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

Building a social care system fit for purpose – Chris Creegan

Can Holyrood succeed where Westminster is floundering? A vexed question we have become wearingly familiar with north of the border in recent years. But with respect to the future of social care, it is far from fantasy politics.

The Scottish Government’s Programme for Government, published in September, indicated it would ‘establish a National Care Service, backed by at least 25% more investment in social care over this Parliament.’ The government would, it went on, bring forward legislation to enable its creation by June 2022.

Back in September, that seemed a way off. With Christmas rapidly approaching, it is beginning to feel like no time at all. And with consultation on what legislation might contain recently completed, now is a good time to ask whether the early signs suggest the government can pull it off.

The Coalition of Care and Support Providers in Scotland (CCPS) represents the interests of more than 80 of the most substantial third sector/not for profit providers across the country. Social care reform has been high on its agenda for more than a decade. In 2020, it published Big Ideas which advanced a detailed exploration of how social care might be planned, purchased, and paid for.

Big Ideas offered four key tests on which proposals for reform could be judged. Do they shift power? Do they increase choice and control? Do they improve accountability and transparency? And finally, do they improve social care sustainability?

Publication proved timely. Not only had Scotland, along with the rest of the world, been plunged into the Covid-19 pandemic, the crisis that came in its wake exposed fault lines in our social care system like never before. It was in that context and with an election looming, that the government commissioned Derek Feeley and a small team of experts to undertake the unenviable task of conducting an independent review in record time.

The central plank of that review, the establishment of a national care service, was never in doubt. Whatever the wisdom of that precondition, for CCPS, Feeley’s team succeeded not only in an impressively comprehensive feat of engagement during lockdown, but also in advancing a compelling case for reform. At the heart of its findings was the basis for a paradigm shift in the delivery of social care – as an investment in, not a burden on, Scottish society. We were heartened too by the recognition it gave to the quality of social care provided by the third sector.

Feeley’s team posed questions as well as answers, particularly on the how as distinct from the why and the what. And there were, unsurprisingly, given the pace of the review, gaps in its coverage. The digital and data challenge ahead was just one of note. Alignment to housing support was another.

Nonetheless, CCPS’s starting point in assessing the proposals in the government’s consultation was, do they match the review’s ambition? And while we applauded the government’s efforts, regrettably we were left underwhelmed and unconvinced in several key respects.

Chief among our concerns is the absence of any fundamental change to commissioning and procurement practice, without which the new local boards will be hampered from the start. The principle of ethical commissioning is indisputable. But the four tests set out in Big Ideas – and the principles set out in the review – demand something bolder than the framework proposed in the consultation. In particular, a shift from price-based competition to values-based collaboration is long overdue.

Of course, any system of commissioning must test the offer of providers. And no one would question the importance of value for money. But competitive tendering has not delivered – it treats social care as a commodity which is inherently unethical.

Second, the proposals lack (or at least appear to lack) a coherent model of change. As far as there is one, it seems to be control more and try harder. But this will not be enough, and neither will an approach predicated on structures and practices alone.

Any model of change to a public service which is about supporting people must be relational. Of course, the proposals necessarily focused on the technical aspects of change which would need to be incorporated into legislation. But cultural and behavioural change are neither optional nor add-ons.

Third, whatever the merits of the structural changes proposed – and CCPS believes they are workable in principle – much more needs doing to get the balance of national and local accountability right.

The absence of an inclusive national board as recommended by the review is a significant omission. At a local level meanwhile, there is insufficient focus on enabling flexibility. The success of any national care service has to be judged on what happens at a hyper local level – a commitment to person-centred, let alone person-led, care is meaningless otherwise.

CCPS’s fourth concern is about co-production. The independent review asserted unambiguously that a new national care service must be co-designed with the people it is designed to support.

Alongside the launch of the consultation, the government announced the establishment of a Social Covenant group made up overwhelmingly, though not exclusively, of people with lived experience of receiving social care. This was a very welcome step, but it will be vital to ensure that the group’s contribution is firmly embedded in the process of reform to come.

Indeed, we remain perturbed that too often criticism of the proposed reforms – and this is borne out in some consultation responses – completely neglects the business of social care and the people supported by it.

Finally, the scale of the proposed reform poses yet more questions. Does the government have the capacity and capability to make it happen? Ongoing reform elsewhere has demonstrated this is more than a process question.

And does it have a model of funding which makes it realisable let alone sustainable? Bluntly, considering all of the pledges written into the proposals – the scrapping of eligibility criteria for example – do the sums add up? And where is the investment required to create an equitable and coherent pay policy for all social care workers, and close the gaping hole left by decades of outsourcing? There is much more thinking to do here, as so clearly articulated in Reform Scotland’s recent paper, The Cost of Caring.

Then there is the question of scope. The government has chosen to respond to a question posed by the independent review by simply throwing a blanket over a host of other functions, most notably children’s services. This is far from uncontentious not least given The Promise change programme, another flagship reform, already underway.

From the perspective of those whose focus is determinedly on keeping that promise to care experienced children and young people, the extension of scope, without a clear evidence base to support it, poses a serious risk to momentum. At the other end of the telescope, many of those who thought when Feeley reported that adult social care was finally getting the attention it had so long needed are now scratching their heads at the risk of dilution. Is this a double whammy?

We will be exploring what others have said and watching closely as the government commissions its consultation analysis. It will be no small undertaking for the contractor with around 1100 written responses and notes from more than 100 events to capture and distil. As we do so, these concerns will inform our approach to what comes next – along with a critical underlying question.

What is the government actually trying to do here? Is this a plan for a national care service or a national health and care service? Further integration unquestionably matters – but health and social care are not the same thing and cannot be delivered by the same means.

Contrary to media focus, social care is about more than care for older people – huge challenge though that is. A national care service must give expression to the principles of Self Directed Support for disabled people too. Simply absorbing social care into the NHS is not the way to do that.

Public service reform is notoriously difficult. Within two years of Labour’s landmark victory in 1997, Tony Blair, who had made it his mission, bemoaned that his back was already scarred from early attempts at reform.

Two years later, Blair’s government commissioned the Wanless review of NHS. In her foreword to a report reflecting on that review 20 years on, Jennifer Dixon, Chief Executive of the Health Foundation, notes that the challenge for social care at Westminster is even greater than that for health in the aftermath of Covid-19. There is, she says, no reform strategy and an urgent need for investment. It is here, Dixon says that ‘political leadership, deal-making and creativity’ – all called for by the report’s author Nick Timmins – will be sorely needed to ‘fix social care once and for all’.

Here in Scotland we are also, as Paul Gray argued eloquently in a recent paper for Reform Scotland, at a critical juncture for health and social care. The Scottish Government will need all the things Timmins calls for to respond to it. But first it must ensure it has a coherent reform programme, and on the basis of its current proposals it may need to take a step back before it can go forward.

Building a social care system fit for purpose is a race against time, but it should not be a competition. Yet it is also true that 10 years on from the Dilnot and Christie commissions, Holyrood has a chance to show its mettle and steal a march on Westminster. Whether it will, remains to be seen.

The shift so persuasively argued in Feeley’s review still offers a huge opportunity. But right now, getting its strategy back on track – and building greater consensus in doing so – would be a smart move for the government. The road ahead may be paved with good intention – but it is a long and arduous one too.

Chris Creegan is Associate Director at CCPS