How Not to Design a National Care Service – 2

Nick Kempe – 12 May 2022

Five months after the Scottish Government’s decision to appoint KMPG to design the National Care Service,  it appears that the Scottish Government has little intention of meeting the hopes and aspiration for a new care system that arose out of the Covid crisis. Common Weal’s Care Reform Group has received a copy of the papers for the National Care Service Key Stakeholder Group which is meeting today, 12th May.  They provide a frightening indication of what a service designed by KPMG, and managed by Scottish Ministers might look like.

The first paper lists the members of the reference group for the “Target Operating Model (TOM)” being developed by KPMG.  The term will be incomprehensible to most people but is the jargon used in the commercial world for creating a new blueprint for a business.  The point here is that instead of designing a service that might be capable responding to care in all its complexity, which requires diversity and local decision-making, the Scottish Government is trying like a business to design a single model for care and a care system that can be driven from the top down.

The membership of the Reference Group tells another tale about the direction of travel. 

11 of the 28 representatives on the Group are from health and another three from the Integrated Health Boards which currently manage adult health and care services.  Local authorities are limited to a single representative from the Society of Local Authority Chief Executives, with not a single councillor or representative from Cosla. 

By contrast, private and voluntary sector providers have four representatives on the Group and the Third Sector has been given another three places.  There is no place for the Chief Social Work Officer for Scotland, although the Social Work profession is represented by Social Work Scotland and the Scottish Association of Social Workers.

Trade Unions and organisations representing people who use services and their carers are noticeable by their absence. 

The second paper, on the legislative process, is filler which provides an overview of how the Scottish Parliament works but says nothing about the Scottish Government’s proposals which are due to be published in a few weeks.  It appears not even the Reference Group is to be trusted with that.

The third paper is about co-design and reveals the fundamental contradictions behind the Scottish Government’s approach to this. The paper claims that “The National Care Service (NCS) will be co-designed with the people who access and deliver social care support and other relevant services”.  Why then has the Scottish Government handed KPMG the task of designing the new service?  And how come Trade Unions, Service Users and Carers are not represented on the NCS Reference Group?

The answer lies in the Scottish Government’s understanding of what “design” is about:

“Design is the process of understanding what people need to achieve a certain outcome, and the creation of all the processes and changes needed to deliver that outcome within the constraints of what is possible or available.”

This appears to be all about government doing what they think is best for people, within limited resources, rather than supporting them, whatever their needs and circumstances, which is what social work and social care should be all about.  That interpretation is then confirmed by:

“How will design decisions be taken? 

Scottish Ministers will ultimately be responsible for taking decisions about the scope and functioning of the National Care Service at national level, and how local bodies are structured and governed”

This is not co-design, it’s further centralisation of power and decision-making.  

The references to the importance of “lived experience” – about which Common Weal has serious concerns –are in fact a smokescreen designed to conceal the power grab from the people who use services and their carers.  Together with the workforce, all would be much better off with local designed and democratically controlled services as we outlined in Caring for All.

Paper 4 is about future engagement.  It reveals the Scottish Government has identified a number of areas where it believes further engagement would be beneficial, including children’s services, justice, workforce, human rights and healthcare. The reason for this selection is not given but “The attendees for these events will be carefully considered to ensure the discussions are valuable, informative and capture the required range of perspectives to ensure the best possible outcomes.”  Yet more top-down management, the opposite of co-design!

Paper 5 is a “governance” diagram.  This will be incomprehensible to anyone not in the know.  For example the Programme Delivery Board feeds across the Health and Social Care Management Board which feeds into the Health and Social Care Assurance Board which feeds into the Scottish Government Audit and Assurance Board.  Why these boards exist and who is on them is not explained (there appears nothing publicly available on the Scottish Government website).  This should provide a warning of what a centralised care service bureaucracy directed by Scottish Ministers will look like.  

Papers 6 and 7 are about the Current Operating Model, Target Operating Model, Programme Business Case and “journey maps”, all of which KPMG has been tasked with developing.  This work is ostensibly intended to improve people’s “lived experience” of the care system, rather than reforming what is fundamentally broken.  The second paper quotes the UK Treasury’s approach to Programme Business Cases called the Five Case model.  This includes The Strategic Case, The Economic Case, The Commercial Care, The Finance Case and The Management Case.  Not a mention of care!

The papers for the Key Stakeholder Group suggest that the Scottish Government has completely lost sight of the reasons why we need a National Care Service: because everyone needs care and support at various points in their lives and should be able to access care services when needed;  because care provision is distinct from health but equally important and needs to be properly  funded; because profiting from care, like profiting from health, is wrong;   because Scotland needs to invest in the care workforce and end poverty wages; because service users, carers and the workforce need to be empowered to take everyday decisions about care and to have far more control over how services are managed;  because the top-down management favoured by the Scottish Government hasn’t worked.

The Care Reform Group will continue to expose what the Scottish Government is getting wrong and to make the case that, even with its limited powers, the Scottish Parliament could create a National Care Service worthy of the name.

4 thoughts on “How Not to Design a National Care Service – 2”

  1. A very interesting thought provoking and worrying article. Don’t agree with the comment “care is distinct from health”. It is wrong to generalise ‘care’ as it manifests itself in all kinds of activity and certainly ‘care’ is a crucial part of health.

  2. Peter Cramond

    Common Weal, I’m glad you’re in here and blowing the whistle on what is going wrong with this proposed scheme. One of the stock phrases in political circles that I really hate is the term “stake holders”. As soon as you read that you know that the stake holders are going to be businesses and and the elites in the establishment circles — the phrase never applies to those to whom the ‘service’ will be directed towards. Bizarre really, as those are the people that have most skin in the game, the real ‘stake holders’. Whenever I read that phrase I know that I’m about to be worked-over and patronised again.

  3. CRIKEY!!
    What is it? And What is Going On? That KPMG and Atos aka Maximus aka Unum through the back door are still taking over government contracts and government departments and the management of most of our country’s and other countries public services and internal structure?

    Why is it, despite all the reports and negative effects our governments and the Scottish government gives contracts to Atos. What hand do they have on everyone’s kajoules?

    PS: in case nobody knew KPMG is a branch and sister to Atos and is truly terrible with many disasters God knows how many reports and investigations of incompetence and damaging effects to all it touches, All sales and no ability or substance.

    Questions and Inciteful answers on a postcard please.

  4. Ian Davidson

    Similar to, perhaps worse than, the highly centralised approach taken to “co-design” of Scottish Social Security system? All very depressing. It is difficult to engage with this morally corrupt Scottish Government as critical inputs are either ignored or twisted? There will be opportunities to lobby Holyrood Committees but may be too late at that stage?

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