Is there a “once-for-Scotland” solution to health and social care reform?

As Scotland looks to the 2026 Election, the RSE’s Policy in practice: How Scotland can get it right paper sets out an uncompromising diagnosis of the health and social care system, which is under strain, and a politics too often trapped by short‑termism.

Nowhere is this more evident than in health and social care. The paper underscores that without decisive structural reform – delivered with honesty, ambition, and cross‑party resolve – the pressures facing Scotland’s public services will continue to deepen.

A central message is clear: Scotland must shift the balance of investment from acute healthcare into community‑based social care. This is not a matter of cutting NHS spending; rather, it is about recognising that investment in self-directed support in homes and communities is not only one of the most effective ways to improve wellbeing, and a necessary response to changing population demographics; it is perhaps the finest example of preventative spending easing pressure on overstretched acute health services.

The Christie Commission articulated this 15 years ago, and today, the evidence is even more compelling. If Scotland continues to focus resources into clinical settings whilst social care remains structurally fragile, the cycle of crisis will not only continue, but accelerate.

As CEO of Enable; one of Scotland’s largest NGO providers of care and support; I recognise that moving resource into social care will only achieve meaningful impact if the sector itself is open to fundamental reform. As the RSE paper highlights, fragmentation, short‑term funding cycles, and inconsistent commissioning have weakened delivery and constrained innovation. Reform must therefore be comprehensive, not piecemeal – once for Scotland, not multiple variations.

Critical to that reform is fair work. It has long been recognised that social care requires a national pay bargaining body to deliver terms and conditions comparable to the NHS Scotland Agenda for Change. For a workforce which is over 80% women and of which 20% experience in-work poverty, the absence of such a mechanism for social care  has entrenched inequity, undermined recruitment and retention, and allowed progress on pay to become vulnerable to political fluctuation. The impact of workforce insecurity is felt daily by citizens who access care and support and their families; we owe it to them – and to all of us who will have call upon social care in our futures – to get it right now.

However, reform on this scale is often viewed as politically unmanageable. The perception that restructuring health and social care carries intolerable political risk has, for years, paralysed meaningful action. The RSE challenges this directly: without cross‑party consensus, Scotland will continue to experience cycles of unfulfilled reform and public frustration. The abandonment of a National Care Service in the current Parliament, leaving the key recommendations of the Feeley Review unmet, is the latest example of this.

A true national care system – collaboratively designed, fairly funded, transparently delivered, once for Scotland – requires not just governmental commitment, but buy-in across parties.

The RSE paper calls for a reset in how Scotland approaches policy as a whole, highlighting the need for delivery‑first thinking, clear accountability, and a willingness to confront trade‑offs openly. In social care, this means acknowledging that new investment must be accompanied by structural redesign; that improved wellbeing requires sustained, long‑term commitment; and that transformational change cannot be achieved through incremental adjustments or pilot programmes that never scale.

Scotland stands at a defining moment. Health and social care reform is not just a technical or fiscal question; it is a moral one. We have an opportunity to build a fairer, more resilient system by investing where it makes the greatest difference: in the social care workforce, in community‑based support, and in a national model designed for the Scotland of the future.

Theresa Shearer FRSE, CEO of Enable and an RSE Council Member.

The RSE’s blog series offers personal views on a variety of issues. These views are not those of the RSE and are intended to offer different perspectives on a range of current issues.