Approach to Co-Design - Continuing to Fail

Nick Kempe - Common Weal Care Reform Group

The Scottish Government’s approach to co-design – continuing to fail

Generally Common Weal’s publications about the care system have been positively received by those prepared to comment publicly.   This week, however, Jim Elder Woodward, one of Scotland’s leading disability rights activists, launched a blistering attack on “Ready to Fail”, the Care Reform Group’s recent critique of the Scottish Government’s approach to co-designing the National Care Service .  While we don’t agree with how Jim has presented our position and believe we have far more in common than he suggests, there are important differences between us about whether a rights-based approach to social care can work and the role of local authorities.  We are grateful to HealthandCareScot for fostering the debate.

Meantime, the Scottish Government’s version of co-design “continues apace” as Jim put it.  Their latest survey is supposed to “inform the ‘keeping care support local’ co-design theme within the National Care Service” and is aimed at those who receive or work in social care and community health services and their carers. It provides an excellent example of all that we argued in Ready to Fail going wrong.  

The stated purpose of the survey is to ask people about services and decision-making in their local area, as if the Scottish Government did not already know that local social care services are collapsing, and decisions are taken by the Integrated Joint Boards (who incidentally are far more “accountable” to Scottish Ministers than the general public).  

There is nothing in the survey about people’s “lived experience” of social care services: the call centres and form filling; the endless waits; the virtual impossibility of seeing anyone face to face when you need help; the local facilities such as day centres that have been shut; the high staff turnover which make continuity of care impossible for many.

Instead, the survey starts by asking the respondent several questions about their background, including mandatory questions about date of birth and post code, followed by questions about identity (religion, race, gender, and sexuality).   Such questions are normally included at the end of surveys, are off-putting and serve as a deterrent to anyone who wants to see what the survey is about before deciding whether to respond.  

The survey asks just two questions about the respondent’s social background, both of which relate to the past (the jobs of the person’s parents when aged 14 and whether they had been in care as a child – people under 18 are excluded from completing the survey).  There are no questions about the respondent’s current social circumstances, e.g., if they live alone, are supported by a family, or have family commitments or the relationships that are so important for meeting care needs. Such background information is crucial for understanding people’s views, if that is what the Scottish Government is trying to do by asking these questions.

The survey then moves on to ask five sets of tick box questions about what services the respondent received.  Most of these tick box options are linked to the two questions about health services.  The first of these is a list of community health services, the second a set of hospital-based services which includes such things as “forensic medicine” and “hyperbaric chambers”.  What this question has to do with designing a National Care Service is unclear and suggests other agendas.  

The list of social care services in questions 3-5 is sparse by comparison and extremely telling.  All care at home services, for example, are included under one tick box whereas each type of community health service (district nursing, physiotherapy, mental health etc) has its own box. Sheltered housing is included under “residential services” but that is what you get if you hand the design of the NCS to management consultants rather than local government which knows about these things.

The bias towards health in a questionnaire which is meant to be about a National Care Service is also reflected in the absence of any questions about housing – if you can’t get around or out of your house your need for care services increases – and preventive services and facilities.  Lunch clubs, community halls, advice centres etc are crucial to the lives of many people with care needs or those supporting to them.  The Scottish Government may have recently reached a deal with COSLA agreeing that social work and care staff will not be removed from local authorities, but still appears to have very little understanding of the role that local authorities should play in providing basic infrastructure that supports people and communities to create a more caring world.

Preventive services, moreover, are often local initiatives, the product of various different people and interests coming together to meet local needs and offer the best examples of co-design that we have.  Preventive services would have been a good place for a survey about local co-design to start but instead they are totally missing.

Having stated in the preamble that “we would like to understand how you feel about social care support and community health services in your local area”, the survey asks not a single question which would allow the Scottish Government to ascertain how respondents feel about services in their local area. Instead, the survey goes on to ask a couple of general questions, which appear quite random but again possibly betray other agendas:

• “Is it important to you to have social care support or community health workers who live in your local area?”  
  This is the wrong question. Where staff live should not be the concern of the Scottish Government.  What matters is whether staff are organised and based locally, working out of offices that are accessible to the public.
• “Do you consider the social care support or community health services you get to be local to you?”  
  How do you answer that one?  A more objective question would be to ask people how long it takes to get to a GP surgery or local social work office and then explain the impacts this has on their lives.

Most of the remainder of the survey is about decision making.  This is crucial to co-design. Instead of services being designed and imposed from the top down, both on those needing them and those working in them, Ready to Fail argued we need services to be designed from the bottom up.  Unfortunately, none of the questions allow any opportunity for people to say what they think about real co-design. Most glaringly, there are no questions about the potential for service users, their informal carers and frontline staff to work together to design and control services locally.

After various questions asking respondents whether they know how decisions are made about services in their area (the real answer is it all down to money but there is no opportunity to say that), who they think it is important to involve, whether they would like to be involved and how best they would like to contribute (more surveys?!) the final question of the survey shows the Scottish Government really doesn’t “get” co-design:

“What do you think the top priorities should be for the National Care Service to help improve local delivery of social care support and community health services in Scotland?”
Never mind the tick box list of possible answers, local co-design is about local control, not local delivery of something that is designed centrally.  Successive Scottish Governments have been obsessed with improvement, getting more for less, for the last twenty years.  It hasn’t worked but they are still flogging the dying horse.  A radical re-think is required so that power can be decentralised to enable people to act locally.

The survey closes on Monday, 7th August 2023.  Rather than filling it in, it might be better to spend the time, if you have it, lobbying politicians to stop the current design work on the NCS from “continuing apace” and ask for a re-think based on our proposals at the end of Ready to Fail.