Sustainable Care Systems: Learning from the Four UK Nations

This Care Initiative Seminar: Conversations on Care event took place at Green Templeton College on 11 October 2018. This report was written by Ertu Polat.


Patrick Hall and Catherine Needham, Health Services Management Centre, ESRC Sustainable Care Programme


Professor Mary Daly, Governing Body Fellow, Green Templeton College; Professor of Sociology and Social Policy, University of Oxford

Lecture report

The speakers introduced their programme of research on the four nations of the UK which is part of the ESRC funded Sustainable Care Research Programme.


In the project, sustainability is interpreted along the lines suggested by the Brundtland Report (1987): ‘Sustainable development meets the needs of the present without compromising the ability of future generations to meet their own needs.’

The research focus on ‘sustainable care’ is underpinned by the perception that provision of social care in advanced welfare states is in crisis due to:

  • population ageing
  • austerity imposed after the 2008 global financial crisis
  • shortages of supply in unpaid caring labour (and the low pay and status this gendered work is accorded).

The research aims

Twenty years on from devolution, the research project seeks to understand what has happened to the care systems and care outcomes in the four devolved administrations.

Four Nations: A Natural Experiment?

  • 1950s: Northern Ireland established unified welfare departments
  • 1968 Social Work (Scotland) Act: established unified social work departments in Scotland
  • 1972: Health and Personal Social Services (Northern Ireland) Order 1972 establishes joint Health and Social Care bodies

There is considerable divergence between the four nations.


  • Scotland has developed self-direction as a principle of care services, distinct from the more market-oriented personalisation that exists across the border in England.
  • Free personal care for the over 65s has been a distinct feature of the Scottish system, embedded in law since 2002. This has recently been extended to working age adults under Frank’s Law.


  • For Wales, well-being is a key underpinning principle of its public services, embodied in two recent pieces of legislation: the Social Services and Well-being Act 2014 and the Well-being of Future Generations Act 2015.
  • Like Scotland, Wales has been keen to (at least rhetorically) distance itself from the marketised care system of England, and has emphasised a co-production approach to care.

Northern Ireland:

  • In Northern Ireland, the current political impasse is limiting the scope to update the care system, for example by extending carers’ rights to bring them into line with other parts of the UK.
  • Conversely, Northern Ireland has a long history of health and social care integration (brought in during the 1970s). It provides useful learning for the other parts of the UK.

There are some common routes to sustainability across the four jurisdictions.

Route 1: Focus on wellbeing

England: The Care Act 2014 stated that local authorities must promote wellbeing when carrying out any of their care and support functions in respect of a person. Wellbeing is defined very broadly to include:

  • personal dignity
  • physical and mental health
  • emotional wellbeing
  • protection from abuse and neglect,
  • control by the individual over day-to-day life
  • participation in work, education, training or recreation
  • social and economic wellbeing
  • domestic, family and personal situation
  • suitability of living accommodation
  • the individual’s contribution to society.

The Social Services and Wellbeing Act 2014 and Wellbeing of Future Generations Act differentiate Wales from England with their focus on rights and entitlements, more like the model found in the Scandinavian countries.


There is a focus on service delivery and organisational performance.

Northern Ireland:

Wellbeing occurs in the language of policy documents but rather vaguely: “We must move beyond simply managing illness and instead ensure that our health service supports people to stay well.”

Route 2: Integrate with health

Care service users are often also users of health services. Therefore integration with health is a key policy goal.

  • England: focused the integration efforts through NHS
    • Better Care Fund, Sustainability and Transformation Partnerships (STPs) and now Integrated Care Organisation (ICO)
    • A criticism is that there is too much focus on NHS performance rather than individual outcomes
  • Wales: Intermediate Care Fund, Public Service Boards
    • Local government has the duty to promote integration, e.g. with police etc.
  • Scotland: Unlike England and Wales, there is a centralised approach to integration
    • Public Bodies (Joint Working) (Scotland) Act 2014
  • Northern Ireland: Integrated Care Partnerships
    • In Northern Ireland there has been integrated structures for a long time (which may reflect distrust of local government).

Route 3: Keep focused on outcomes

  • As Birrell and Gray (2018) say:
    • ‘Outcomes have been seen as a tool of scrutiny, enabling the government to be held to account and assisting parliamentary scrutiny committees… and securing transparency’
    • An attraction of [outcomes-based accountability] has been the apparent offer of a simple solution to complex problems.’
  • Scotland – National Performance Framework
    Wales – Outcome Agreements
    Northern Ireland – Programme for Government
    England – outcomes-based commissioning within local authorities
  • But as Birrell and Gray (2018) argue, ‘many of the outcomes were somewhat vague and aspirational’. Many outcome measures are chosen by public agencies because they are easy to game in performance management or evaluation.
  • There is a wider critique of outcomes approaches as ‘outcome theology’ (Tunstill and Blewett, 2015) or ‘fools’ gold’ (Bovaird, 2012).

