms and conditions which differ between NHS and social care staff, meaning they are not employed on a level-playing field. 

Integrated Joint Boards (IJBs) – the main decision makers for planning health and social care delivery –are comprised of senior NHS staff on the one side and democratically elected councillors on the other, with third sector and lay members also at the table. 


(Cam Donaldson)

But, the intention of enhancing community connectedness and, through this, the potential to make the best use of all resources available in a locality, is being lost. 

Shifting the balance of care becomes challenging for IJBs when the NHS holds substantial power and, can easily resist legislation and inevitable proposed resource shifts. 

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Local councillors, too, naturally gravitate to answering their constituents’ concerns which detract from grander plans of aiming for equitable improvements in community wellbeing. 

The proposal is now for further reform, with a move to a National Care Service in Scotland, providing the opportunity for thinking further about what a truly-integrated and participatory system might look like. 

For example, can we design a system of locality planning whereby communities work with extended primary care teams to direct social care and health resources, including for hospital care?


However, it will all hinge on taking learning from previous reforms, looking at what happened and why they were not successful so as to ensure that this latest reform will be different and overcome issues of culture, power imbalances and staff contracts. 

If these all remain the same, then how will this next stage of reform prove to be different? 

A final consideration is how to support those working on the ground at a local level in managing the inevitable trade-offs. 

Of course, reform does not eliminate resource scarcity. 

We, as a society, need to wake up to this reality. Approaching its 75th birthday, the NHS has still never managed to embed at the local level more systematic frameworks, based on principles from economics and ethics, in its decision-making processes, with the aim of having more transparent and fair allocation of resources. 

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Integrating social care with health, along with lessons from the pandemic, and the need to co-produce services with local communities, add further complexity to this, but also necessity for it, especially in what will be a highly constrained budgetary situation. 

Pandemic preparedness, companionship and quality in death as well as in life are now more important than before. 

But, accounting for them alongside health gain when considering competing resource spends requires transparent processes along with the ability to manage discord; as not everyone will get their way.

The time is right to consider a distinct health and social care system for Scotland and new expenditures may be required. 

Around £18 billion is allocated from Scottish Government for the health and social care portfolio for 2022/23, of which, £1.6bn goes to social care and integration and £12.9bn to NHS boards.

Clearly, the NHS retains a majority of the allocated resource. 


Furthermore, the headline banner of “free personal care” hides many questions as to eligibility for public funding and the extent to which clients are expected to pay. 

The more that has to be funded privately by individuals, the less fair it will be. 

This is something that no governmental jurisdiction in the UK has yet solved and variations exist across local authorities in how eligibility criteria are applied. 

Current plans involve inadequate funding increases, backed by a regressive “tax” in the form of the national insurance hike and with initial 
increased funds, at least in England, not even going to social care, but rather to the NHS. 

No matter what the funding level is, we will need to ensure existing and additional resources are used in the appropriate health and social care areas so as to maximise population benefit. 

This will require balanced power structures and rigorous decision processes.

If we get these right, it may not cost as much as we might think and, importantly, would renew the bonds of social solidarity to help ensure more efficient and equitable cradle-to-grave care for the people of Scotland. 

Marissa Collins is a Research Fellow and Cam Donaldson is Yunus Chair & Distinguished Professor of Health Economics in the Yunus Centre for Social Business & Health at Glasgow Caledonian University.