Co-Design Is at A Crossroads

Nick KempeIt is almost ten months since Common Weal published Ready to Fail our critique of the Scottish Government’s top-down proposals for co-designing the National Care Service (NCS). Just how all the so-called co-design workshops which took place in the second half of last year have influenced the Scottish Government is unclear but recent evidence and developments demonstrate the process is fundamentally flawed.In her letter of 28th March which informed the Scottish Parliament’s Health, Social Care and Sport Committee that she would not be publishing the Scottish Government’s proposed amendments to the NCS Bill as promised, Maree Todd, the minister responsible, included a co-design plan for 2024-25 (pages 15-22).This “plan” was not co-designed with stakeholders but consists of a list of topics which the Scottish Government has selected for further consultation. The list omits almost all the real issues which would need to be addressed to create a proper National Care Service and is full of meaningless policy-speak. For example, the Scottish Government says it wants to ask “What might a human rights approach to procurement look and feel like?” If they are still unable to answer this question after several years of talking about a human rights approach to care, perhaps it’s time to acknowledge they are asking the wrong question? Why not ask people how Scotland could create a not for profit NCS like the NHS instead of assuming care provision should continue to be outsourced through procurement?Although the pre-amble refers to “participants” and “other stakeholders” the “plan” does not even set out who the Scottish Government believes should be involved in co-designing the answers to its questions. From the papers circulated so far to the new Expert Legislative Advisory Group (Common Weal is one of around 60 members) it appears that much of the consultation going forward may be through that group.The most significant information in Maree Todd’s letter is that “Through this period of ‘understanding phase’ activity, over 1,000 people with lived experience, as well as 112 stakeholder organisations, were directly engaged in a range of co-design activities”. This confirms that there has been no real co-design to date, only “activity” with people with Lived Experience.The contrast between what the Scottish Government has achieved nationally – at one stage they had taken on 200 extra staff – and what the East Lothian Health and Social Care Partnership, has delivered in terms of co-design is striking:“Between August and December 2023, ELHSCP organised a series of community engagement events, which formed the first part of the co-design process. The programme of events involved direct engagement with 702. The online survey provided 141 individual responses, and the team received 11 printed questionnaires. Together, the engagement activities accumulated 2,458 individual pieces of feedback and/or suggestions on how we can improve older people’s services in East Lothian. This included 314 suggestions, which were consolidated to form 105 long-list options, which were each individually assessed against four pre-set hurdle criteria.”Not only has one small area managed to engage almost as many people for one service as the Scottish Government has managed to do for all of Scotland, it has analysed the responses into a set of suggestions and from that created a long-list of options. It puts the Scottish Government to shame.This also shows that what we argued in Ready to Fail, that co-design of services should be from the bottom up rather than the top down, was correct. Had all the resources the Scottish Government has wasted on co-design nationally been devolved to local authorities/health and social care partnerships, the proposals to develop the NCS and care provision would be in a much better place than they are now.The resources the Scottish Government is now devoting to national co-design, appear to have reduced dramatically, perhaps in response to media coverage about the costs involved. According to the latest Lived Experience Experts Panel (LEEP) newsletter, the team at the Scottish Government can now only be contacted by phone Tuesdays 9-11am and Thursdays 1.00pm - 4pm and there appear to be no plans for large national events.Far from admitting that the idea a National Care Service can be designed nationally by groups of self-selected individuals has been a total failure, the Scottish Government is now in the process of asking people on the LEEP panel to nominate themselves for much smaller working groups. The two groups proposed so far are to consider how the Scottish Government should select people with Lived Experience to sit on the proposed National Care Service Board and to look at a new complaints system (without, apparently, any reference to all the other complaints systems that currently exist: to local authorities; the Care Inspectorate Scottish Social Services Council etc). The people most likely to put themselves forward and be selected for these groups are those who agree with the Scottish Government that care is best managed from the top down, rather than the bottom up, and that care provision can be improved by tweaks to the current system rather than fundamental reform.It should now be clear that co-design at the national level is going nowhere and is at best a fig leaf being used by the Scottish Government to mask its centralising tendencies. The challenge now is whether the organisations representing those with a stake in care provision can persuade MSPs that this whole approach is doomed to failure, that the Scottish Government needs to be negotiating with representative organisations, rather than listening to individuals, and that the best way to involve those with lived experience is to devolve power.