Key issues for all four nations

  • Support for informal carers: There are six million people who do care work on a daily basis; formal care is only the tip of the iceberg. There have been moves to better support carers, for example in Scotland an increase in carers’ allowance has recently been granted. It will be interesting to see if that puts pressure on other parts of the UK.
  • There is a big question of ‘who pays?’, which brings together funding and political challenges. Another question is how to make the system financially sustainable.
  • The ‘B word’: Given the heavy reliance of the UK on migrant care work, what is going to happen after Britain leaves the EU? What are the care implications of Brexit?
  • While there are some developments, it seems also that there is political stalemate around social care in all the four nations (although to a differential degree).


The discussion focused on a number of themes. Some questions focused on the core elements of the research – for example, how the research understands sustainability and deals with complex sustainability issues in the care system across the four regions. Discussion also focused on whether the four regions constitute four different systems or variation on a similar system. In this regard, the speakers pointed out the significance but also ‘messy nature’ of devolution. As a result the four jurisdictions have different aspects but share similarities also.

The considerable variation within the jurisdictions was also adverted to. Consider the differences between places in England alone, especially if one broadly defines the care system to include factors like norms around gender and family, the economic supply of labour, how markets work in home care and in residential care. When we think about ‘the system’ in those terms, the huge variation in conditions that obtain in London, which has a high population, high migration, large entry into and out of home care and a complicated residential care market, as compared with somewhere like Somerset for example is laid bare. So examining different systems within England and perhaps the other three jurisdictions would also be an interesting exercise.

That said, while there is variation within the countries, looking at four nations is still important because it crystallises the legal and policy context. But of course, one should remember that national identity or location is a simplistic code and hence different places might have different features. Actually in some cases there might be more similarities across borders than within.

Discussion also focused on the components and foundations of a ‘care system’. In this regard it was pointed out by the speakers that when countries legislate on social care, they are positing a public ethics, saying something about, for example: What is the role of the family? What is the role of women? What is the role and contribution of the state and the community?

The care regime literature focuses on generosity of provisions, but we should also discuss whose role it is to provide and how we as a society values that. Answering those questions pushes ethical and emotional issues to the fore. Legislation and policy discussion needs to reflect the values that obtain, it should not be only about funding.

In the discussion, one of the participants suggested seeing the care system in terms of layers. The bottom layer is independent living, the next layer family care, above that there is domiciliary care services, above that there’s a layer which is home nursing, and then there are more specialist levels of speech therapy, physiotherapy, etc. None of those layers seems to be working very effectively. In particular, in recent years the domiciliary care workforce has been downskilled.

For international comparison, one could look at the Netherlands, where the home care system is provided by some 8,000 registered nurses. By upskilling the home care work force, it facilitates early interventions for medical problems, and this takes a lot of the pressure off the system.

It was also pointed out that social care and the systems that make up social care are very much interlinked with economics and environmental sustainability. It may be that factors that are good for economic growth might be bad and unsustainable for the care system, and indeed may be bad environmentally. As suggested by one participant, an ecological perspective on social care would undoubtedly help to make the necessary interconnections.

The nature of wellbeing and the degree to which wellbeing is a consideration of the current policy landscape was also prominent in the discussion. Questions were raised about the 2012 Health and Social Care Act which establishes Healthwatch and Health and Wellbeing Boards. Here it was pointed out that if only local authorities had understood the task, power and authority of Health and Wellbeing Boards, and had implemented them together with the provisions for joint strategic needs assessment (the annual strategic plan to improve the health of the local population), we might be in a better place than we are.

In the discussion it was generally agreed that the true potential of the Health and Wellbeing Board has not been realised. A suggested cause is the dominance and the interests of the NHS. The history of integration attempts is that they start out with the great aspirations based on the intelligence and data set up by public health epidemiology and deep understanding of the needs of the local area. But these considerations become secondary to the organisational sustainability of the NHS, particularly of the hospitals. The health parts of the system have dominated also because they have more power, money, employees and buildings.

A question was also raised about the move on the part of the local authorities to place greater emphasis on technology, and whether this will become more relevant to concerns around sustainability in next ten years. In reply, it was pointed out that technology has to be about facilitating relationships. It is not a magic pill which replaces the centrality of relationships in care or displaces its relational nature. It has to enable people to care for one another by removing some back-office bureaucracy. But care still has to be people based. Therefore the we should approach the idea of “robots who do everything” with caution.