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National Care Service – Design stuck in a rut

Nick Kempe

At the end of June, Common Weal’s Care Reform Group published Ready to Fail, a critique of the Scottish Government’s commitment and approach to co-design.  Although we had a sympathetic hearing from the Scottish Government’s Chief Designer, so far little appears to have changed.  

The Scottish Government has now published (27th September)  no less than twelve reports on nine “regional” workshops they held over the summer to “co-design” the National Care Service:  a “finding summary” and an “easy read findings summary” on the five themes it had selected (with one theme having four reports).   Both versions read more like a record prepared for the benefit of participants than reports for the general public.  Even trying to read through the Easy Read versions is a penance because there is so much duplication.  Instead of six full reports comprising c70 pages, the whole lot could have been condensed into half that length.

In each report the Scottish Government claims it will take away “insights” and “learning” from the events to inform the development of the NCS.  That is no different to standard consultation.  The problem is that the Scottish Government, like anyone else, can take away from the lists of points and suggestions what they will.  A real co-design process would have debated and resolved all the conflicting experiences and views expressed within the reports. Unfortunately in Scotland central government still believes it knows best. 

Some of the suggestions made in the  reports support the vision for a National Care Service we set out in Caring for All, for example:

  • “care professionals, rather than independent advocates, should be talking to people about their care support options”; 
  • more social workers are required as time is needed to form caring working relationships;
  • the need for “better links between social care support provision and leisure, housing and third sector amenities within areas” – an argument for social care provision remaining “integrated” within local authorities who provide all this infrastructure. (However, a little further down this was qualified by the claim that “social care support services don’t have to be delivered by local authorities in order to be well connected to the local area”.
  • people representing Service Users, Carers and the workforce on Care Boards should be elected rather than appointed by Scottish Ministers.

We have doubts that many of these suggestions, which conflict with current Scottish Government policy, will get very far.  

What is remarkable about the reports, however, is how much of what is recorded reflects the recommendations of the Adult Care Review and current Scottish Government thinking:  the emphasis on rights; the focus on improvement; the alleged need to tackle a post code lottery etc.  All the Scottish Government’s care shibboleths are here.  

Some of this may partly be a consequence of the five themes selected (from the top down) for the six events:

  • Information Sharing; Keeping care support local (2 events);
  • Valuing the Workforce;
  • Making sure my Voice is heard;
  • and Realising Rights and Responsibilities.  

The themes appear designed to attract those who agree with Scottish Government policy, particularly its advocacy of a rights-based approach.  (Why anyone would think a charter of rights, the focus of the Rights and Responsibilities workshop, will change anything when the Scottish Government has said it will create NO new rights is unclear).  Unfortunately, although the reports state 606 people attended in all, no breakdown is given of how many were people in need of care, carers and the workforce and no breakdown by care group.

There are good reasons to doubt those who attended were representative.  Given the extortionate fees being charged by the private care home sector, for example, and the number of people involved in the care home relatives group, it is extraordinary that fees are not recorded as in issue in any of the reports, not even those on the Charter of Rights or Making people’s voices heard.  That is not the fault of the people who attended.   Perhaps the Scottish Government just left out older people and their relatives from the workshops?  

Linked to this omission, there is little sense from the reports that our care system is on its knees. Issues, where recorded, are consistently underplayed.  Two examples. “There are questions about the standard of training available, especially when the training is delivered online”.  I was talking recently to a young person who had worked in care in Edinburgh and all she got before having to work alone with very confused, frail and incontinent older people was two days training in “moving and handling”.  That is the norm.  Or how about this: “in some areas, for some types of services, people said waiting lists are very long and caseloads are high – creating concerns that people are unable to access support that is essential to their health and wellbeing”.  Talk about understatement!   

Only a group of managers could have said that.  There is further evidence to show that the whole consultation process has been manipulated. Very little of the Valuing the Workforce theme sounds like it has come from front-line staff.  What social care worker, for example, would say “It is vital the social care workforce experience is improved to attract and retain Staff”?  That is more management speak.  Workers talk about better pay and conditions. Had care workers been given the opportunity, almost all could have recounted horror stories showing how care services in Scotland are on their knees.

The decision to hold two separate events on the Keeping Care Local theme was extraordinary.  The first workshop was open to all, the second (the wording is not 100% clear) appears to have been reserved for staff working in community health services.  The failure to include service users and carers completely undermines the claims from the Scottish Government that it is interested in co-design. It also confirms what the Valuing the Workforce report said about social care workers – who did not get their own workshop – being valued far less than health staff.  Only a design process being driven by NHS management could have been as insensitive.

In general, the reports add very little to understanding and reinforce our argument that the Scottish Government needs to reconsider its whole approach to designing the NCS.  There is one exception:

Eligibility – lessons learned 

We learned that the current system of using eligibility criteria to determine if an individual can receive social care support is deeply unpopular.

“People described the system of eligibility criteria as unfair as the availability of social care support can be determined by budgets and resource availability rather than ‘need’ and that this could be discriminatory”.

That is absolutely right.  If the Scottish Government were to accept this lesson and abolish eligibility criteria in favour of providing help free at the point of need, like in the NHS, the reports would have achieved something.

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