Democracy and the future of public care provision
Today, Thursday, a motion is being submitted to City of Edinburgh Council by Council leader Adam McVey (SNP), supported by his labour coalition partners, about the future of the care homes it owns. The reasons why the ruling administration of a democratically elected local authority is having to do this illustrate what will happen if the Scottish Government’s proposals for a centralised National Care Service “integrated” with health are allowed to go ahead.
Until recently, the political consensus in Scotland was that the answer to the problems in the NHS lay with social care. If only care services could stop people going into hospital and discharge them more quickly, all would be solved. Politicians prioritised joint working between the NHS and Councils above all else and then, when that did not solve the problems, in 2014 created statutory Integration Joint Boards IJBs)to plan the community health and care services. This, it was hoped, would reduce demand on hospitals.
It hasn’t worked, as Audit Scotland found in a report in 2018. But instead of recommending a re-think, their response was to urge IJBs to try harder and squeeze ever more out of inadequate resources. The former Auditor General, Caroline Gardiner, joined Derek Feeley, who as a former Director General of Health and Care at the Scottish Government had been one of the architects of the new system, on the Independent Review of Adult Social Care. Unsurprisingly their report, published in February, recommended further integration.
The Scottish Government’s consultation on creating a National Care Service is now proposing to transfer further responsibility for care from local authorities to “Community Health and Social Care Boards”, effectively beefed up IJBs but under greater ministerial control. That has shattered the political consensus and COSLA, representing all political parties, immediately condemned the proposals as a power grab while both the Tories and Liberals were quick to express concern nationally. What is happening in Edinburgh shows they are right to do so.
On 22nd June a meeting of the Edinburgh Integrated Joint Board was presented with a paper (which is no longer available on their website) that proposed closing four of the Council’s Care Homes and converting another, Drumbrae, into a clinical care facility. There had been no consultation about this with Councillors, the workforce or the public and, if it hadn’t been for quick action by the Edinburgh TUC who briefed some of the Board Members, it appears likely the closure would have been agreed on the nod. Since then a campaign has developed, spearheaded by Edinburgh TUC and Another Edinburgh is Possible, which has forced the EIJB to consult and has led to the motion to the Council today.
Whether either the campaign or the Council, however, will be able to force the EIJB into a re-think is another matter. At their Board Meeting on 17th August a further paper on their “Bed-based care” strategy – the change in terminology from care home illustrates the managerialist mindset – contained this chilling statement:
“As a separate public body, the IJB is not required to work within either NHS Lothian or City of Edinburgh Council frameworks even though the consequence of the eventual IJB decision, may have an impact on services run by both partners.”
What’s more, IJBs have the power to issue legal instructions, known as “Directions”, to the NHS and Councils requiring them to undertake specific actions. This allows these unelected and unaccountable bodies to pull the rug from under any NHS or Council services they want without regard to the consequences.
What’s happening in Edinburgh is likely to be repeated across Scotland if the Scottish Government’s model of a centralised managerialist National Care Service is allowed to go ahead.
No-one disputes the four care homes have failed to meet modern standards, though paradoxically this has been the situation for some time and care the homes’ residents and families haven’t complained. Rather than addressing the failure to invest, however, the proposals to close the homes are part of a cost saving exercise driven by financial problems in the NHS.
The story is complicated, but basically the NHS in Edinburgh is caught in a massive financial crisis and part of the solution to this involves “rationalising” services which come under the IJB, including long-term hospital beds for older people, now known as Hospital Based Complex Clinical Care (HBCCC). Despite the shortage of beds in the NHS, the IJB wants to halve the number of HBCCC places and displace those people into private care homes.
The EIJB’s room for manoeuvre, however, is very limited because a number of NHS services, including three of its HBCCC services, are based in buildings developed through the Private Finance Initiative. While these suck money out of the system and are a significant contributor to the financial crisis in the NHS, the IJB cannot shut services in those locations. It is therefore seeking to move or close services elsewhere and sell off land owned by the NHS to help balance the books.
The logic-chain behind the EIJB recommendation is as follows: move intermediate care beds from Liberton (so it can be sold) into two of the PFI buildings (the contract for the third is up next year and can be terminated); move the remains of the HBCCC service from the PFI buildings into Drumbrae, a newer care home owned by the Council (but possibly not fit for NHS use); move residents out from Drumbrae into private sector care homes.
What’s driving this, however, is not just the PFIs, it’s the fact that private sector care services are cheaper than both NHS and Council provision due to the way their treat their staff. If all responsibility for commissioning moves to IJBs, as the Scottish Government is proposing, it is predictable what will happen. While protesting that they wish to see staff treated fairly, faced with balancing the books, they will inevitably stop contracting with Councils for services across Scotland.
To be fair, Derek Feeley in the Adult Care Review did express concern both about how the workforce was treated by the private sector and about people making profits out of care provision. In a welcome step, the Edinburgh City Council motion goes one step further committing the Council “to expand publicly owned and operated residential care provision”.
The only sure way for a National Care Service to stop the race to the bottom in staff pay and conditions and the standards of care continuing is for responsibility for commissioning and delivery of care services to remain with Local Authorities. As one Winston Churchill said:
“No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time.…’
Local Government may have serious faults at present and a lot to answer for, but what’s happened in Edinburgh shows the alternative, a National Care Service run by unelected boards under the patronage of Scottish Ministers, will be far worse. We need to make local government work for care.
What happens today at the City of Edinburgh Council is significant for the future of local democracy, not-for-profit care provision and the future of the social care workforce.