Global Health and social care

What is the health and social care ecosystem?


Photo by Hillary Ungson on Unsplash

The existence of the UK’s NHS and “single-payer” medicare programmes like the ones in Canada and Australia might suggest to the layperson that healthcare is essentially a rationally ordered system. You have a medical problem; you go to your GP or A&E; they treat you or send you to a specialist; you’re cured, the government foots the bill from taxpayer money, and everybody’s happy.

The reality is much messier.

What does the ecosystem look like?

In our new LGIU member briefing, Emily Burn and Catherine Needham of the University of Birmingham employ the metaphor of the ecosystem to reflect the complexity of healthcare as it actually exists.

  1. There are the visible statutory parts of the ecosystem, like the ones mentioned above, as well as long-term care homes, rehab facilities, and so on.
  2. But there are also invisible parts of the ecosystem. Indispensable roles are played outside those public institutions, in the home, within families, between friends, and in the community.

Maybe you take care of an elderly relative; maybe a friend picks up your groceries when you’re taking care of your kids; maybe you are in a religious organisation; maybe you’re in a weekly poker game. Burn and Needham labels these types of informal organisations as part of social care and argue for a holistic understanding of health and social care that recognises that those systems operate in a broader context involving socioeconomic determinants of health as well as environmental and cultural influences.

Looking at the ecosystem in this way, as a dynamic mix of formal and informal, visible and invisible elements spanning institutions and communities, Burn and Needham argue that it might ultimately be beyond the capacity of policy to determine how the health and social care system functions.

“While policy makers influence how the social care system functions,” they state, “they will not have complete control of the ecosystem.”

What are the issues facing the ecosystem?

The precise way in which this ecosystem functions varies from place to place depending on institutional, social, and cultural context. Take the UK. The NHS emerged to fill an urgent social need for publicly funded health care. Over time, as gaps emerged in what the NHS could offer, people developed their own informal care systems to supplement the NHS. Reform efforts tend to focus on pressuring Westminster to regulate and even take over social care to integrate it into the NHS and ensure that it rises to NHS standards. But that would likely require tax hikes, an untenable political risk in an era of austerity. Social care is then left in a grey area, both indispensable to the overall health and wellbeing of the country and often excluded from its health institutions.

Though specifics naturally differ, it’s a similar story elsewhere. In Canada, Covid-19 revealed discrepancies between the care levels in non-profit and for-profit long-term care facilities. According to the CBC, in 2021 and 2022, for-profit long-term care facilities delivered 500,000 fewer care hours than they were funded for by the province of British Columbia. In comparison, facilities run by non-profit societies delivered 93,000 more care hours than what they were funded to provide.

Reformers have naturally protested what amounts to the taxpayer subsidising corporate profits and advocated for assurances that funding for care actually goes toward care. But in a complex and fragmented ecosystem it remains difficult to figure out what policy lever to pull that would be in the majority’s best interests without causing unintended consequences elsewhere. For instance, in many places, particularly those under austerity conditions, just throwing money at the problem might seem like a solution. But in situations like the one in Canadian long-term care, it’s clear that that wouldn’t solve anything—it would just make for-profit companies a little richer. Nor is regulation an obvious answer if it means that those for-profit companies on which the system depends decide that it’s not worth the extra cost and just close up shop. There will be those who then call for nationalisation—but that’s costly to the taxpayer, and in federal systems like the ones in Canada, Australia, and the US, it’s constitutionally impossible.

What can be done about it? And is there a role for local government?

Yet there must be a solution. These systems are broken. They are failing large amounts of people—both carers, who are underpaid, under-resourced, under-protected, and cared-for, who are forced to settle for a lower standard of service than they need and to which they are entitled.

Burn and Needham, for their part, advocate for an ecosystem-level lens that focuses on outcomes. In their analysis of Scotland’s proposed National Care Service to supplement the National Health Service, Burn and Needham find that it is unlikely to improve outcomes. One major reason for this is that it pulls social care out of the purview of local government into a centralised bureaucracy.

The advantage of local government is that it can foster those community-level resources that people actually need rather than a one-size-fits-all approach that might not leave a lot of people’s needs unmet. This is because there’s a lot of unglamorous stuff that might not even look like health or social care that actually helps outcomes a lot—things like dance classes, bingo nights, and after-school programmes that bring communities together and help people to help themselves before a problem becomes acute enough to need formal care. As Burn and Needham conclude,

“Building trusting relationships between the visible and invisible parts of the ecosystem should be prioritised to support people accessing care and support to achieve better outcomes.”

Interested in reading more about this topic? Check out Burn and Needham’s research paper, What role for local government in Scotland’s National Care Service?


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