What is Subsidiarity in Health and Social Care?

Subsidiarity is a principle used in governance, including health and social care, that focuses on making decisions at the lowest possible level, as close as possible to the people affected by them. It means that issues should be handled by the smallest, least centralised competent authority, unless a larger body is required for effectiveness. In health and social care, subsidiarity shapes how responsibilities are shared between local, regional, and national levels, aiming to improve efficiency and responsiveness to local needs.

The concept comes from political and social philosophy and is widely applied in public administration. It prevents higher authorities from taking over functions that can be effectively carried out at lower levels, while still allowing national oversight when necessary.

The Origins of Subsidiarity

Subsidiarity has historical roots in European governance, particularly within the European Union’s legal framework, but its use in public services extends beyond EU policy. In health and social care, it aligns with the idea that communities and local authorities often know their needs better than central government. The principle recognises that while national policy creates consistency, local implementation can tailor services to specific circumstances.

Application in Health and Social Care

In health and social care, subsidiarity is applied by giving certain powers and decision-making responsibilities to local authorities, NHS Trusts, Integrated Care Boards (ICBs), and community groups, rather than holding every decision centrally in Westminster or Whitehall. This means local bodies can adapt services to fit their population’s demographics, health profiles, and social needs.

Examples include:

Local councils deciding on care home provision based on community demand.
NHS Trusts setting up specialised services in response to local health conditions.
Community health groups running prevention programmes using culturally relevant methods.

Each of these examples shows how subsidiarity supports more personalised and responsive care without removing the national standards and legal requirements that apply across the UK.

Benefits of Subsidiarity in Practice

Subsidiarity can bring several advantages to health and social care:

Local expertise is valued and used in decision-making.
Services can be adapted for quicker and more suitable responses to local issues.
Community engagement is strengthened, as people have more say in how services are delivered.
Resources may be used more efficiently because local teams understand the most pressing needs.
Staff morale can improve when professionals feel trusted to make decisions without unnecessary central oversight.

Risks and Challenges of Subsidiarity

While subsidiarity can bring clear benefits, it can also present challenges. Variations in service quality may arise if local authorities have different levels of funding, experience, or capacity. This can lead to inequalities between areas.

Other risks include:

Overlapping responsibilities when local and national bodies do not clearly define their roles.
Differences in interpretation, leading to inconsistent policy application.
Difficulty in maintaining national standards without interfering in local control.

Addressing these risks requires good communication between national and local bodies, clear guidelines, and sufficient funding across all regions.

Subsidiarity and Integrated Care Systems

The UK’s move towards Integrated Care Systems (ICSs) reflects the principle of subsidiarity. ICSs bring together NHS organisations, local councils, and other partners to plan and deliver consistent, joined-up services. Subsidiarity is central to this approach, as it encourages decision-making closer to the patient while still having a collaborative framework across larger areas.

Through ICSs, local knowledge is combined with regional support, making it possible for services to adapt without losing broader coordination. This helps manage conditions that require both local action and national strategy, such as tackling obesity, addressing mental health needs, and preparing for pandemic responses.

Legal and Policy Framework

In UK law and policy, subsidiarity is not always mentioned by name, but its principles are reflected in:

The Health and Social Care Act 2012, which gave more powers to local health commissioners.
The Care Act 2014, which placed duties on local authorities to shape local markets for care and support.
NHS England’s guidance on commissioning, which encourages local decision-making and engagement with communities.

These legal frameworks balance the protection of national standards with local flexibility.

The Role of Community and Voluntary Organisations

Subsidiarity is not limited to official bodies. Community and voluntary sector organisations are often closest to service users in health and social care. They can react quickly to needs, gather feedback directly, and communicate concerns to decision-makers. This grassroots involvement shows subsidiarity in action, bridging the gap between citizens and formal structures.

Examples include:

Charities providing mental health support tailored to specific cultural communities.
Volunteer networks delivering food and companionship to isolated older adults.
Local advocacy groups helping patients understand and influence service changes.

Decision-Making Under Subsidiarity

In practice, subsidiarity means asking whether a given decision can be taken effectively at a local level. If it can, it should be left there. Only decisions that require wider coordination, resources, or consistency should be moved upward.

Steps to assess this include:

Determining the level of expertise available locally.
Checking availability of resources in the area.
Evaluating the impact of local variation compared to national uniformity.
Communicating with stakeholders to confirm local capacity.

By following these steps, health and social care organisations can respect the principle of subsidiarity while meeting broader responsibilities.

Examples from UK Health and Social Care

Let us consider some specific examples:

A rural GP practice knows that transport is a barrier for patients. Under subsidiarity, it can create outreach clinics in neighbouring villages without waiting for national approval, as this decision is best handled locally.
A local authority identifies that a growing number of residents need dementia care. They develop specialist day centres tailored to local cultural needs. National policy supports dementia care in principle, but the exact design is determined locally.
In public health, a council might run a targeted vaccination campaign where uptake is low. They can shape messaging, locations, and timing according to what works best in the community.

Monitoring Subsidiarity

Respecting subsidiarity does not mean stepping back entirely from oversight. Monitoring is needed to check that local services meet legal requirements and deliver safe, effective care. This involves:

Data collection and analysis from each locality.
Assessments by regulators such as the Care Quality Commission (CQC).
Ongoing communication between local providers and national bodies.

This ensures that subsidiarity supports local decision-making without undermining standards and fairness.

Balancing Local and National Interests

One of the most important parts of applying subsidiarity is finding the right balance between local autonomy and national responsibility. Some services, like specialist surgery or rare disease treatment, are too complex or costly for each locality to run alone, so they remain centralised. Meanwhile, routine care, social support, and preventive measures fit naturally into a local framework.

Clear boundaries help avoid confusion. National authorities may set outcomes or targets, but allow local bodies to choose the methods for achieving them.

Final Thoughts

Subsidiarity in UK health and social care is about placing decisions as close as possible to the people affected by them while keeping the benefits of national oversight. It relies on trust, local expertise, and strong communication between all levels of service delivery.

By allowing local bodies to tailor services to the needs of their communities, subsidiarity supports more responsive, efficient, and meaningful care. At the same time, it requires clear policies, shared standards, and balanced relationships between local and national authorities to work well in practice.