Scotland’s independent think tank
Scotland’s independent think tank

The Proposed National Care Service – Gordon Hector

Exactly ten years ago, the UK Government was trying to reorganise the NHS in England. It was a massive, complex set of changes, and a senior mandarin warned that it was ‘the only change management system you can actually see from space – it is that large’.

This year in Scotland, we are about to witness an equally massive bit of policymaking: a National Care Service, or NCS. Last week, the Scottish Government launched a consultation on creating the new service.

The consultation confirms that the label of ‘NCS’ perhaps overstates the radicalism. This not another NHS, but a new central body to set standards and oversee care. There is even one function for the NCS proposed which is ‘market oversight’, making it plain that we will still have a care home market.

And in some ways, the Scottish Government has actually pulled back from the Feeley review which began this process. That plan suggested the NCS take on not just standard-setting and quality improvement, but inspection and scrutiny functions, too. The risk is obvious: that a single organisation is conflicted over which mode of operation it prioritises. Ministers are about to de-merge education inspection from improvement work, for exactly this reason. But the paper rejects the idea of the NCS being a single super-body, and the Care Inspectorate and the Scottish Social Services Council will continue to exist. On the face of it this looks like a clearer, more robust delineation of responsibilities.

Feeley also suggested changing the way that funding works, ending all non-residential charges for care. The consultation uses quite careful language. It implies other alternatives could be explored, like changing the means-testing process, and only promises ‘fairness’ for self-funders. There’s enough wriggle-room there to leave this for future years. This is astute, given uncertainty over the public finances and on how much this could cost.

In other words, the core architecture of the NCS itself has some pretty pragmatic choices. Kevin Stewart, the minister in charge, might well feel the hand of history on his shoulder because the NCS itself feels quite expensive and quite extensive, is dripping in the language of values and human rights – but also feels like a fundamentally technocractic exercise about better managing a market. This is not Bevanite: it is Blairite.

But that might not matter. Because the consultation also proposes, quite casually, that entire swathes of wider community and public health services are wrapped into the NCS.

Drugs and alcohol, for starters: there is no detail, just a suggestion it could ‘become part of the NCS’.

Similarly mental health: ‘appropriate elements’ should be merged.

There is so little detail here that it’s possible this is a red herring, set up to concede later so other controversies look sensible.

If not, then this is massive change. And there are other less eye-catching changes which are equally significant.

Children’s social work and social care are proposed to be ‘located within’ the NCS. The difficulty here is that places have different mixes of health, justice and families services carried out by combinations of councils and the existing Integrated Joint Boards (IJBs, which unite councils, the NHS and other organisations to guide community and care services). Some people would call this status quo incoherent; others would say this reflects local realities. Either way, changing it means elbowing out councils in favour of national organisation of some of the most sensitive, complex public services. This is not something to do lightly. It is a bit like doing Named Persons and centralising the police service at the same time.

Then the IJBs themselves will become new Community Health and Social Care Boards.

IJBs are a funny bunch. They rest on a myth that goes deep in Scottish public life: that different organisations collaborate simply because you create a structure which says they should collaborate. That is not how organisations work. In the real world, some places have IJBs with combinations of brilliant people, easy geography and traditions of close work between health and care – and really are leading change. But other IJBs just remain cobbled-together collages of different organisations who can still barely organise themselves, let alone govern collectively: a board, maybe, but neither integrated nor joint.

Something has to happen to IJBs. The system envisaged by the consultation is that they get beefed up to become ‘delivery’ organisations, responsible for buying and organising services in their patch, accountable to the NCS. They will have new powers, too, over things like GP contracts.

If the accountability relationship between the NCS and the new community boards is too strong and directive, then this will just be a centralised system. But if it’s too weak, they will just be IJBs with a new logo. In between these extremes is the giddy prospect of something effective – but also the prospect of a uniquely awful outcome where we retain the ineffectiveness of some IJBs, but with new pressures to deliver, and new-found ability to dodge responsibility and pass the buck up to the NCS. What probably makes the difference is likely not structure, but culture and leadership. The role of a central body in shaping those things is difficult and requires expert calibration: the challenge is that such sophistication has to be executed alongside all the other massive institutional changes. It’s a big ask.

If those new powers over GPs turn out to be more significant than they appear at face value – well, it’s a brave politician who starts fights with GPs.

And that’s the curious thing about the politics of this. Social care is a patchy system, and it really hurts people when it doesn’t work. My hunch is that creating an NCS purely for adult social care would be a battle, but fundamentally opposition attacks about centralisation would never quite land. By massively increasing the scope of the NCS, that could shift. I might be wrong on this but I reckon the public back an NCS: it’s not obvious to me they back this NCS.

Not least as the plan has to go through a parliamentary mincer where no party has a majority.

All of this raises the stakes for the Scottish Government – and ultimately people who need good care services. Getting adult care right is a difficult job of political and policy stewardship. It’s one hell of a risk to expand that process to a complete redrawing of all community and care services.

Thinking back to a decade ago down south, the temptation to do everything in one super-bill in a parliament of minorities is what did for the UK Government’s approach. It passed, but it was a mess. It all but ended the Health Secretary’s career, was in trouble as soon as it was implemented, and is now being undone. It is the peerless case-study of how not to reform public services.

That plan may have been visible from space. This one has similarly extra-terrestrial potential.


Gordon Hector is a policy consultant and former Director of Policy and Strategy for the Scottish Conservatives