Care service should not be centralised

The SNP Government’s legislation to create a ‘national care service’ should be attracting attention beyond those who have an interest in the future of care services. The statement of benefits set out in explanatory information about the legislation is quite specific about the massive structural change proposed, but noticeably light on how this will achieve the target of service improvement.
There are fears the new Bill will remove the crucial link with local accountability.There are fears the new Bill will remove the crucial link with local accountability.
There are fears the new Bill will remove the crucial link with local accountability.

There is really no dispute about the fact that the shortage of social care workers is a severe problem for the delivery of care services across Scotland, including the Western Isles. One approach to easing this difficulty would be to provide a national focus on recruitment, training and conditions of employment for social care workers.

Instead, the care service legislation proposes to draw the decision-making and accountability from local authorities to Scottish Ministers, while claiming a range of future benefits which appear largely aspirational rather than evidenced within the legislation or its explanatory information.

There is little to argue about when the case is made for change that will provide national consistency in provision and standards of care, will drive up quality and be based on human rights, dignity and respect. Yet there seems to be little evidence to support the claim that the national care service will ensure equality of access to care services, provide person-centred care, and support for informal carers.

There is also plenty to take issue with when the claim is made that the changes will deliver a system that is genuinely accountable to people.

Two questions to be answered are, firstly, whether the national care service will resolve the problem of the shortage of social care workers and, secondly, what effect the proposals have on the future of local government as a whole.

Recruiting and training a valued workforce

When shortage of care workers and shortage of funding for their employment cause delays in being able to discharge patients back into the community after hospital treatment, discussion is often framed in the context of the effect these ‘blocked beds’ have on the ability of the NHS to provide its acute care services.

Less attention tends to be paid to the fact that delays actively harm the people waiting for care arrangements by accelerating loss of confidence and independent skills, making the prospect of support at home even more of a challenge.

A snapshot of patients delayed in hospitals in the Western Isles towards the end of 2022 shows 13 delayed discharges and the occupancy of over 500 bed days during the month being measured.

Add to that the more widespread problem of people who continue to live at home, but at increasing risk because of the inability to provide the number of points of care contact daily that would contribute to an adequate and safe service.

The proposals to address these problems will naturally be of greatest interest to those who are directly or indirectly affected by the shortage of care workers.

But a by-product of the proposed national care service legislation, the impact on local government as a whole, should be attracting an even wider interest group, because it represents a fundamental change for local councils.

The impact on local government

The introduction of the national care service would see the funding and decision-making about care services being removed from council control and vested in Scottish Ministers in Edinburgh.

Closely mimicking the NHS model, there would be local boards, appointed by ministers rather than being elected, to ensure that services meet local priorities.

Can we be reassured by the claim that the boards will be able to draw on genuinely local experience to ensure that services meet local priorities? Does the assertion this will provide better local accountability than presently exists with the local authority stand scrutiny, when the experience in the Western Isles in recent times, for both the NHS and CalMac, has been of an influx of professional quango-hunters to appointed boards?

The Nuffield Trust, a respected national commentator and analyst of social policy, has made various observations about the new service.

It clarifies some of the confusion that has been introduced by the very use of the term ‘national care service’ and the hype about it being the biggest change since 1948, drawing on the parallels with the creation of the NHS.

Nuffield points out that this is not a new care service free at the point of delivery (as may be assumed from the language) and the means test will still apply to care services.

They also note that there is a considerable risk in shifting accountability from local areas. Evidence, they say, points to structural reorganisation often being a distraction, bringing limited improvements to the problems they are trying to resolve.

The Institute for Fiscal Studies (IFS) is another well-regarded independent commentator on financial and social policy. It has underlined the seismic change that removing funding control from local authorities to Scottish Ministers represents.

For 2022-2023 expenditure by Scottish local authorities will amount to £4.3 billion, one-third of overall expenditure and ten times what is spent on roads and transport. If control of that funding is withdrawn from local government, then education services, currently on average accounting for 47% of local authority spending, will rise to 70%.

The SNP in their years in power have had an insatiable appetite for drawing power to the centre, away from local authorities; they do not bear all the responsibility for this trend but have followed the pattern of the last 40 years with some enthusiasm during their period in government.

It is sometimes too easy to forget that the Comhairle was the lead organisation for social housing provision and management, and played a central role in the successful drive to improve the privately owned housing stock; that water and sewage services were directly managed services; and that the Comhairle, in pan-Highland partnership, had engagement in the management of police and fire services.

What will remain if social care, community justice and childcare services are pulled to the centre?

The Comhairle to all intents will come closer to resembling what in the 19th century would amount to an amalgam of parish education boards, but probably with less autonomy.

Having genuine local accountability

If we consider more closely the question of local accountability, it is worth examining in more detail the strengths and weaknesses of the two systems by looking at the Comhairle and NHS Western Isles. I was an employee of local government for over 35 years and later, for 8 years a non-executive director, latterly vice-chair, of the health board.

Local councils, of course, can at times make parochial decisions that fly in the face of attempts to take a strategic approach to service improvement. The Comhairle since its inception has attracted, as you would expect from an elected public body, a range of members with varying qualities.

There have been few whose absence from the scene would have been beneficial, a significant number whose presence or absence from the chamber made no discernible difference, and a good number who worked as diligent committee members and provided effective governance.

There have also been a few outstanding and inspirational members who made a lasting difference for the better.

And, good, bad or indifferent, every four years or so the voters can turf them out, in search of better representatives.

My transition from local government to the health board was a bit of a jolt. For most of the time, the local NHS board felt like a minor branch office of an organisation where most executive decisions came from the NHS in Edinburgh.

The balance of power between senior executive directors and the local board is also entirely different to that between senior local government officers and the council. The Comhairle, and all councils, hold their executives to a far higher degree of accountability than NHS local boards can.

One of the central promises of the national care service is that it will ensure consistency of service and standards of care across Scotland.

Although the proposed care service closely follows the structural model of the NHS with its local boards and control by Scottish Ministers, the NHS itself struggles with the goal of national consistency with almost daily reports of health services that are subject to ‘postcode lottery’. Just look, for example, at the current state of Children and Adolescent Mental Health (CAMHS).

Financing social care in the future

The current projections for funding the new service range over a 5-year period range from £500 million to well north of £1 billion.

The Scottish Parliament Finance Committee recently said that without an indication of the potential scale of all costs associated with the Bill, it is difficult to assess whether the service is affordable or sustainable.

The financial uncertainty is compounded by the potential inclusion of children’s services, justice social work and mental health services within the scope of the service.

CoSLA, the national body representing local authorities across Scotland, has set out, in partnership with the government, the aim of securing the Real Living Wage for all care workers, delivering minimum standards, terms and conditions, working to remove charges for non-residential care services and improving support for unpaid carers.

With set-up costs of £250 million for the national care service and annual running costs of £500 million, there appears to be, as an alternative to the major structural change set out in the Bill, a financial opportunity to address the central deficiency in care services, the availability of a trained and motivated workforce.

Instead, in its apparent search for eye-catching headlines, the government has skirted around the workforce problem that stares everyone in the face, while at the same time pulling the rug from under local democracy and accountability.

Some weeks ago, I wrote to our local MSP setting out some of my reservations about the national care service legislation and seeking information on the approach he was taking on the subject. There has been no acknowledgement or response to my enquiries.