National Care Service

The Scottish Government has published a consultation paper on the creation of a National Care Service in Scotland. This follows the Independent Review of Adult Social Care (Feeley report, Feb 2021). Many of us with long experience in the sector welcomed the Feeley Report while expressing concerns about over-centralisation and funding.

The paper seeks views on the scope of the NCS, which goes further than adult social care to include children's services, alcohol and drugs, mental health, criminal justice social work and all community health services, including general practice. Ministers will be accountable for social work and social care, leaving local government as simply another service provider. The mixed economy of care will continue with services commissioned from health boards, councils, third and private sector providers. Workforce regulation and inspection services will remain independent of the NCS.

The NCS will set the commissioning framework, including pay and conditions and outcomes. Complex and specialist services will be commissioned centrally with others commissioned locally by new Community Health and Social Care Boards (replacing the IJBs), directly funded by the Scottish Government. The CEO will report to the NCS. There will be national workforce quality standards to help deliver Fair Work principles, which could include a 'Fair Work Accreditation Scheme'. In addition, the consultation seeks views on national sector-level collective bargaining arrangements as recommended by the Feeley Report. 

I was involved in drafting the SHA Scotland response to the consultation and broadly agreed with the concerns they set out, which include:

• It will take a significant amount of time to implement organisational change of this magnitude. In the meantime, the system is in crisis now. In particular, we have a demoralised, tired, and financially stretched frontline staff who immediately need a break, decent pay and a vote of confidence.
• The scope of the NCS is too broad. The range of services removed from local democratic accountability will damage integration. For example, separating children's services from education makes no sense, and social Work is also a local service with essential links to community activity that will be undermined by the dead hand of ministerial intervention. It will also create new barriers to shifting resources from acute to community services as health boards focus on acute services.
• The proposals involve a high degree of centralisation, giving ministers new powers that effectively remove local democratic accountability - rebranding IJB's (again) with even less local accountability. This approach is contrary to the Christie Commission principles and the recent legislation on the European Charter of Local Self Government. Moreover, the lessons from previous centralisations (e.g. Police Scotland) have clearly been ignored.

• The workforce proposals are less than firm. Trade unions have long argued for national collective bargaining supported by job evaluation and comprehensive workforce planning. Only those providers who meet that standard should be considered for service commissioning. The current Fair Work initiative suffers from a lack of enforcement, as set out in the recent Jimmy Reid Foundation paper. The Scottish Government has all the levers required to achieve better outcomes in the social care sector.
• The proposals effectively retain the marketisation of social care with the inclusion of for-profit services. It does not address the growing involvement of private equity, hedge funds and real estate investment trusts in the care sector and the use of predatory financial techniques. Let alone look seriously at the lessons of the pandemic for the future provision of residential care. 
• The funding arrangements are inadequate for the scale of the challenges facing social care now. The NHS has a £1billion recovery plan, but there is no equivalent plan for social care. In fact, there are no costings in the consultation on the development of the NCS or how it is to be funded. 
• The UK Government plans to fund an increase in social care spending, including addressing accommodation costs, by raising national Insurance (NI). This is the wrong approach, placing the burden on working people. However, the Scottish Government’s funding plans also fail to address these issues. £840m barely meets the current funding deficit, let alone improve services. Audit Scotland's analysis shows that spending on adult social work care needs to rise incrementally from £4.35bn in the next financial year to £7.66bn in 2034.

• Most western European countries have implemented some funding reforms in recent years, while the UK's means-tested care funding remains broadly unchanged. The pandemic has also highlighted social care challenges across Europe. The proposals in the consultation simply increase the financial support.
• The consultation gives little consideration to the broader impact of social care and has only limited support for unpaid carers. Post-pandemic, there is also an opportunity to create a caring economy by linking the NCS to a wider economic strategy. This was promised in the Gender Pay Gap Plan back in 2018, but not for the first time; bold statements are not followed through with action.

Creating a National Care Service remains the right approach. However, its role should be to create a national framework, with services designed and delivered locally. I agree with COSLA that this represents a direct attack on localism and on the rights of people to make and benefit from decisions taken locally.