More money or more reform? How are the UK and Scottish Governments thinking differently about health and care reform

Reading Time: 5 minutes

This blog considers some of the recent activity by the UK and Scottish Governments in the area of health and social care and considers the implications for Scotland.

In brief, social care has been under the spotlight since the start of the pandemic. Responses north and south of the border have been different: the UK Government has introduced the Health and Social Care Levy to increase overall funding and the Scottish Government is consulting on a National Care Service, without, at this stage at least,  including proposals for similar funding reform.

The UK Government has announced reforms that will limit (cap) what a person will have to pay over their lifetime for care. The Scottish Government has not addressed the so-called ‘hotel costs’ of care that can quickly diminish a person’s assets.

Last but not least, the UK Government has started on the journey of health and social care integration for England with its Health and Care Bill, albeit from a different starting point, that Scotland started on at least a decade ago. Some of the provisions in the Bill will impact devolved areas. The Scottish Government is concerned about some of these wide-ranging regulation making powers of the Secretary of State in devolved areas.

The remainder of the blog considers these issues in more detail.

Independent Review of Adult Social Care in Scotland

The Independent Review of Adult Social Care was published in February 2021.  The Review proposed a National Care Service based on:

“a new narrative: replacing crisis management with prevention and wellbeing; burden with investment; competition with collaboration and variation with fairness and equity.”

It also suggested that a new way of thinking about social care should be adopted, from one of social care being a burden to society, to one where it is regarded as an investment in and for society. The report highlighted that social care is not currently funded or organised in a way that is sustainable, nor in a way that supports transformation and innovation.

On 9 August 2021, the Scottish Government launched a consultation on ‘A National Care Service for Scotland’ setting out its proposals to improve the delivery of social care.

The proposals in the consultation take forward some, but not all, of the recommendations from the Independent Review. They say nothing about funding for social care.

A key change would be that the Scottish Ministers would become accountable for social care, as they are for health, rather than local authorities. COSLA immediately put out a statement about the proposals, saying:

“…it is an attack on localism and on the rights of local people to make decisions  democratically for their Place.  It once again brings a centralising approach to how decisions which should be taken locally are made.”

The National Care Service (NCS) – or the Scottish Government –  would define the strategic direction, quality standards and the framework for how community health and social care is delivered in Scotland. There is clearly a tension between further centralisation, or standardisation of operation here, which distances decision-making from local communities, and the professed desire of the Government to be more responsive to an individual’s needs and circumstances, to be more person-centred. Is it possible for a nationally organised service to respond to an individual’s needs or to separate their needs from their local community and local circumstances?

The scope of a National Care Service, including funding, has been considered in a blog by the Fraser of Allander Institute The National Care Service – an evolving beast but will the funding feed its appetite?

So, what has been the approach to reform in England?

On 7 September 2021, during a statement on the Government’s plans for health and social care, the Prime Minister announced that from 6 April 2022 to 5 April 2023 National Insurance contributions would increase by 1.25 percentage points – with the additional revenue to be spent on the NHS and social care in the UK.  And then from April 2023 – there would be a separate Health and Social Care Levy.  The SPICe blog: Health and social care: who pays, who decides? explores the costs and benefits to Scotland. The House of Lords Library also published a blog on Social care funding: a rise in national insurance

The Prime Minister said:

“from next April we will create a new UK-wide 1.25% health and social care levy on earned income, hypothecated in law to health and social care, with dividends rates increasing by the same amount.


“Although Scotland, Wales and Northern Ireland have their own systems, we will direct money raised through the levy to their health and social care services. In total, Scotland, Wales and Northern Ireland will benefit from an extra £2.2 billion a year and, as this is about 15% more than they will contribute through the levy, it will create a Union dividend worth £300 million.”

The statement was accompanied by a policy paper Build Back Better: Our Plan for Health and Social Care. The Prime Minister said the following as part of his  Statement on 7 September:

“Wherever you live, whatever your age, your income or your condition, from October 2023 no one starting care will pay more than £86,000 over their lifetime, and no one with assets of less than £20,000 will have to make any contribution from their savings or housing wealth—up from £14,000 today. Meanwhile, anyone with assets between £20,000 and £100,000 will be eligible for some means-tested support. This new upper capital limit of £100,000 is more than four times the current limit, helping many more people with modest assets”

So, we see two very different approaches to reform in social care, in systems which are different in some key features: since 2002, Scotland has provided personal care and nursing care free of charge to those assessed as needing it. This is good for those who are eligible, (the judgements about someone’s eligibility vary from area to area) but see this SPICe blog on why free care might not apply to all those who think they might need it or who feel they could benefit. Also, as has recently been said, the elements of personal care covered are tasks, and have allowed, alongside other factors, a ‘time and task’ approach to be taken in social care. The other is that Scotland is further down the integration route for health and social care.

The next section doesn’t look at the UK Government’s proposals for integration in any depth, but the UK Health and Care Bill is worth a mention because of concerns the Scottish Government has with some of the ‘Miscellaneous’ provisions that make up Part 5 of the Bill.

Health and Care Bill

The Health and Care Bill was introduced to the House of Commons in July 2021.

The Explanatory Notes comment that “largely the provisions in the Bill extend to England and Wales only, and apply to England, as health is largely a matter for devolved competence.” Clause 133 of the Bill sets out the territorial extent of the Bill. 

The Bill and its interactionwith the devolved administrations in the UK is explored further in a briefing published by the House of Commons library.

A subsequent briefing by the House of Commons library, published in September 2021 ahead of a debate on the Future of the National Health Service, includes links to briefings on the Health and Care Bill and the Health and Social Care Levy.

A legislative consent memorandum on the Health and Care Bill was lodged in the Scottish Parliament by the Cabinet Secretary for Health and Social Care in August 2021. The LCM includes the following comment from the Scottish Government:

“At this time, the Scottish Government cannot recommend to the Scottish Parliament that it gives its consent to the Bill. While aspects of the Bill are not contentious (section 2 on pages 1 and 2), there are several that impinge on the legislative competence of the Scottish Parliament and the executive competence of the Scottish Ministers.”

The LCM concludes:

“The Scottish Government’s position, which has been explained to the UK Government, is that, if satisfactory amendments should be made to the Bill to respect the devolution settlement, the Scottish Government may be able to recommend that the Scottish Parliament consents to the Bill. If, during the remaining stages of the Bill, appropriate amendments are provided which address concerns, a supplementary memorandum with a final position on consent may be lodged.”

So, to sum up, there are big, and very different, changes afoot for health and social care in England and in Scotland. These will be realised through at least two major pieces of legislation: the Health and Care Bill, going through the UK Parliament currently, and a National Care Service Bill in Scotland, expected by June 2022. Reforms in England appear to be grappling with the difficult funding issue, whereas the focus of reform in Scotland is further centralisation and a continuation of the project of integration of health and social care.

Anne Jepson and Rebecca Bartlett