213.We took evidence from witnesses with experience of public services in Scotland, Wales and Northern Ireland to inform our understanding of how COVID-19 affected public service delivery in England. Our key findings are in the boxes below.
Health and social care integration in the devolved administrations before COVID-19
In Scotland, more than half of the total NHS and adult social care budget is now delegated to an Integration Joint Board (IJB) for each area. IJBs are made up of representatives from the local authority, the local NHS board, and service user and third-sector organisations. They are led by a ‘neutral’ Chief Officer, who ensures that the commissioning strategy of the IJB does not prioritise the NHS agenda or social care agenda and takes an integrated approach. They are accountable to the members of the IJB, and the local NHS Board and council.223
A July 2018 King’s Fund report on the Chief Officer’s role found that IJBs provided an “unprecedented scope to work collaboratively to shift resources to community-based services and to develop new models of care as a shared, cross-system endeavour”.However the report found that NHS boards were still the dominant partner in local systems.
In 2018, the Welsh Government published ‘A Healthier Wales: our plan for health and social care’.This plan was supported by a “transformation fund” to support the development of collaborative pilot projects in health and social care, led by multi-agency regional partnership boards. By January 2019, £89 million had been allocated for proposals across Wales.
However, there has been a lack of substantial recurrent funding. In July 2019 the Wales Audit Office published a report on the Integrated Care Fund, an initiative also designed to support integrated working and new models involving health, social care and the third sector. The report found little evidence of successful projects being mainstreamed into core budgets or improving service outcomes.
Uniquely within the United Kingdom, Northern Ireland has had a structurally integrated system of health and social care since 1973. Social care is integrated with health care under five health and social care trusts. They manage their own budget, which is allocated by the Northern Ireland Executive through the Northern Ireland Department of Health. Provision of continuing health care is organised directly by the health and social care trust, and therefore does not represent an additional source of revenue.
However, a July 2019 Nuffield Trust study found that structural integration had not translated into equality between health and care: “Despite the notional integration of health and social care, there are signs that the latter remains overlooked” with “little sign so far of the intended shift of care and resources into care outside hospital.”
What went well during the pandemic
The Nuffield Trust outlined how the Scottish Government’s pandemic response had put health and social care on a more equal footing. The Scottish Government “explicitly recognised the crucial role of social care as early as 24 March” and committed to “shared leadership” across health and care.
Anna Fowlie, Chief Executive of the Scottish Council of Voluntary Organisations (SCVO), elaborated:
“We have had a statutory process of integration of health and social care in place since 2016. Integrated joint bodies were set up and run jointly by the NHS boards and local authorities, and they oversee the running of the health and social care partnerships. Therefore, the mechanisms were there, and the right people were around the table at the start of this and already had established relationships. Like any partnerships, some will work better than others, but the mechanism is established.
“There is also joint leadership in the form of the Cabinet Secretary for health and social care and the Convention of Scottish Local Authorities, the local government association in Scotland, and its spokesperson for health and social care.
“One of the real successes we have seen is that a few years ago the Scottish Government committed to paying the Scottish living wage to all front-line workers in social care.”
The Nuffield Trust wrote that in Northern Ireland, “perhaps aided by its integrated systems”, staff were “redeployed” from the NHS into social care. The Northern Ireland Executive is planning to “embed a new permanent framework for nursing and medical input into care homes”.
Dr Victoria Winckler, Director of the Bevan Foundation, a Wales-based think tank, described a similar level of integration:
“The different arrangements in Wales for the delivery in particular of healthcare and the relationships already established between healthcare providers and social care providers have probably eased the approach to the pandemic. … In any situation, integration of shared values, protocols and procedures helps.”231
What went less well during the pandemic
Professor Nick Pearce of the University of Bath presented a less clear picture:
“In Scotland, where there has been a longer-term tradition of a funding settlement for health and social care and more integration, there has been a much higher number of deaths proportionately in its care homes than in England and Wales.”
Anna Fowlie of the SCVO noted:
“Not … everything has been perfect. We have had … problems … in care homes and with PPE … I think the social care sector would say—I am sure the Scottish Government would disagree—that it has definitely come second to the NHS, understandably because acute services were the thing at the beginning, but it has brought into sharp relief again that it is not quite as integrated as we like to think.
“There is very much a protective attitude towards the health service because it belongs to government, which I can understand, and the plethora of different providers … makes it really hard to engage with social care.”
Dr Anthony Soares, Director of the Centre for Cross Border Studies, a think tank in Northern Ireland, told us that while the Northern Irish health and social care system’s “approach to the COVID-19 crisis” had been “absolutely astounding”, and that it had been “extremely successful in dealing with [the pandemic] in general terms”, there had been “some challenges, with pressures being placed on the social care provision coming out of the healthcare system”. For example, “there have been certain difficulties in ensuring that those moving from the hospital to social care setting have been tested, or their COVID-19 status established”.
He pointed to some fundamental deficiencies:
“The whole health and social care services are generally integrated in Northern Ireland in their delivery organisations, but the provision of social care is often shaped by different legislation in comparison with healthcare, and there is a lot more diversity in the providers of social care, with both the private and voluntary sectors being involved.”
Victoria Winckler reported that in Wales there had been “issues in the transfer of patients, testing and so on… it is not quite so different from that experienced elsewhere … I would not like to pretend that everything was perfect”.
The Bevan Foundation described how at the beginning of the pandemic, while the Welsh Government had “considered the option” of giving food vouchers to children’s parents and carers, “a growing number of local authorities” had chosen to offer “cash payments to families in lieu of meals”:
“We understand that 17 out of 22 authorities now make cash payments. The Welsh Government subsequently announced that the local authorities would continue to receive funding towards the cost of free school meals during the school summer holidays.”
David Isaac CBE, Chair of the Equalities and Human Rights Commission (EHRC), called on the UK Government to emulate this approach:
“In relation to education, there is a lot that could be done. For example, in Wales free school meals over the summer were paid in cash. That has a huge impact on families’ ability to feed themselves. For me, that is a very quick win and something that could be applied throughout the UK.”
Nick Davies of the IfG drew a similar comparison:
“It might have been better … to give more responsibility, if there was more capability and capacity, at a local level to make … decisions. In Scotland, Wales and Northern Ireland, for example, there has been a much greater role for local authorities in decisions on free school meals, and they have also had the ability to provide cash to families rather than doing it through voucher schemes.”
223 Scottish Parliament, Health and social care integration: spending and performance update (26 June 2019): [accessed 7 November 2020]
224 The King’s Fund, ‘Learning by doing: integrating health and care in Scotland’ (3 July 2018): [accessed 9 November 2020]
225 Welsh Government, ‘A healthier Wales: long-term plan for health and social care’ (1 October 2019): [accessed 9 November 2020]
226 Wales Audit Office, Integrated Care Fund (2019): [accessed 9 November 2020]
227 Nuffield Trust, ‘Change or Collapse: lessons from the drive to reform health and social care in Northern Ireland’ (10 July 2019): [accessed 10 November 2020]
228 Nuffield Trust, ‘What steps are currently being taken to reform social care’ (18 March 2020): [accessed 10 November 2020]
230 Written evidence from the Nuffield Trust ()
236 Written evidence from the Bevan Foundation ()