A Scottish Care Service
Even before the pandemic, it was clear that the social care system in Scotland was in urgent need of reform. The current system is underfunded, lacks capacity, and has major workforce recruitment and retention problems with fragmented delivery through a discredited commissioning process. When former Conservative ministers are openly talking about the nationalisation of care homes, there is widespread recognition that there is a problem (even if not agreement on what should be done to solve the issue). The system is not just failing those who need social care but is also damaging the NHS with over half a million hospital bed days lost every year because of delayed discharges at the cost of £120m. These problems have been magnified during the pandemic. The lack of Personal Protective Equipment (PPE), inadequate testing, minimal sick pay, and use of agency staff, have all contributed to the tragic deaths in care homes and amongst social care staff. Care at home has also been impacted with care packages reduced or abandoned. Informal carers have all too often been left to pick up the pieces.
The concept of a (national) Scottish Care Service (SCS) as part of the solution is not a new one. It has been Scottish Labour policy for a number of years, most recently as a 2019 General Election manifesto commitment (see p35 here). My own organisation, the Social Health Association, outlined the idea in its recent social care consultation paper. And, UNISON Scotland has recently published what it describes as a ‘road map’ towards the creation of a national care service. But while there is growing support for the principle of a Scottish Care Service, many in the sector have reasonably asked what it means in practice.
There seems to be a consensus in favour of a national framework rather than a service delivery organisation or making it part of NHS Scotland, not least to recognise the different models of care. But that leaves open what the SCS would undertake directly and what would be the governance arrangements. A national framework approach must end the current marketisation of social care. It could set consistent standards, contracts and charges for services not covered by free personal care. Most importantly, it would include a statutory workforce forum to set minimum terms and conditions, organise effective workforce planning and put a new focus on training and professionalism.
On governance, the usual approach would be to create a new Non-Departmental Public Body (NDPB). This would leave the SCS with a similar democratic deficit to NHS Scotland and would undoubtedly be populated with the ‘usual suspects’ by the ministers who make the appointments. As the service will be delivered locally, another approach would be to create a joint board from councils across Scotland. This was a solution UNISON Scotland proposed for police and fire, which had the added advantage of keeping the VAT exemptions. The joint board could have places for relevant stakeholders, including users and worker providers.
A national service would also need to address regulation. The Care Inspectorate’s ‘light touch’ response to rising complaints has highlighted the need for reform. In fairness, it has been constrained by the Scottish Government’s own ‘Better Regulation’ code, together with inadequate powers and resources. There would also need to be a review of workforce regulation currently administered by the Scottish Social Services Council and UK professional regulatory bodies.
If the service is going to be delivered locally, this leaves open the question of local governance and ownership. As the Accounts Commission noted in its annual overview, the current system of Integrated Joint Boards (IJBs) has struggled to deliver integration or a shift in spending from hospitals to community care. There have been many attempts to improve integration in Scotland since the joint finance arrangements of the 1970s and all have struggled. It may be that this iteration will eventually deliver, but many will argue that it requires stronger democratic accountability to make difficult decisions, and that means a bigger role for councils. This happens in other parts of Europe, but even here, they have not always shifted resources from hospitals to community services.
Greater integration does not require staffing integration. Professional barriers have been broken down in recent years, and joint teams have shown that they can work effectively together, particularly when physically working together in community hubs. A huge staffing reorganisation would create stasis, just at the time when we need to free up staff to innovate. When IJBs were created, I – as a UNISON Scotland official - wrote a workforce framework, which would have addressed many of the current problems. Sadly, workforce issues were largely ignored at the time.
The fragmentation in service delivery is a significant problem that does need to be addressed with more than one thousand care at home providers, and the scandal of care home firms registered in tax havens. In the short-term, the pandemic has highlighted the need for greater coordination on issues like procurement. Abolishing the market, standard contracts and common workforce standards will help shift resources to the front-line. In the medium-term, there should be greater common ownership, particularly in residential care.
Common ownership does not preclude innovative voluntary sector operators who can meet the new standards as the best in the sector already do. The private sector likes to make a false link between personalised care and marketisation. All care should be personalised, and that requires a range of services, not a range of ownership models. Local delivery should also be about greater innovation in service delivery, trying new models of care that integrate people with care needs into communities.
Finally, there is the tricky issue of funding. In England, the issue has at least been considered in the Dilnott Report, although it was overly focused on protecting assets. In Scotland, we cannot simply hope for the Barnett consequentials of reform in England to plug the current funding gap, let alone future demographic pressures. It requires a mature conversation with citizens about taxation. If we want to go further and fund care on the same basis as the NHS, then the conversation shifts to proposals like the former health minister Andy Burnham’s care levy, which involved a form of inheritance tax. Calling it and similar plans a ‘death tax’ is not a mature conversation.
The creation of a Scottish Care Service is an idea which has come of age. Turning it from a concept into a practical solution requires more work and some difficult conversations. If we are to ‘Build Back Better’, as the Tories implore, an integrated health and care service, with national standards and local delivery should be the highest priority.
Dave Watson, Secretary of the Socialist Health Association Scotland