Nick Kempe – 2nd December 2022
Since our critique of the National Care Service Bill Common Weal’s Care Reform Group has been working on a set of amendments which would deliver the vision we set out in Caring for All. Because the NCS Bill is a framework bill, with limited content, we believe relatively few changes would be needed to do this.
However, creating mechanisms to ensure adequate government funding, making care not for profit, instigating national pay and conditions for staff and national collective bargaining, creating a system which would enable services to be co-designed from the bottom up and returning responsibility for care to democratised local authorities are all major changes which require a major re-think on the part of the Scottish Government. We don’t believe that can be done in current parliamentary timescales. As a consequence we strongly support recent calls for the bill to be paused or temporarily withdrawn in its current form.
While we understand the feeling behind calls to kill the bill, we have two major concerns about the consequences if that were to happen. The first is that the Scottish Government might drop the calls for reform completely, as they did with Council tax, leaving Scotland with its current care system which, as Covid demonstrated, is not fit for purpose. The second is that the Scottish Government already has enormous powers over the care system, as is illustrated by its powers over the Integrated Joint Boards which are currently responsible for adult care. Those existing powers include the right of ministers to issue directions, instructing IJBs what to do whatever local people think.
We are seeing the consequences of that in many places, including Edinburgh, which Kathy Jenkins wrote about in the newsletter last week. The current system is therefore already totally undemocratic and the consequences of scrapping the bill completely would be as bad as continuing with it in its current form. It is predictable that as long as care in not properly funded and controlled by people appointed by Scottish Ministers, privatisation and the deterioration of the quality of care services will continue.
We have also seen that in the last week where NHS Chief Executives, starved of funds, have been mooting the idea of a two-tier NHS. What has not been commonly realised about the Scottish Government’s proposals in the NCS Bill to create care boards with new powers is that they would also have responsibility for primary health care and be under no obligation to buy these from the NHS. Deprived of resources, over time the pressure to privatise community health services would become irresistible, just as has been happening with care services, and there would be no democratic recourse.
The NCS Bill is therefore neither in the interests of the NHS nor care services and the opportunity for a re-think should include how the NHS is helped to survive the current crisis. That should include consideration of how current structures in the NHS could be democratised to create checks and balances against the centralised power that has helped cause the current crisis (e.g the lack of funding for nurse and doctor training).
In our view health and care are equally important but should be served by two independent services, both properly funded so that they support each other.
If this is to happen for the NCS, there need to be two changes to the current design process. The first is that the Scottish Government needs to stop outsourcing the design of the NCS to private businesses. This is not just about design of the NCS itself, which the Scottish Government handed to KPMG, but also about the work that is commencing on new systems to enable the sharing of information about people create better data as proposed in Part II of the bill. That work offers potentially huge profits which explains the number of IT companies circling like vultures around the Scottish Government.
The second change is that the Scottish Government needs to abandon its current attempt to design care services centrally and from the top-down. Instead it should ask and resource local authorities to initiate work within local communities to redesign services from the bottom up. While some commentators critical of the bill have been calling for care services to be co-designed before the bill is discussed in the Scottish Parliament, co-design of all services across Scotland would probably take ten years (including the time required to turn privately owned into public services).
As importantly, one size fits all national co-design won’t work. That is partly for obvious reasons e.g. the way services are organised cannot be the same in urban and rural areas and varying levels and types of need in different localities, but also because community infrastructure for preventive services varies widely across Scotland. Designing appropriate community infrastructure is essential for preventive services to work and can only be done locally. Where there is no warm hall, there can be no lunch club, even though this may be far cheaper than providing home helps and a much better way of tackling isolation and loneliness.
All this doesn’t mean that there are not some things the Scottish Government should be doing centrally and now. There are a few very specialised services, like for some people with sensory impairments, which would be best provided nationally and the Scottish Government could start demonstrating how these might be co-designed from the bottom up. There are also 25 plus pieces of legislation that affect social work and social care and which are likely to get in the way of any real co-design of services actually being implemented and urgently need to be reviewed. Work on a national training programme for all staff whatever the final form of the NCS couldn’t start soon enough.
The one national initiative instigated by the Scottish Government as part of the NCS design which is really welcome is the independent review of “inspection, scrutiny and regulation” which started in October. It provides an opportunity to re-think the role of regulation in the light of the creation of a NCS and to merge the Care Inspectorate with the Scottish Social Services Council, as we proposed in Caring for All. Staff currently involved in workforce planning, training and improvement could be moved to a new National Care Board housed in one of the redundant buildings. But for the Independent Review to come up with proposals like that, the Scottish Government would need to have a much clearer vision for the NCS, one that included all services from the womb to the tomb like the NHS and not potentially different systems for children, adults and criminally justice.
While adding our name to those calling for the bill to be paused or temporarily withdrawn, Common Weal is hoping we can help build a broad alliance between the many people and organisations who feel let down by the Scottish Government’s proposals and come up with an alternative which would enable the Scottish Parliament to create a National Care Service worthy of citizens, carers and the workforce. Rather than waiting for the Scottish Government to do this, it might be better if stakeholders co-designed their own bill!