Social care reform - again!

 The new Programme for Government signals a renewed effort to advance social care reform. After the National Care Service (NCS) debacle, the government is now proposing to “use these next three months to engage with local authorities, trades unions, and healthcare and service providers to reach agreement on reform of social care.” However, the First Minister has also said, “Although I am not proposing a prescriptive solution, I cannot see how we can deliver integration of social care without the National Health Service being in the lead.” This comes as the programme also plans to slash health boards from 14 to two and begin discussions on local government reform. I explain the implications of this in a new briefing for the Reid Foundation.

I was speaking about social care at a meeting in Edinburgh recently, before this latest initiative. I was fairly downbeat about the prospects of making progress, although the meeting itself was more positive. It was agreed that the Feeley Review went too far on centralisation, and the Scottish Government compounded the problem, bringing the whole NCS plan into disrepute. Several people at the meeting, including those on the advisory group, felt we should not lose sight of the Feeley report’s positive aspects.

It is unclear how broad the Scottish Government’s review of social care will be. They drew it too broadly in their NCS proposals. Social care covers children, young people, and disabled people, although the elderly are often the focus. While one in 23 people in Scotland receives formal social care, three-quarters are over 65. 97,000 people receive care at home and 34,000 in residential care, mostly in the private sector. This is formal, assessed social care, while 800,000 are cared for by unpaid carers. The Scottish Government sets overall strategy, with local delivery handled by Health and Social Care Partnerships, although councils and the NHS employ the workers. The FM has also signalled that he sees an end to the partnerships, saying, “That was the purpose of the integration joint boards, and I think that we have all come to the conclusion that however well-intentioned that approach was, it has not delivered the level of integration that is required.”

50,000 workers are employed in care homes, and 75,000 in home care. With other private care provision, around 200,000 (mostly women) work in this sector, making it a major economic contributor. The private sector has a very high turnover rate of 43%, compared with 11% in other sectors. The FM has not indicated who will employ the workers, but if he plans to shift them into the NHS, that really will create a massive HR problem, with equal pay being a particular challenge.

While there will rightly be scepticism about the level of centralisation being proposed, the challenges facing social care are enormous and urgently need solutions. We have a growing proportion of elderly people (25% increase in o/75s by 2030), which will drive extra demands on social care, particularly in Scotland, with healthy life expectancy flatlining due to health inequalities. Recruiting enough workers to run the service will become increasingly difficult due to demographic shifts in the working population and the cessation of immigration. Paying the Scottish Living Wage helps, but workers are still low-paid and can earn the same wage in far less onerous jobs. Workforce planning to address this is limited, and the long-awaited collective bargaining structures are still moving slowly. Technology may help a bit, but there are no Ann Droid’s coming to save us!

Health and Social Care Partnerships are already underfunded with a budget shortfall of £449m. Andy Burnham is driving reform in England, hopefully faster than his predecessor, although the focus is on care home fees. That may result in extra Barnett funding, but not quickly. We have huge provider fragmentation, which creates bureaucracy for social workers trying to find packages. Few plans address the privatisation of large care homes, which have high debt ratios and related costs that take £28 of every £100 spent. As the STUC study shows, they are more likely to be lower quality, pay lower wages, and spend less on staff: 58% on staff compared to 75% in not-for-profit homes. 

While social care should be addressed in its own right, we cannot ignore the impact on the NHS. Delayed discharge takes over one in nine hospital beds, at a cost of £440m. That doesn’t mean the NHS should take over social care; it means building the capacity to ensure patients are discharged when they are ready, and that will free up bed capacity in hospitals. Social care organisations have rightly highlighted the very different care models used in both services. 

The two-health board solution is simply shorthand for running the NHS and social care from St Andrew’s House. The two boards have no geographical or delivery purpose; they will simply become two administrative departments. All local input into service delivery will be lost. That doesn’t mean that everything should be done locally. I have long argued that there should be national frameworks for issues like procurement, pay and conditions, even the one public service worker, outlined by Christie. This would allow local organisations to decide how services are delivered. I favour doing this through smaller local authorities, as they do in Norway, and leave acute NHS services to three or four health boards.

The drive for ever-increasing centralisation of public services is a real worry for those who believe in local democracy. Communities are best placed to decide on the provision of services, with appropriate national frameworks. Ministers and their civil servants in Edinburgh are not the solution.