The Future of Adult Social Care

The Independent Review of Adult Social Care in Scotland published its report today. It makes a wide range of recommendations that might address the long-standing need to reform this sector.

Most of us would agree with Derek Feeley's summary of the challenge: "This is a time to be bold and radical. Scotland needs a National Care Service to deliver the high quality, human rights-based services people need to live fulfilling lives, whatever their circumstances. Scotland has groundbreaking legislation on social care but there is a gap, sometimes a chasm, between the intent and the lived experiences of those who access support. We have a system that gets unwarranted local variation, crisis intervention, a focus on inputs, a reliance on the market, and an undervalued workforce."

The headline is creating a National Care Service, something many of us have supported for a long time. A national framework setting consistent standards on ethical commissioning, care standards and workforce issues should be the aim, with delivery as local as possible. There will be a concern that the report gets the balance between the national and the local wrong. If you put a senior civil servant in charge of a review, you shouldn't be surprised if he recommends a high degree of centralisation. Democratic local government is to be replaced by what looks like clear direction and funding from Edinburgh of the reformed IJBs. Social care should not exist in isolation from a wide range of other local services, and there is a real risk that those links will be lost. 

The report's support for reducing the use of institutional care, early intervention, technology, human rights, and involving people and families is uncontroversial. It also rightly recognises the role of unpaid carers and recommends bringing support for them within the National Care Service scope. However, it does perhaps fall into the trap of listing interesting local initiatives, without clearly explaining how we systemically ensure that best practice is rolled out in a way that reflects local circumstances. A national approach to improvement and innovation is fine, so long as it doesn't become the one size fits all approach that centralisation inevitably entails.

The chapter on commissioning signals a welcome move away from the market towards collaboration in the procurement and commissioning of services.  The trade-off is that providers have to be accountable for new standards of accountability, quality, staff wellbeing and transparency. However, the report is light on how this is to be delivered in practice, particularly in those sections that duck issues of ownership and the culture that for-profit services bring to the process. Sharing the 'unease' about care homes being run on a profit-making basis is pretty weak, and it is unclear what an 'actively managed market' means in practice. There are other ways to shift the balance of ownership than outright nationalisation. It also avoids tackling the sheer number of providers in the system and the duplication that this brings. 

The chapter on Fair Work is one of the strongest in the report. It supports the recommendations of the Fair Work Convention's report on the social care sector. It says that priority should be given to creating national sector-level collective bargaining of terms and conditions. The importance of getting a grip on workforce planning, training and development are also very welcome. A national job evaluation exercise should address many of the inequities in the current workforce pay structures, and bring Personal Assistants into the fold is also positive. The report recognises that the SSSC cannot meet the needs of the workforce in full, and it is right that its role, along with Care Inspectorate in regulation, is reformed.

Separating need from affordability is the right approach, but it brings funding challenges that the report skirts around. It is positive that the report recognises social care as an investment rather than a drag on resources, and the report seeks to identify some of the costs and savings involved in raising standards. Having been involved in previous efforts to cost this, it is not straightforward by any means and the suggested 20% increase in real terms funding is certainly required. Some options for raising the revenue are outlined in the report, but it makes no recommendations.

Overall, the report is a bit of the proverbial curate's egg. The creation of a National Care Service, workforce and investment are all positive reforms. On the other hand, the report is vague on how we are to shift from markets to collaboration, and it fails to address ownership and fragmentation in the delivery of services. I am concerned that it looks and feels like an overly centralised approach, which replicates other initiatives in education, police and fire - few of which have been successful. When in doubt - local is best. How to fund social care was probably too big a task for a review concluded in a commendably short time period.

Nonetheless, the report is an important step forward. We now need some political leadership to move from process to delivery.

On Monday, before the report was published, I was speaking at an event looking at the future of care from a devolved nation perspective with speakers from Wales and Scotland, including Julie Morgan MS the Welsh Government Minister and Monica Lennon MSP. There are some interesting initiatives in Wales, and they are facing similar challenges. The presentations were recorded and can be viewed on the SHA Scotland website.