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Tuesday 24 January 2023

Local autonomy or national clout? Scotland’s care conundrum

By Craig Ryan

The social care shake-up in Scotland will affect the lives of more than a million people and could have far-reaching repercussions for local government and the NHS. But are the reforms missing the point?

Nicola Sturgeon with child - Scotland plans for National Care Service

The scale is huge. Social care in Scotland involves well over a million service users, unpaid carers and social care workers, as well as many NHS staff. In all, the Scottish Government reckons almost a quarter of Scots will be directly affected by its plans to set up a new National Care Service (NCS).

If passed, the bill currently before the Scottish Parliament will shift control of social care from local councils to Scottish ministers and create a single social care workforce in place of the dense network of council, NHS, private and voluntary sector employers. The NCS could also pull huge chunks of the NHS into its orbit, including community and mental health services, and much of primary care, including GPs.

Under the plans, the NCS will set national policies and standards, do national workforce planning and commission specialist services. It will oversee an as-yet-unknown number of local care boards, commissioning and delivering care on the ground.

“Shifting the paradigm”

The reforms are the Scottish Government’s response to the long-standing problems seen in social care across the UK: chronic underfunding, severe staff shortages, limited integration with NHS services and a Cinderella-service reputation.

“We’ve got to do something,” says Claire Pullar, MiP’s national officer for Scotland. “We have an ageing population and we don’t have the social care infrastructure or people to cope with that. And we have to find a way to co-ordinate services better.”

The government says Integrated Joint Boards – set up in 2014 to facilitate collaboration between the NHS and local authority social care – have worked, but not well enough. “Inconsistencies remain”, it warns, claiming its plans will “strengthen and value” the care workforce and Scotland’s 800,000 unpaid carers. Boldly, it also says the NCS will “shift the paradigm”, so that social care is seen as a resource rather than a burden. It has dangled the prospect of a 25% increase in funding, although it’s unclear how or when this would be delivered.

Responses to the government’s consultation, from professional bodies, councils, NHS organisations and care staff, mix broad support for the principles behind the reforms with profound scepticism about whether they can deliver what’s promised. The bill is vague about how the NCS will work and which services it will include – deliberately so, the government says, so the new service can be “co-created” with partners, service users and staff. But it also means the people most affected are still in the dark about what happens next.

A dominant partner?

Wayne Gault, is a former member of MiP’s National Committee, working for NHS Grampian. He runs a multi-disciplinary drug and alcohol programme, working with some of the most vulnerable people in rural Aberdeenshire. This involves “a lot of hard work building partnerships between a mishmash of agencies”, he explains – the police, courts and housing as well as NHS and social care services.

Wayne Gault from NHS Grampian: “Because we don’t have anyone in charge, it’s easy to factor in community involvement. But if we create large bodies distant from the community, those sorts of interventions will deteriorate.” 

He expects his job to be absorbed into the NCS, along with clinicians working for addiction services, local GPs and mental health services. “But the bill is so goddamn vague, I honestly don’t know how it’s going to affect people,” he says.

He fears the gravitational pull of a “dominant partner” like the NCS could undermine the “parity of esteem” between different services – the notion that “everyone’s voice counts the same” – on which partnership working and community engagement depends.

“The people we serve are perfectly able and motivated to provide a huge service to their peers, but that support depends on how much respect we offer them,” Gault explains. “Because we don’t have anyone in charge, it’s easy to factor in that kind of community involvement. But if we create large bodies distant from the community,” he warns, “those sorts of interventions will deteriorate.”

Gault’s concerns about autonomy are widely shared within local government. The Convention of Scottish Local Authorities (COSLA), representing Scotland’s 30 single-tier councils, says the proposals “raise real and fundamental questions about the state of localism, democracy and governance in Scotland”.

COSLA insists accountability to local communities is “critical” to ensuring that care services meet local needs. The wide-ranging powers the bill gives to ministers, COSLA warns, “represent over-centralisation and control at the expense of services being designed and delivered locally, based on local knowledge and expertise”.

There is also the danger, highlighted by Inverclyde Council among others, that weakened councils could be left with notional responsibilities they have no powers to meet. “Councils currently have a duty to promote individual and social welfare. The removal of social care and social work services from local authorities will significantly impede their ability to do so,” the council says.

The impact on NHS services could be just as significant. Shorn of community and mental health services, and much of primary care, Scotland’s eight NHS health boards could be left with little more than acute hospitals. “Some of the smaller boards are probably not sustainable without the primary and community elements,” says Gault, which could, he warns, result in fewer, larger health boards that are even more remote from local communities.

One care workforce

Alarm bells are ringing elsewhere in the NHS. The Scottish Ambulance Service says the “fragmentation” of NHS services could disrupt continuity of care and lead to delays for people trying to access services. And the Royal College of Occupational Therapists has criticised government policy goals which focus entirely on social work and social care, ignoring the NHS services likely to be be absorbed by the NCS. Occupational therapy, it notes, is not even mentioned in the bill or the government’s accompanying policy document.

While some “fisticuffs over professional boundaries” are inevitable, Pullar says, creating a single national social care workforce promotes “the understanding that social care is part of the fabric of our society”. She hopes the reforms will “give social care the same status as the NHS” and eliminate some of the poor working conditions and professional standards found in some care providers. Attitudes are changing, she suggests, with more young people considering long-term careers in care, and the NCS is an opportunity to build on that.

So far, the Scottish Government has skirted over the tricky business of harmonising the pay, terms and conditions of care staff working for dozens of different organisations. “The NCS will have to resolve those inconsistencies,” warns Gault. “It won’t be a cheap or easy process, and they could lose any residual goodwill.”

Where’s this going?

MiP's Claire Pullar: “This doesn’t have to be up and running in 18 months, it has to be right... We want people to take their time and not feel pressurised into going along with it as it stands.” 

Trade unions, including MiP, are also concerned that the reforms are being rushed through, putting additional pressure on a health and care workforce still exhausted from the pandemic.

The government’s “impatient” approach and “don’t question it” attitude mean issues raised in the consultation “haven’t been understood or properly explored”, Pullar says. “This doesn’t have to be up and running in 18 months, it has to be right. With less staffing and management capacity in health and care at the moment, we want people to take their time and not feel pressurised into going along with it as it stands.”

The consultation responses reveal widespread doubts within the sector that the NCS will have much impact unless the staffing crisis in health and care is resolved, with many suggesting that, if the government really has 25% more to spend on social care, it might be better spent on recruiting staff rather than re-organising the service.

“Personally, I don’t think it will make a blind bit of difference,” says Gault. “Our social care infrastructure is inadequate because we can’t recruit and retain enough staff. There’s no evidence that governance is the problem.”

Social care minister Kevin Stewart’s “heart is in the right place”, and his commitment to “co-producing” the detail is welcome, he concludes, “but it’s unclear where this is going. It could be the best thing since sliced bread or it could be a disaster. But as I see things at the moment, it doesn’t look good.”

Photo: Jane Barlow/Alamy

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